REVIEW ARTICLE


Clinic-based Procedures
C O N T I N UU M A UD I O
I NT E R V I E W A V AI L A B L E
ONLINE
for Headache
By Matthew S. Robbins, MD, FAAN, FAHS
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ABSTRACT
PURPOSE OF REVIEW: Headache disorders are common and disabling, and
many therapies that are effective and safe are procedural.

RECENT FINDINGS: After pivotal clinical trials, onabotulinumtoxinA has

become an established preventive therapy for chronic migraine; it is better
tolerated than many other treatments and may be useful for other
headache disorders. Peripheral nerve blocks, especially greater occipital
nerve blocks, have amassed evidence from randomized trials in the acute
and short-term preventive treatment of migraine and cluster headache.
Trigger point injections and sphenopalatine ganglion blocks have recent
trials suggesting efficacy and safety in properly selected patients. Medical
education initiatives are needed to train neurologists in these procedures
to help manage the large population of patients with headache disorders
who need them.

CITE AS: SUMMARY: Evidence exists for the efficacy and safety of procedural therapies
CONTINUUM (MINNEAP MINN)
2021;27(3, HEADACHE):732–745.
to be incorporated into neurology practice for the management of
patients with migraine, cluster headache, and other headache disorders.
Address correspondence to
Dr Matthew S. Robbins, Weill
Cornell Medicine, 525 E 68th S,
F 603, New York, NY 10065, INTRODUCTION
mar9391@med.cornell.edu.
The management of headache disorders has increasingly featured the
RELATIONSHIP DISCLOSURE: incorporation of procedures into clinical practice. In a 2011 survey
Dr Robbins serves on the board of practicing neurologists by the American Academy of Neurology,
of directors of the American
Headache Society and the New onabotulinumtoxinA injections and nerve blocks were the only procedures
York State Neurological Society, demonstrating an increase in use by neurologists over the preceding decade.1
as an associate editor for
Headache, and as a section
OnabotulinumtoxinA received regulatory approval by the US Food and Drug
editor for Current Pain and Administration (FDA) for chronic migraine in 2010 after two pivotal clinical trials,2,3
Headache Reports. and in recent years an accumulation of evidence for the use of other procedures
UNLABELED USE OF
for headache, most notably peripheral nerve blocks4-9 and, to an extent, trigger
PRODUCTS/INVESTIGATIONAL point injections10,11 and sphenopalatine ganglion blocks, has mounted.
USE DISCLOSURE: Although headache practice has diversified substantially with the advance of
Dr Robbins discusses the
unlabeled/investigational use migraine-specific drug therapies and neuromodulation, it is challenging to
of onabotulinumtoxinA for practice contemporary headache medicine comprehensively without the
new daily persistent
capability of performing or access to such procedures (TABLE 10-1).12-25
headache and chronic
posttraumatic headache.
ONABOTULINUMTOXINA
© 2021 American Academy
Peripheral administration of onabotulinumtoxinA is an important treatment
of Neurology. option for chronic migraine and remains the only specific therapy approved for

732 JUNE 2021

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this particular indication, largely because the evidence supports its use for
chronic but not episodic migraine. After several years of study for migraine of
varying frequency and with different treatment protocols, two large clinical trials
were conducted for chronic migraine and form the basis of the use of
onabotulinumtoxinA today.2,3
The PREEMPT (Phase 3 REsearch Evaluating Migraine Prophylaxis Therapy)
trials took place in Europe and the United States and cumulatively randomly
assigned 1384 patients. The pooled data from the PREEMPT trials demonstrated a
significant reduction of headache days per month over placebo at week 24
(−8.4 versus −6.6, P<.001).26 The benefit from placebo was substantial, which
generates consideration that the treatment effect may not be just from the
biological action of onabotulinumtoxinA but also from any neuromodulation
related to mechanical factors such as the needle insertion and the injected
solution volume or lack of blinding resulting from effacement of brow
wrinkles.27 Longer-term studies have demonstrated a durable benefit of
onabotulinumtoxinA for at least 2 years.28 Evidence from a 2019 post hoc
analyses of the PREEMPT data suggests that pain relief in many patients develops
within the first few weeks of onabotulinumtoxinA administration.29

Summary of the Procedures for Headache Disorders Most Commonly TABLE 10-1
Performed by Neurologists

Procedure Treatment type Injection frequency Evidence highlights

OnabotulinumtoxinA Preventive 12-week intervals Randomized controlled trials for chronic

migraine2,3

Randomized controlled trial for sleep-related

bruxism12

Observational studies for new daily persistent

headache,13 chronic posttraumatic headache,14
nummular headache,15 trigeminal neuralgia16

Peripheral nerve blocks Acute, short-term Single or repeated at Randomized controlled trials for migraine
preventive 2-week or longer intervals (short-term prevention)6–9,17
as needed
Randomized controlled trials for migraine in
emergency department18,19

Randomized controlled trials for cluster

headache (short-term prevention)4,5

Observational studies in pediatric,20

pregnant,21 and geriatric22 populations

Trigger point injections Acute, short-term Single or repeated at Randomized controlled trials for tension-type
preventive 2-week or longer intervals headache10,11
as needed

Sphenopalatine Acute, short-term Single or repeated twice Randomized controlled trial for acute and
ganglion blocks preventive weekly or longer intervals preventive treatment of chronic migraine23,24
as needed
Randomized controlled trial for acute
headache in emergency department25

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CLINIC-BASED PROCEDURES FOR HEADACHE

After internalization of its light chain within neurons, onabotulinumtoxinA

cleaves proteins of the soluble N-ethylmaleimide-sensitive factor attachment
protein receptor (SNARE) complex, which are responsible for fusing synaptic
vesicles to the neuronal membrane. Such proteins include synaptosomal
associated protein of 25 kDa (SNAP-25), syntaxin, and synaptobrevin.30 In the
periphery, the inhibitory effect of onabotulinumtoxinA may prevent the release
of inflammatory substances important in migraine and pain, such as calcitonin
gene-related peptide. Anatomically, extracranial administration of
onabotulinumtoxinA to the scalp may prevent activation of C-type meningeal
nociceptors that cross skull suture lines31; conversely, dural trigeminal branches
may also cross suture lines and receive sensory information from extracranial
structures.32 Therefore, extracranial administration of onabotulinumtoxinA may
directly impact intracranial dural afferent signaling.
After reconstitution of the toxin in saline, onabotulinumtoxinA is administered
in small equal doses totaling 155 units distributed throughout the head, neck, and
shoulder musculature, including the corrugator, procerus, frontalis, temporalis,
occipitalis, cervical paraspinal, and trapezius muscles (FIGURE 10-1).33 An
additional 40 units in total can be injected into the temporalis, occipitalis, and
trapezius muscles depending on the location of the pain, although no clear
evidence has shown that the addition of other units aside from the initial 155 units
is superior for durable pain relief. The injections are generally performed with
the patient in the sitting position. However, in the phase 3 clinical trials, patients
were positioned supine for the anterior and lateral injections and sitting for
posterior injections. Injections are repeated every 12 weeks, with
recommendations to attempt at least two injection cycles to assess for efficacy.
One of the major benefits of onabotulinumtoxinA relative to other preventive
therapies, particularly oral drugs, is its tolerability, which has been verified in

FIGURE 10-1
Injection paradigm for onabotulinumtoxinA in the treatment of chronic migraine. Injection
site locations for onabotulinumtoxinA in the treatment of migraine include the following
muscles: corrugator (A, purple dots), procerus (A, red dot), frontalis (A, orange dots),
occipitalis (B, purple dots), cervical paraspinal muscles (B, orange dots), trapezius
(B, red dots), and temporalis (C, purple dots).
Modified with permission from Blumenfeld A, et al, Headache.33 © 2017 Allergan plc.

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comparative studies versus oral preventive agents (CASE 10-1).34 Although neck
pain was the most common side effect in clinical trials, a protocol revision
recommends more superior injection of cervical paraspinal injections to reduce
its incidence by minimizing any neck extensor weakness.33 Medial brow ptosis is
also a potential cosmetic side effect, and the revised protocol may reduce its
incidence by placing the lateral frontalis injection more lateral to the vertical
plane of the midpupillary line. OnabotulinumtoxinA should be avoided in
patients with any neuromuscular junction disorder, and caution should be
exercised if the patient has a skull defect or an implanted neurostimulator in the
head or neck. Reconstitution of onabotulinumtoxinA should only be with
preservative-free normal saline; reconstitution with local anesthetics has been
reported to cause fatal anaphylaxis.35
Although many clinicians avoid using onabotulinumtoxinA in pregnant
women36 and its safety for the treatment of chronic migraine in pregnant women
is not well explored, no clear evidence to date has shown significant harm.37
OnabotulinumtoxinA has a high molecular weight and should not cross the
placenta. Cases of botulism by ingestion have not been associated with fetal
toxicity. A database of pregnant women exposed to onabotulinumtoxinA in
clinical trials and postmarketing surveillance did not show any increase in fetal
loss or malformations relative to the general population.38 OnabotulinumtoxinA
is generally considered safe in breastfeeding women given its peripheral
administration and large molecular weight.
One issue that has emerged with the use of onabotulinumtoxinA is the
phenomenon of drug wear-off, defined broadly by the establishment of initial
efficacy followed by diminishing therapeutic effect before the next scheduled
dose. This phenomenon has recently been examined specifically in chronic

A 48-year-old man had a history of episodic migraine without aura that CASE 10-1
had evolved over the previous year to 25 days per month, of which
15 monthly days featured severe headache. Previous trials of topiramate,
nortriptyline, and propranolol were not effective, so onabotulinumtoxinA
injections were administered. After the first 12 weeks, his headache
frequency reduced to 20 days per month with 13 severe headache days;
however, 12 weeks after the second round of injections, his headache
frequency had diminished to 12 days per month, with 5 severe headache
days. He experienced no side effects.

This patient had episodic migraine that evolved to chronic migraine. COMMENT
OnabotulinumtoxinA or a calcitonin gene-related peptide ligand- or
receptor-targeting monoclonal antibody are appropriate treatment
options. The patient had only modest improvement after the first injection
series but more robust improvement thereafter, which is often what is
observed. This has led to the recommendation of a trial of at least two or
three injection cycles before considering another preventive therapy.
This patient experienced no side effects, which is typical for
onabotulinumtoxinA, a treatment that is generally very well tolerated.

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CLINIC-BASED PROCEDURES FOR HEADACHE

migraine,39,40 demonstrating a prevalence as high as two-thirds of patients.

Although the mechanisms for wear-off may be biological or related to the nocebo
response, it has been suggested that increasing the units administered within the
range of 155 units to 195 units may mitigate against its occurrence.39
Although not specifically approved for these disorders, onabotulinumtoxinA
has rationally been used in the same protocol for other chronic headache
disorders that are otherwise treated like chronic migraine if they feature the same
headache phenotype, including chronic posttraumatic headache14 and new daily
persistent headache.13,14 Specialized protocols have been employed to use
onabotulinumtoxinA for other headache and facial pain disorders featuring more
unique pain distributions, such as sleep-related bruxism,12 trigeminal neuralgia,16
and nummular headache.15

PERIPHERAL NERVE BLOCKS

Peripheral nerve blocks for headache consist of injections of local anesthetic and,
at times, steroids in accessible nerve branches on the head, including the greater
occipital nerve, lesser occipital nerve, auriculotemporal nerve, supratrochlear
nerve, and supraorbital nerve (FIGURE 10-241).33 Peripheral nerve blocks have
generally been conceptualized and studied as acute or short-term preventive
therapies (CASE 10-2), although they may be used on a scheduled basis as a
preventive therapy.
The preponderance of higher-quality evidence for peripheral nerve blocks
relates to the use of greater occipital nerve blocks or injections for migraine and
cluster headache, although they are used widely for occipital neuralgia despite a
lack of randomized controlled trials for this specific indication. Observational
data suggest that the typical duration of benefit of greater occipital nerve
injections for headache is approximately 1 to 4 weeks.42,43 Therefore, the
majority of clinical trials have focused on their use as short-term preventive
therapies. Of the five sham/placebo-controlled randomized controlled trials for
migraine, four studies demonstrated statistically significant benefits of the

FIGURE 10-2
Cranial and upper cervical nerve branch injection sites for peripheral nerve blocks for
headache disorders. Common peripheral nerve block injection site locations include the
greater and lesser occipital nerves (A), the supraorbital and supratrochlear nerves (B, C),
and the auriculotemporal nerves (B, C).
Reprinted with permission from Blumenfeld A, et al, Headache.41 © 2013 American Headache Society.

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primary end point over placebo for short-term prophylaxis.6-9 The fifth study
showed both active and placebo to be equally beneficial, although the primary
end point for a single greater occipital nerve block was measured later at 4 weeks
rather than at 2 weeks for the other trials,17 possibly contributing to the result.44
Two emergency department randomized trials also studied greater occipital
nerve blocks in acute headache and demonstrated benefit over placebo18 or
parenteral therapies19 in patients for whom first-line IV treatment had failed or in
comparison to such therapies. However, a 2020 study showed that greater
occipital nerve blocks were not as efficacious as IV metoclopramide as first-line
therapy for migraine attacks in the emergency department.45 Peripheral nerve
blocks may be used in addition to repetitive IV medications for patients electively
admitted for intractable migraine.46
For cluster headache, two randomized clinical trials demonstrated greater
occipital nerve injections of steroid (either betamethasone or cortivazol [not
available in the United States]) ipsilateral to the side of the pain as superior to
placebo for short-term prevention, either as a single injection or in repeated
injections over a few days.4,5 This intervention provides an additional option to
oral steroids for short-term cluster headache prevention. Although potentially
safer given local rather than systemic steroid administration, a retrospective
comparative study suggested outcomes may be better for oral steroids, although
most patients improved with either treatment.47 The two randomized trials led to
greater occipital nerve steroid injections receiving a Level A recommendation in
the latest American Headache Society guideline for cluster headache treatment.48

A 34-year-old woman with a history of frequent migraine without aura CASE 10-2
since the age of 12 developed a bout of gradual-onset, intractable
throbbing, generalized headache with nausea and photophobia for 7 days
that led her to miss work for 2 days. Repeated home doses of eletriptan
and naproxen sodium were ineffective. She had previously had bouts of
status migrainosus that had not responded well to courses of oral
dexamethasone and oral methylprednisolone.
She did not wish to go to the emergency department or an urgent care
facility, so she came to the clinic and was treated with bilateral occipital,
auriculotemporal, supraorbital, and supratrochlear nerve blocks using
0.5% bupivacaine. She tolerated the injections well; within 24 hours her
pain intensity reduced, and within 48 hours the attack ceased.

This patient with long-standing migraine developed another bout of status COMMENT
migrainosus. Although the evidence is quite limited for treatment in this
particular setting after first-line therapies fail, peripheral nerve blocks
provide a reasonable and safe option that may lead to the avoidance of an
emergency department visit. Peripheral nerve blocks are often performed
as just one component of treatment; other recommendations, such as
augmentation of preventive therapy or counseling about acute medication
overuse and lifestyle management, may be important in many individuals.

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CLINIC-BASED PROCEDURES FOR HEADACHE

No randomized controlled studies have yet examined whether the addition of

other peripheral nerve blocks to greater occipital nerve blocks or injections would
be superior to greater occipital nerve blocks alone for any headache disorder, but
observational data suggest that it may be helpful for many patients,43 even
patients who have not responded to greater occipital nerve blocks.49
Methodologically, finding the appropriate placebo for peripheral nerve block
studies has been challenging,50 as even saline injections or dry needling may have
a neuromodulatory effect; an intradermal injection at the greater occipital nerve
puncture site seemed more likely to be identified as a sham in a randomized
controlled trial.18
Peripheral nerve blocks may work to treat headache disorders by targeting
extracranial sensory trigeminal and upper cervical projections. All sites blocked
peripherally have first-order neuronal projections that converge on the
trigeminocervical complex in the brainstem. Clinical data suggest that the
improvement that patients receive is not directly correlated to a simple local
anesthetic effect, as the duration of analgesia generally far exceeds the duration
of anesthesia. Other clinical observations strongly suggest a central mechanism of
action for peripheral nerve blocks by demonstrating improvement of allodynia
distant to the site injected as well as improvement in aura.41 In addition, cluster
headache is considered a trigeminal autonomic cephalalgia, but an upper cervical
injection of steroid (greater occipital nerve) even without anesthetic use is
effective.
Peripheral nerve blocks can be performed in an office-based setting effectively
and safely, presuming understanding of peripheral nerve anatomy and

TABLE 10-2 Safety Considerations for the Performance of Peripheral Nerve Blocks and
Trigger Point Injections for Headache Disordersa

Safety consideration Concern Action

Local anesthesia allergy Allergic reaction, Use corticosteroids only
anaphylaxis

Pregnancy Maternal and fetal Use lidocaine or ropivacaine instead of bupivacaine; avoid
toxicity steroids, particularly betamethasone and dexamethasone

Vasovagal attacks Near syncope or Perform and allow for extra time in supine position; use
syncope bupivacaine instead of lidocaine; use lower anesthetic
concentration; reduce total number of injections

Open skull defect or craniotomy Intracranial anesthetic Avoid injections in such locations
diffusion

Antithrombotic or anticoagulant use Hematoma Compress at injection site for several minutes after
injection

Cosmetic concerns Alopecia Avoid or use lower dose of steroids

Unclear anatomic landmarks Pneumothorax Avoid trapezius injections; use small gauge needle; use
because of body habitus technology guidance (ultrasound, EMG)

EMG = electromyography.
a
Modified with permission from Blumenfeld A, et al, Headache.41 © 2013 American Headache Society.

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landmarks. All sites described (greater occipital nerve, lesser occipital nerve, KEY POINTS
auriculotemporal nerve, supraorbital nerve, supratrochlear nerve) can be
● In the periphery, the
injected bilaterally in the same appointment, as the cumulative anesthetic dose inhibitory effect of
still lies far under the threshold of volumes associated with local anesthetic onabotulinumtoxinA may
systemic toxicity.41 In general, greater occipital nerve injections use the largest prevent the release of
volumes (2 mL to 4 mL), followed by auriculotemporal nerve injections (0.5 mL inflammatory substances
important in migraine and
to 1 mL) and supratrochlear nerve and supraorbital nerve injections (0.2 mL to
pain, such as calcitonin
0.5 mL). No consensus exists for the most effective anesthetic; clinicians most gene-related peptide.
commonly use lidocaine 1% to 2%, bupivacaine 0.5%, or ropivacaine 0.5% or a
combination of any of these agents. A steroid should be administered in addition ● One of the major benefits
to an anesthetic for greater occipital nerve injections for cluster headache of onabotulinumtoxinA
relative to other preventive
(typically methylprednisolone, dexamethasone, or triamcinolone) based on the therapies, particularly oral
available evidence and guidelines. However, for migraine, the few studies drugs, is its tolerability,
performing direct comparisons of anesthetics alone versus anesthetics with which has been verified in
steroids do not show added benefit.51,52 Ultrasound guidance has been proposed comparative studies versus
oral preventive agents.
to provide anatomic insights and improve the efficacy and safety of greater
occipital nerve injections in particular, but randomized trials comparing ● Although not
techniques are lacking.7,53 specifically approved
Peripheral nerve blocks generally cause numbness in the dermatomal for these disorders,
onabotulinumtoxinA has
distribution injected but otherwise have an excellent safety profile in properly
rationally been used in the
selected patients. Peripheral nerve tenderness may help to predict respondents.42 same protocol for chronic
Procedural safety considerations are summarized in TABLE 10-2.41 The most headache disorders that are
important precaution is to be aware of any skull bone defect or history of otherwise treated like
chronic migraine if they
craniotomy or craniectomy, as two cases of reversible coma from intracranial
feature the same headache
diffusion of anesthetic have been reported. Although peripheral nerve blocks phenotype, including
may be an excellent treatment option in pregnant patients with migraine,21 chronic posttraumatic
ideally lidocaine or ropivacaine should be used as bupivacaine has more headache and new daily
unpredictable pharmacokinetics and has been associated with maternal cardiac persistent headache.

conduction abnormalities.54,55 Peripheral nerve blocks may be an excellent and ● Peripheral nerve blocks
safe treatment option for older adults who frequently have more polypharmacy for headache consist of
and intolerability to medications affecting the central nervous system.22 injections of local anesthetic
and, at times, steroids in
accessible nerve branches
TRIGGER POINT INJECTIONS on the head, including the
Trigger point injections involve the administration of anesthetics into myofascial greater occipital nerve,
structures that may serve as mechanical sites that evoke or perpetuate an lesser occipital nerve,
underlying headache disorder, most commonly tension-type headache or auriculotemporal nerve,
supratrochlear nerve, and
migraine. Trigger points are identified on physical examination (most commonly
supraorbital nerve.
as a taut band of muscle) and are defined as sites of pain in muscle or fascia that
when irritated or compressed evoke referred head, face, or neck pain, ● Clinical data suggest that
reproducing symptoms of the index disorder. Trigger points are found more the improvement that
often in patients with frequent tension-type headache or migraine. The patients receive from
peripheral nerve blocks is
hypothesis is that persistent activation of a myofascial structure leads to not directly correlated to a
excessive local muscle contraction, ischemia, release of inflammatory substances, simple local anesthetic
and peripheral sensitization.56,57 effect, as the duration of
The evidence for trigger point injections includes randomized controlled trials analgesia generally far
exceeds the duration of
for tension-type headache and migraine, with the strongest evidence for frequent anesthesia.
tension-type headache.10,11 In clinical practice, trigger point injections are rarely
performed in isolation as they are most commonly indicated in patients
otherwise requiring headache prophylaxis. In addition, trigger point injections
may be performed in concert with peripheral nerve blocks.

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CLINIC-BASED PROCEDURES FOR HEADACHE

Trigger point injections are performed based on physical examination. The

most common sites of injection are the trapezius, sternocleidomastoid, and
temporalis muscles, but other muscles of the head and neck are commonly
injected (FIGURE 10-3). Anesthetics are generally used alone, given the local
and systemic myotoxicity of steroids.56 No clear evidence exists that
onabotulinumtoxinA specifically injected into trigger points provides benefit;
although the PREEMPT protocol allows for 40 additional units to be injected in
areas of increased pain, these may not actually be active trigger points. Trigger
point injections feature variable volumes (0.1 mL to 0.3 mL) but can be repeated
frequently (at least monthly). Safety concerns are similar to peripheral nerve
blocks (TABLE 10-2).

SPHENOPALATINE GANGLION BLOCKS

The sphenopalatine ganglion is a large parasympathetic ganglion lying in the
pterygopalatine fossa that also contains trigeminal (V2) and sympathetic
projections. The sphenopalatine ganglion is a reasonable target for blocks and
neuromodulation as it is the key peripheral structure involved in the expression
of cranial autonomic symptoms and plays an important role in the
trigeminoautonomic reflex in trigeminal autonomic cephalalgias and migraine
and in regulation of cerebral blood flow.58 A number of therapies developed may

FIGURE 10-3
Common sites for trigger point injections for headache disorders. Muscle sites that may
feature trigger points amenable to injections for headache disorders with their pain referral
patterns (arrows) include the trapezius (A), sternocleidomastoid (B), temporalis (C),
occipitalis (C), frontalis (C), semispinalis cervicis (D), splenius capitis (D), splenius cervicis (E),
semispinalis capitis (F), masseter (G), levator scapulae (H).
Reprinted with permission from Robbins MS, et al, Headache.56 © 2014 American Headache Society.

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target the sphenopalatine ganglion, including intranasal medication delivery, KEY POINTS
percutaneous and intranasal blocks including new catheters, neurostimulation,
● A steroid should be
chemical neurolysis, and ablation procedures. administered in addition to
For sphenopalatine ganglion blocks in the clinic, the evidence is somewhat local anesthetics when
limited and largely confined to one specific catheter. One randomized controlled greater occipital nerve
trial in an emergency department setting that studied bilateral sphenopalatine injections are used for
cluster headache (typically
ganglion blocks with bupivacaine for acute headache did not show benefit over methylprednisolone,
placebo for the primary end point of pain and nausea reduction at 15 minutes dexamethasone, or
but at 24 hours later demonstrated a higher proportion of pain freedom in the triamcinolone) based on the
active treatment arm.25 A randomized controlled trial assessed repetitive available evidence and
guidelines. However, for
sphenopalatine ganglion blocks (twice weekly for 6 weeks) as an acute treatment migraine, the few studies
for chronic migraine.23,24 Acute pain reductions relative to placebo were achieved performing direct
at multiple time points, but no statistically significant preventive effect was comparisons of anesthetics
observed over 1 and 6 months after treatment. alone versus anesthetics
with steroids do not show
Sphenopalatine ganglion blocks in the clinic are generally accomplished by added benefit.
two techniques. The older technique is to dip a cotton swab in liquid or viscous
anesthetic such as lidocaine or bupivacaine and insert it into the nasal passage ● Although peripheral nerve
with the tip resting at or near the posterior wall while the patient lies supine. The blocks may be an excellent
second technique is to use a more recently developed nasal catheter attached to a treatment option in
pregnant women with
syringe that administers the liquid anesthetic closer to the pterygopalatine migraine, ideally lidocaine
foramen. No evidence suggests which technique may be more effective. or ropivacaine should be
Headache specialists surveyed do not seem to have a consensus for the most used as bupivacaine has
effective and feasible technique.59 more unpredictable
pharmacokinetics and has
Intranasal sphenopalatine ganglion blocks do not specifically require any been associated with
imaging guidance and are generally safe to perform. However, they should be maternal cardiac
avoided in any patient with a history of any local bone or sinus defect, including a conduction abnormalities.
history of sinus surgery. Common side effects include a poor taste (from the
● Trigger point injections
anesthetic), numbness or paresthesia in the nose or throat (which indicates a
involve the administration of
patient should not swallow until resolved), low blood pressure, epistaxis, and anesthetics into myofascial
nausea. structures that may serve as
A much-needed future area of investigation is to elucidate the optimal mechanical sites that evoke
or perpetuate an underlying
sphenopalatine ganglion blocking approach. Imaging-guided percutaneous
headache disorder, most
sphenopalatine ganglion blocks can be effective and safe but are more costly.58 commonly tension-type
Recent anatomic studies have called into question the validity of the intranasal headache or migraine.
approach as the pterygopalatine foramen may be a closed passage with a longer
distance than previously appreciated.60 A related area of future study is the use of ● The evidence for trigger
point injections includes
onabotulinumtoxinA administered to the sphenopalatine ganglion percutaneously, randomized controlled trials
as demonstrated in pilot studies.61 for tension-type headache
and migraine, with the
TRAINING strongest evidence for
frequent tension-type
Mechanisms for teaching headache procedures for neurologists in training and in headache.
practice are lacking. Although continuing medical education programs are
available for neurologists to gain experience with indications, safety, and practice
on models through the American Academy of Neurology and the American
Headache Society, they do not provide real-world experience, and clinicians in
practice may need to seek out training from colleagues in practice. In the long
run, educating neurology residents in training may be most effective to help
remedy this deficiency.
Although 12% of the US population has migraine62 and 1% has chronic
migraine,63 headache education among neurology trainees is disproportionately

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CLINIC-BASED PROCEDURES FOR HEADACHE

KEY POINT underrepresented in the graduate medical curriculum.64 In a 2016 survey of

neurology residency program directors,65 formal training in these procedures by
● The sphenopalatine
ganglion is a reasonable
programs was uncommon. However, most residency program directors felt that
target for blocks and exposure was important, and over half felt that headache procedural competence
neuromodulation as it is the for their trainees was desired.
key peripheral structure Proposed headache fellowship milestones dictate competence in performing
involved in the expression of
these procedures for headache.66 However, it is unreasonable to expect that only
cranial autonomic symptoms
and plays an important role headache specialists should have such expertise given their relative scarcity and
in the trigeminoautonomic poor geographic distribution67 and the high overall prevalence of headache
reflex in trigeminal disorders.
autonomic cephalalgias and
migraine and in regulation of
cerebral blood flow.
CONCLUSION
Procedures are important aspects of clinical practice for neurologists who
manage patients with headache disorders. OnabotulinumtoxinA is an effective
and safe preventive treatment for chronic migraine, and peripheral nerve blocks
and trigger point injections are effective and safe for the acute and short-term
preventive treatment of a variety of headache disorders. Intranasal
sphenopalatine ganglion blocks are also feasible to perform in a clinic-based
setting. More widespread training mechanisms are needed for neurologists to
develop procedural expertise to better serve patients with these highly prevalent
and disabling disorders.

USEFUL WEBSITES/RESOURCES
PERIPHERAL NERVE BLOCKS (HEADACHE VIRTUAL ISSUE) SPOTLIGHT ON: INTERVENTIONAL HEADACHE
This collection of articles published in Headache MANAGEMENT
provides a useful evidence summary for peripheral This page on the American Migraine Foundation
nerve blocks. website describes approaches used for
headachejournal.onlinelibrary.wiley.com/doi/toc/ interventional headache management.
10.1111/(ISSN)1526-4610.peripheral_nerve_blocks_in_ americanmigrainefoundation.org/resource-library/
headache_treatment understanding-migrainespotlight-on-
interventional-headache-management/
OCCIPITAL NERVE BLOCK: DR ANDREW BLUMENFELD
This video shows the procedure for administering CERVICOGENIC HEADACHE
an occipital nerve block. This page on the American Migraine Foundation
youtube.com/watch?v=JGLOaZpZwqU website explains what cervicogenic headache
is and how it is treated.
BOTOX FOR MIGRAINE BY DR ANDREW BLUMENFELD americanmigrainefoundation.org/resource-library/
This video shows the procedure for administering cervicogenic-headache/
onabotulinumtoxinA injections for chronic migraine.
youtube.com/watch?v=hocClpTS7KU SPHENOPALATINE GANGLION BLOCKS IN HEADACHE
DISORDERS
THE SPHENOPALATINE GANGLION (SPG) AND HEADACHE This page on the American Migraine Foundation
This page on the American Migraine Foundation website describes the roles of the sphenopalatine
website explains what the sphenopalatine ganglion ganglion and sphenopalatine ganglion block in
is and its role in headache disorders; it also explains headache disorders.
the role and procedure of sphenopalatine americanmigrainefoundation.org/resource-library/
ganglion block. sphenopalatine-ganglion-blocks-in-headache-
americanmigrainefoundation.org/resource-library/ disorders/
understanding-migrainethe-sphenopalatine-
ganglion-spg-and-headache/ OCCIPITAL NEURALGIA
This page on the American Migraine Foundation
INTERVENTIONAL HEADACHE PROCEDURES website provides a guide to occipital neuralgia.
This page on the American Migraine Foundation americanmigrainefoundation.org/resource-library/
website explains the three most common occipital-neuralgia/
interventional procedures to treat patients with
migraine and other headache disorders:
onabotulinumtoxinA injections, peripheral nerve
blocks, and trigger point injections.
americanmigrainefoundation.org/resource-library/
interventional-headache-procedures/

742 JUNE 2021

Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

THE BASICS OF TRIGGER POINT INJECTIONS FOR INTERVENTIONAL THERAPY FOR MIGRAINE
HEADACHE AND MIGRAINE This video provides an explanation of and
This page on the American Migraine Foundation discussion on the use of interventional therapy for
website describes trigger points, what trigger point migraine.
injections are, and who should receive them. youtube.com/watch?v=qnAYks-F-gQ
americanmigrainefoundation.org/resource-library/
understanding-migrainethe-basics-of-trigger-
point-injections-for-headache-and-migraine/

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