Expert Consensus Recommendations for the Performance of Peripheral Nerve Blocks for Headaches – A Narrative Review

Authors


  • Conflict of Interest: Dr. Blumenfeld reports no conflict of interest in relation to nerve blocks. He does have consulting agreements, research grants, and/or speaking contracts with Allergan, Merz, Ipsen, Forrest, Pfizer, Posen, Zogenix, MAP Pharm, Impax. Dr. Ashkenazi – reports no conflicts. Dr. Napchan – received honoraria from GlaxoSmithKline and Zogenix. Dr. Bender – member of the advisory board of Nautilus Neurosciences and a member of the speakers bureau of IMPAX Pharmaceuticals. Dr. Klein – reports no conflict of interest. Dr. Berliner – received honoraria from Allergan, Nautilus, and Zogenix. Dr. Ailani – reports no conflicts. Dr. Schim – member of the advisory boards of Allergan, Zogenix, and MAP – honoraria: Allergan, Zogenix, Pfizer. Dr. Friedman – reports no conflicts. Dr. Charleston – reports no conflicts. Dr. Young – received funding for travel and speaker honoraria from Allergan, GlaxoSmithKline, Iroco, Merck, and Zogenix; serves as a consultant for Merz Pharmaceuticals; received research support from AGA Medical, Advanced Bionics, Advanced Neuromodulation Systems, Allergan, Capnia, Chorus (Lilly), Eli Lilly, Endo Pharmaceuticals, GlaxoSmithKline, MAP Pharmaceuticals, Medtronic, Minster, National Institute of Neurological Disorders and Stroke/National Institutes of Health, NuPathe, and Valeant; and receives royalties from Migraine and Other Headaches (2004) published by Demos Medical. Dr. Robertson – reports no conflicts. Dr. Dodick – research grants from Advanced Neurostimulation Systems, Boston Scientific, Mayo Clinic, Medtronic, NINDS/NIH, St. Jude Medical Inc. Honoraria: Alexza, Allergan, Kowa, ATI, Boston Scientific, Bristol Myers Squibb, Coherex, Eli Lilly & Company, Endo, HS Luncbeck, MAP Pharmaceuticals, Merck Serono, Medtronic, Inc., Minster, Nautilus, Neuralieve, Neuraxon, NuPathe, Inc., Novartis, Pfizer, SmithKlineBeecham. Speakers bureau for: Annenberg Center, CogniMed, Intramed, SAGE Publishing, Lippincott Williams and Wilkins, Oxford University Press, Cambridge University Press, Miller Medical. Dr. Silberstein – honoraria: Amgen, AGA, Allergan, Boston Scientific, Capnia, Coherex, Colucid, GlaxoSmithKline, Lilly, MAP, Medtronic, Merck, NINDS, Nupathe, Novartis, Pfizer, St. Jude Medical, Valeant. He is part of the speakers bureau for Endo Pharmaceuticals, GlaxoSmithKline, Merck. Research grants have been received from: AGA, Allergan, Amgen, Boston Scientific, Capnia, Coherex, Endo Pharmaceuticals, GlaxoSmithKline, Lilly, Map, Medtronic, Merck, Minister, Neuralieve, Novartis, NINDS, NuPathe, Opt-Nose, Pfizer, St. Jude Medical, Valeant Pharmaceuticals. Dr. Robbins – reports no conflicts.
  • Disclaimer

    This publication is neither an official position paper nor an official guideline from the American Headache Society.

Address all correspondence to M.S. Robbins, Saul R. Korey Department of Neurology, Montefiore Headache Center, Albert Einstein College of Medicine, Bronx, NY 10461, USA.

Abstract

Objective

To describe a standardized methodology for the performance of peripheral nerve blocks (PNBs) in the treatment of headache disorders.

Background

PNBs have long been employed in the management of headache disorders, but a wide variety of techniques are utilized in literature reports and clinical practice.

Methods

The American Headache Society Special Interest Section for PNBs and other Interventional Procedures convened meetings during 2010-2011 featuring formal discussions and agreements about the procedural details for occipital and trigeminal PNBs. A subcommittee then generated a narrative review detailing the methodology.

Results

PNB indications may include select primary headache disorders, secondary headache disorders, and cranial neuralgias. Special procedural considerations may be necessary in certain patient populations, including pregnancy, the elderly, anesthetic allergy, prior vasovagal attacks, an open skull defect, antiplatelet/anticoagulant use, and cosmetic concerns. PNBs described include greater occipital, lesser occipital, supratrochlear, supraorbital, and auriculotemporal injections. Technical success of the PNB should result in cutaneous anesthesia. Targeted clinical outcomes depend on the indication, and include relief of an acute headache attack, terminating a headache cycle, and transitioning out of a medication-overuse pattern. Reinjection frequency is variable, depending on the indications and agents used, and the addition of corticosteroids may be most appropriate when treating cluster headache.

Conclusions

These recommendations from the American Headache Society Special Interest Section for PNBs and other Interventional Procedures members for PNB methodology in headache disorder treatment are derived from the available literature and expert consensus. With the exception of cluster headache, there is a paucity of evidence, and further research may result in the revision of these recommendations to improve the outcome and safety of these interventions.

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