- Email: [email protected]
Use of occipital nerve block in emergency department treatment of status migrainosus
Accepted Manuscript Use of occipital nerve block in emergency department treatment of status migrainosus: A case report
Justin Yanuck, Ariana Nelson, Maxwell Jen PII: DOI: Reference:
S0735-6757(18)30246-8 doi:10.1016/j.ajem.2018.03.054 YAJEM 57405
To appear in: Received date: Accepted date:
19 March 2018 20 March 2018
Please cite this article as: Justin Yanuck, Ariana Nelson, Maxwell Jen , Use of occipital nerve block in emergency department treatment of status migrainosus: A case report. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Yajem(2018), doi:10.1016/j.ajem.2018.03.054
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title: Use of Occipital Nerve Block in Emergency Department Treatment of Status Migrainosus: A Case Report Running Title:
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Occipital Nerve Block for Status Migrainosus
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Authors:
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Justin Yanuck, MD, MS Dr. Yanuck is a PGY2 Emergency Medicine Resident at the University of California, Irvine.
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Ariana Nelson, MD Dr. Nelson is an Assistant Clinical Professor for the Department of Anesthesiology and Perioperative Care at the University of California, Irvine. She is also board certified in Pain medicine and practices interventional pain medicine at the University of California, Irvine.
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Maxwell Jen, MD, MBA Dr. Jen is an Assistant Clinical Professor for the Department of Emergency Medicine at the University of California, Irvine.
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Meetings: none Grants: none Conflicts of Interest: On behalf of all authors, the corresponding author states that there is no conflict of interest. Word Count: 1,078 Key Words: Pain Medicine, Occipital Nerve Block, Headache, Alternative Therapy
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Corresponding author: Justin Yanuck MD, MS Department of Emergency Medicine University of California, Irvine 333 City Blvd. West, Suite 640 Orange, CA 92868 (714) 456-5239 Fax (714) 456-3714 [email protected]
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ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT Use of Occipital Nerve Block in Emergency Department Treatment of Status Migrainosus: A Case Report
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Abstract Migraine headaches make up a significant proportion of emergency department visits. There are multiple pharmacologic treatment modalities for migraine abortive therapy; however, these treatments are rarely targeted to the precise area of pain and thus elicit multiple systemic effects. It has been well established in the anesthesia pain literature that occipital nerve blocks can provide not only immediate pain relief from occipital migraines, but can also result in a longterm resolution of occipital migraines. In this case report, we present how an occipital nerve block in the emergency department resulted in immediate and long-lasting resolution of a patient's occipital migraine.
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Introduction Adult patients presenting with a primary complaint of non-traumatic headache account for up to 4.5% of emergency department visits.1 While it is vital to evaluate and treat any high-risk features of headache, it is also important to employ multiple modalities to manage the pain of these patients. A subset of these headaches may be categorized as occipital migraines which have been shown in the literature to be responsive to peripheral nerve blocks of the occipital nerve.2-5 We report a case of perineural injection of 1 mL of 1% lidocaine to the greater and lesser occipital nerves, which resulted in 100% resolution of a patient’s occipital migraine at 20 minutes post-injection as well as complete abatement of migraines at 30 day follow-up.
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Case Report A 60-year-old female presented to a university hospital emergency department as a code stroke with reported left sided facial droop, and right sided occipital pain for the prior 6 hours. On arrival to the emergency department patient exhibited no focal neurological deficit, and a National Institute of Health Stroke Scale of 0. Patient’s initial vital signs were notable for hypertension of 180/80, which upon reassessment after 10 minutes had decreased to 150/75 without antihypertensive treatment. All other vital signs were within normal limits. The patient reported that she had a history of intermittent occipital migraines in the past, which were typically 12 to 24 hours in duration. Patient stated the headache was not maximal at onset, not associated with any head trauma, denied any recent fevers, neck stiffness, visual acuity changes, auditory changes, and she denied any sensation of motor weakness or sensory deficits. The patient’s daughter had noticed left sided facial droop, however on exam, this was not evident, and patient denied noting any facial asymmetry. Stat computed tomography (CT) of the head and CT Angiography of the head and neck were performed. All initial imaging was negative for any acute findings. Given possibility of transient ischemic attack, the following studies were acquired and demonstrated findings within normal limits: magnetic resonance imaging of head, echocardiography of heart with bubble study, carotid doppler, electrocardiogram, complete blood count, complete metabolic profile, hemoglobin A1c, thyroid stimulating hormone, and lipid panel.
ACCEPTED MANUSCRIPT
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During the course of the patient’s emergency department visit, patient reported her right sided occipital pain to be a 9/10 (numeric rating scale; 0 = no pain, 10 = the worst pain imaginable), throbbing in quality, non-radiating, and was associated with nausea and phonophobia. Patient stated this head pain was typical of her previous occipital migraines. Decision was made to proceed with right sided greater and lesser occipital nerve block. After informed consent was achieved, the right occipital artery was palpated over the occiput between the external occipital protuberance and the mastoid process. 0.5 mL of 1% lidocaine was injected medial to the occipital artery, and 0.5 mL of 1% lidocaine was injected lateral to the occipital artery. Within 2 minutes of the injection, the patient noted her pain was reduced to a 3/10, and after 20 minutes, patient stated her pain score was 0/10. Ultimately, the patient was discharged home, and at 30-day follow-up, she stated she had not experienced another migraine since that visit. Prior to injection, patient stated her migraine episodes would occur 4 to 7 times a month. Discussion
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In this case report, we show that an occipital nerve block in the emergency department can result in immediate pain relief as well as up to one-month of complete resolution of chronic occipital migraines. Occipital nerve blocks may provide not only immediate analgesia and decreased frequency of subsequent episodes, but also reduce exposure to systemic effects of typical pharmacologic therapy for migraines.6,7 The mechanics of this block require a basic understanding of the anatomy, and is a skill set that all emergency physicians should be able to perform easily.
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Multiple nerves innervate the scalp. The region of the posterior scalp is primarily innervated by the greater occipital nerve (GON), the lesser occipital nerve (LON), and a small contribution from the third occipital nerve (TON).8-10 The GON originates from the medial branch of the dorsal ramus of the C2 spinal nerve, and then typically travels along the medial border of the occipital artery subsequently sending off multiple branches after it crosses the intermastoid line (imaginary line between the mastoid process and the external occipital protuberance).8 The LON originates from the ventral rami of spinal nerves C2 and C3, and ultimately innervates the lateral portion of the posterior occiput.10
AC
While there are many techniques described for performance of the occipital nerve block, many involving a fanning technique and addition of some form of a steroid; there is little consensus as to what provides the most effective immediate and long term relief of symptoms.11-14 In this case report, we utilized a simple technique that requires only 2 needle insertions and does not include steroid. Utilizing a 27 gauge 1-3/8 inch needle, 0.5 mL of 1% lidocaine was injected immediately medial to the occipital artery with care taken to target the occiput above the intermastoid line. This anesthetizes the GON. If the occipital artery cannot be detected by palpation, the GON typically lies 1-2 cm lateral to the greater occipital protuberance. Withdrawal maneuver on the syringe prior to injection helps ensure the needle tip avoids vasculature. A subsequent dose of 0.5 mL of 1% lidocaine was then injected lateral to the occipital artery at a target 5-7cm lateral to the greater occipital protuberance along the intermastoid line to anesthetize the LON. Risks of this procedure include occipital artery hematoma formation; however, given the artery overlies the skull, this risk, which can be largely avoided with palpation of the artery as well as
ACCEPTED MANUSCRIPT utilization of small diameter needle, is minimal given the artery can be easily compressed over the hard skull.15 Furthermore, there is a theoretical risk of injection into the cranial vault or the subarachnoid space. This risk is easily preventable as long as one injects above the intermastoid line, palpates bone overlying planned injection site, and inserts needle into this position until bone is contacted, withdrawing the needle tip 2-4 mm before anesthetic is injected. Lastly, there is always a risk of anesthetic associated reactions, however, given the frequency with which this medication is used in the emergency department, these rare side-effects should be well known to any emergency physician.
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With this case report, we aim to demonstrate that an emergency physician can easily and safely provide immediate analgesic relief for patients suffering from occipital migraines.
AC
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PT
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References 1. Torelli P, Campana V. Management of primary headaches in adult Emergency Departments : a literature review , the Parma ED experience and a therapy flow chart proposal. 2010:545-553. doi:10.1007/s10072-010-0337-y. 2. Gutie A, Lo P, Orviz A. Greater occipital nerve block for the acute treatment of prolonged or persistent migraine aura. 2017;37(8):812-818. doi:10.1177/0333102416655160. 3. Fnp-bc CLV, Murphy MO, Facep A. Clinical Review. J Emerg Med. 2015;48(1):115-129. doi:10.1016/j.jemermed.2014.09.007. 4. Mellick L, Verma N. Headache Management with Occipital Nerve Blocks , Cervical Injections and Trigger Point Injections. 2010:32-35. 5. Tang Y, Kang J, Zhang Y, Zhang X. American Journal of Emergency Medicine Influence of greater occipital nerve block on pain severity in migraine patients : A systematic review and meta-analysis. Am J Emerg Med. 2017. doi:10.1016/j.ajem.2017.08.027. 7. Sun-Edelstein C, Rapoport AM. Update on the pharmacological treatment of chronic migraine. Curr Pain Headache Rep. 2016 Jan;20(1):6. doi: 10.1007/s11916-015-0533-9. 6. Soto E, Bobr V, Bax JA. Interventional techniques for headaches. Tech Reg Anesth Pain Manag 2012;16:30–40. 8. Guvencer M, Akyer P, Sayhan S, Tetik S. The importance of the greater occipital nerve in the occipital and suboccipital region for nerve blockade and surgical approaches: An anatomic study on cadavers. Clin Neurol Neurosurg. 2011;113:289–94. 9. Gilroy AM, MacPherson BR, Ross LM. 1st ed. New York: Thieme Medical Publishers, Inc; 2008. Atlas of Anatomy. 10. Fujimaki T, Son JH, Takanashi S, Ishii T, Furuya K, Mochizuki T, et al. Preservation of the lesser occipital nerve during microvascular decompression for hemifacial spasm. J Neurosurg. 2007;107:1235–7 11. Anthony M. Cervicogenic headache: Prevalence and response to local steroid therapy. Clin Exp Rheuma- tol. 2000;18:S59-S64. 12. Inan N, Ceyhan A, Inan L, et al. C2/C3 nerve blocks and greater occipital nerve block in cervicogenic headache treatment. Funct Neurol. 2001;16:239-243. 13. Naja ZM, El-Rajab M, Al-Tannir MA, et al. Occipital nerve blockade for cervicogenic headache: A double-blind randomized controlled clinical trial. Pain Pract. 2006;6:89-95. 14. Young WB, Marmura M, Ashkenazi A, EvansRW. Greater occipital nerve and other anesthetic injections for primary headache disorders. Headache 2008;48:1122–5.
ACCEPTED MANUSCRIPT
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Voigt CL, Murphy MO, Facep A. Clinical Review. J Emerg Med. 2015;48(1):115-129. doi:10.1016/j.jemermed.2014.09.007.
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15.
Figure 1
Justin Yanuck, Ariana Nelson, Maxwell Jen PII: DOI: Reference:
S0735-6757(18)30246-8 doi:10.1016/j.ajem.2018.03.054 YAJEM 57405
To appear in: Received date: Accepted date:
19 March 2018 20 March 2018
Please cite this article as: Justin Yanuck, Ariana Nelson, Maxwell Jen , Use of occipital nerve block in emergency department treatment of status migrainosus: A case report. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Yajem(2018), doi:10.1016/j.ajem.2018.03.054
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title: Use of Occipital Nerve Block in Emergency Department Treatment of Status Migrainosus: A Case Report Running Title:
T
Occipital Nerve Block for Status Migrainosus
IP
Authors:
CR
Justin Yanuck, MD, MS Dr. Yanuck is a PGY2 Emergency Medicine Resident at the University of California, Irvine.
AN
US
Ariana Nelson, MD Dr. Nelson is an Assistant Clinical Professor for the Department of Anesthesiology and Perioperative Care at the University of California, Irvine. She is also board certified in Pain medicine and practices interventional pain medicine at the University of California, Irvine.
ED
M
Maxwell Jen, MD, MBA Dr. Jen is an Assistant Clinical Professor for the Department of Emergency Medicine at the University of California, Irvine.
CE
PT
Meetings: none Grants: none Conflicts of Interest: On behalf of all authors, the corresponding author states that there is no conflict of interest. Word Count: 1,078 Key Words: Pain Medicine, Occipital Nerve Block, Headache, Alternative Therapy
AC
Corresponding author: Justin Yanuck MD, MS Department of Emergency Medicine University of California, Irvine 333 City Blvd. West, Suite 640 Orange, CA 92868 (714) 456-5239 Fax (714) 456-3714 [email protected]
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ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT Use of Occipital Nerve Block in Emergency Department Treatment of Status Migrainosus: A Case Report
CR
IP
T
Abstract Migraine headaches make up a significant proportion of emergency department visits. There are multiple pharmacologic treatment modalities for migraine abortive therapy; however, these treatments are rarely targeted to the precise area of pain and thus elicit multiple systemic effects. It has been well established in the anesthesia pain literature that occipital nerve blocks can provide not only immediate pain relief from occipital migraines, but can also result in a longterm resolution of occipital migraines. In this case report, we present how an occipital nerve block in the emergency department resulted in immediate and long-lasting resolution of a patient's occipital migraine.
ED
M
AN
US
Introduction Adult patients presenting with a primary complaint of non-traumatic headache account for up to 4.5% of emergency department visits.1 While it is vital to evaluate and treat any high-risk features of headache, it is also important to employ multiple modalities to manage the pain of these patients. A subset of these headaches may be categorized as occipital migraines which have been shown in the literature to be responsive to peripheral nerve blocks of the occipital nerve.2-5 We report a case of perineural injection of 1 mL of 1% lidocaine to the greater and lesser occipital nerves, which resulted in 100% resolution of a patient’s occipital migraine at 20 minutes post-injection as well as complete abatement of migraines at 30 day follow-up.
AC
CE
PT
Case Report A 60-year-old female presented to a university hospital emergency department as a code stroke with reported left sided facial droop, and right sided occipital pain for the prior 6 hours. On arrival to the emergency department patient exhibited no focal neurological deficit, and a National Institute of Health Stroke Scale of 0. Patient’s initial vital signs were notable for hypertension of 180/80, which upon reassessment after 10 minutes had decreased to 150/75 without antihypertensive treatment. All other vital signs were within normal limits. The patient reported that she had a history of intermittent occipital migraines in the past, which were typically 12 to 24 hours in duration. Patient stated the headache was not maximal at onset, not associated with any head trauma, denied any recent fevers, neck stiffness, visual acuity changes, auditory changes, and she denied any sensation of motor weakness or sensory deficits. The patient’s daughter had noticed left sided facial droop, however on exam, this was not evident, and patient denied noting any facial asymmetry. Stat computed tomography (CT) of the head and CT Angiography of the head and neck were performed. All initial imaging was negative for any acute findings. Given possibility of transient ischemic attack, the following studies were acquired and demonstrated findings within normal limits: magnetic resonance imaging of head, echocardiography of heart with bubble study, carotid doppler, electrocardiogram, complete blood count, complete metabolic profile, hemoglobin A1c, thyroid stimulating hormone, and lipid panel.
ACCEPTED MANUSCRIPT
CR
IP
T
During the course of the patient’s emergency department visit, patient reported her right sided occipital pain to be a 9/10 (numeric rating scale; 0 = no pain, 10 = the worst pain imaginable), throbbing in quality, non-radiating, and was associated with nausea and phonophobia. Patient stated this head pain was typical of her previous occipital migraines. Decision was made to proceed with right sided greater and lesser occipital nerve block. After informed consent was achieved, the right occipital artery was palpated over the occiput between the external occipital protuberance and the mastoid process. 0.5 mL of 1% lidocaine was injected medial to the occipital artery, and 0.5 mL of 1% lidocaine was injected lateral to the occipital artery. Within 2 minutes of the injection, the patient noted her pain was reduced to a 3/10, and after 20 minutes, patient stated her pain score was 0/10. Ultimately, the patient was discharged home, and at 30-day follow-up, she stated she had not experienced another migraine since that visit. Prior to injection, patient stated her migraine episodes would occur 4 to 7 times a month. Discussion
M
AN
US
In this case report, we show that an occipital nerve block in the emergency department can result in immediate pain relief as well as up to one-month of complete resolution of chronic occipital migraines. Occipital nerve blocks may provide not only immediate analgesia and decreased frequency of subsequent episodes, but also reduce exposure to systemic effects of typical pharmacologic therapy for migraines.6,7 The mechanics of this block require a basic understanding of the anatomy, and is a skill set that all emergency physicians should be able to perform easily.
CE
PT
ED
Multiple nerves innervate the scalp. The region of the posterior scalp is primarily innervated by the greater occipital nerve (GON), the lesser occipital nerve (LON), and a small contribution from the third occipital nerve (TON).8-10 The GON originates from the medial branch of the dorsal ramus of the C2 spinal nerve, and then typically travels along the medial border of the occipital artery subsequently sending off multiple branches after it crosses the intermastoid line (imaginary line between the mastoid process and the external occipital protuberance).8 The LON originates from the ventral rami of spinal nerves C2 and C3, and ultimately innervates the lateral portion of the posterior occiput.10
AC
While there are many techniques described for performance of the occipital nerve block, many involving a fanning technique and addition of some form of a steroid; there is little consensus as to what provides the most effective immediate and long term relief of symptoms.11-14 In this case report, we utilized a simple technique that requires only 2 needle insertions and does not include steroid. Utilizing a 27 gauge 1-3/8 inch needle, 0.5 mL of 1% lidocaine was injected immediately medial to the occipital artery with care taken to target the occiput above the intermastoid line. This anesthetizes the GON. If the occipital artery cannot be detected by palpation, the GON typically lies 1-2 cm lateral to the greater occipital protuberance. Withdrawal maneuver on the syringe prior to injection helps ensure the needle tip avoids vasculature. A subsequent dose of 0.5 mL of 1% lidocaine was then injected lateral to the occipital artery at a target 5-7cm lateral to the greater occipital protuberance along the intermastoid line to anesthetize the LON. Risks of this procedure include occipital artery hematoma formation; however, given the artery overlies the skull, this risk, which can be largely avoided with palpation of the artery as well as
ACCEPTED MANUSCRIPT utilization of small diameter needle, is minimal given the artery can be easily compressed over the hard skull.15 Furthermore, there is a theoretical risk of injection into the cranial vault or the subarachnoid space. This risk is easily preventable as long as one injects above the intermastoid line, palpates bone overlying planned injection site, and inserts needle into this position until bone is contacted, withdrawing the needle tip 2-4 mm before anesthetic is injected. Lastly, there is always a risk of anesthetic associated reactions, however, given the frequency with which this medication is used in the emergency department, these rare side-effects should be well known to any emergency physician.
CR
IP
T
With this case report, we aim to demonstrate that an emergency physician can easily and safely provide immediate analgesic relief for patients suffering from occipital migraines.
AC
CE
PT
ED
M
AN
US
References 1. Torelli P, Campana V. Management of primary headaches in adult Emergency Departments : a literature review , the Parma ED experience and a therapy flow chart proposal. 2010:545-553. doi:10.1007/s10072-010-0337-y. 2. Gutie A, Lo P, Orviz A. Greater occipital nerve block for the acute treatment of prolonged or persistent migraine aura. 2017;37(8):812-818. doi:10.1177/0333102416655160. 3. Fnp-bc CLV, Murphy MO, Facep A. Clinical Review. J Emerg Med. 2015;48(1):115-129. doi:10.1016/j.jemermed.2014.09.007. 4. Mellick L, Verma N. Headache Management with Occipital Nerve Blocks , Cervical Injections and Trigger Point Injections. 2010:32-35. 5. Tang Y, Kang J, Zhang Y, Zhang X. American Journal of Emergency Medicine Influence of greater occipital nerve block on pain severity in migraine patients : A systematic review and meta-analysis. Am J Emerg Med. 2017. doi:10.1016/j.ajem.2017.08.027. 7. Sun-Edelstein C, Rapoport AM. Update on the pharmacological treatment of chronic migraine. Curr Pain Headache Rep. 2016 Jan;20(1):6. doi: 10.1007/s11916-015-0533-9. 6. Soto E, Bobr V, Bax JA. Interventional techniques for headaches. Tech Reg Anesth Pain Manag 2012;16:30–40. 8. Guvencer M, Akyer P, Sayhan S, Tetik S. The importance of the greater occipital nerve in the occipital and suboccipital region for nerve blockade and surgical approaches: An anatomic study on cadavers. Clin Neurol Neurosurg. 2011;113:289–94. 9. Gilroy AM, MacPherson BR, Ross LM. 1st ed. New York: Thieme Medical Publishers, Inc; 2008. Atlas of Anatomy. 10. Fujimaki T, Son JH, Takanashi S, Ishii T, Furuya K, Mochizuki T, et al. Preservation of the lesser occipital nerve during microvascular decompression for hemifacial spasm. J Neurosurg. 2007;107:1235–7 11. Anthony M. Cervicogenic headache: Prevalence and response to local steroid therapy. Clin Exp Rheuma- tol. 2000;18:S59-S64. 12. Inan N, Ceyhan A, Inan L, et al. C2/C3 nerve blocks and greater occipital nerve block in cervicogenic headache treatment. Funct Neurol. 2001;16:239-243. 13. Naja ZM, El-Rajab M, Al-Tannir MA, et al. Occipital nerve blockade for cervicogenic headache: A double-blind randomized controlled clinical trial. Pain Pract. 2006;6:89-95. 14. Young WB, Marmura M, Ashkenazi A, EvansRW. Greater occipital nerve and other anesthetic injections for primary headache disorders. Headache 2008;48:1122–5.
ACCEPTED MANUSCRIPT
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Voigt CL, Murphy MO, Facep A. Clinical Review. J Emerg Med. 2015;48(1):115-129. doi:10.1016/j.jemermed.2014.09.007.
AC
15.
Figure 1