Cervical injection for headache

[medic25]

Has anyone used this technique for management of headaches before? Essentially you inject bupivicaine bilaterally next to C6-7. I've read some articles and watched a video about it, but have never seen anyone actually perform it. We had a migraine patient in the ED recently who listed allergies to all of our usual medications and this seems like it may be a great option for a lot of the headaches we see.

 

http://www.ncbi.nlm.nih.gov/m/pubmed/17040341/

[rcdavis]

I have done bilateral occipital nerve blocks with 0.5%bupivicaine wl epinephrine, but I would be pretty hesitant injecting near cervical nerve roots.. Am not aware of c6-7 trigger for migraines .. thoracocervical headaches.??..??

Perhaps mike (jmj11) could weigh in.

 

Medic25, are you thinking about doing this?

 

Is the patient allergic to toradol, decadron, DEPACON, dhe-45, Benadryl, REGLAN, thorazine, haldol, COMPAZINE?, trytophans, phenergan, magnesium?

 

If she is, then consider telling her that the headache society and the neurologists do not want us to use narcotics, and that you will have to discharge her with non narcotic medications ( muscle relaxants, NSAIDs, and one maybe po Vicodin or Percocet, until she can see the on call neurologist.

 

( an ongoing conversation with the neuro groups might be a benefit.. It is AMAZING. How their "hard line " stance changes when you call at 2am with an admission for status migrainous in such a patient)

 

But.. C7 trigger points? I would tread carefully. I am interested in the responses of other PAs.. ...

 

Note, just read the original artical and it's accompanying references. It seems like they are touting this as a remedy for "tension" or "muscle contraction " headaches. They are claiming a 62percent of pts witn headache relief...

 

I am skeptical, but then, Botox works in a certain segment of patients.

 

My sucess with IV cocktails has been phenomenal.. And patients with true migraines want to kiss me afterwards..

 

 

rc

[medic25]

I'm in agreement about the IV cocktails; I've always had great success with them (compazine/toradol/decadron is a favorite). The patient that led to the discussion wasn't even mine; the MD I was working with was talking about her patients list of allergies and it jogged my memory about the article I'd read. I've been pushing for pharmacy to expand our formulary for these types of migraine patients (I'm at a freestanding ED without a separate pharmacy, so if it ain't in the Pyxis, we don't have it. It would be nice to have things like ergotamine, caffeine and valproic acid available, but it's not always an option).

 

Here's the original article I read that demonstrates the actual technique. It sounds like they've had success with all sorts of headaches, from migraines to corneal abrasions.

 

http://www.epmonthly.com/clinical-skills/emrap/how-to-use-paraspinous-injections-for-complex-headaches/

[jmj11]

You can try it if you want as long as you don't try and do an unguided facet joint or deeper injection. I personally haven't found success with these more superficial injections while I do send patient to intervention pain clinics for guided and deeper injections.

 

I actually wrote my masters paper on this argument and quoted from the paper you mentioned plus many others. There is an on-going debate how effective these are and how well the studies were controlled (headache patients have an extremely high response rate to unblinded procedures like this especially when the provider is doing retrospective study to prove it works).

 

I certainly do occipital nerve blocks all the time and other extra-cranial nerve blocks. I just got back from the International Headache Congress and there was a lot of talk about these blocks and how they might work centrally. But I'm very doubtful about the high success rate they quote because if that were reality, the entire headache world would quickly embrace it as standard of care . . . and they have not.

[True Anomaly]

Although I've done trigger-point injections before (into a sternocleidomastoid muscle, no less), I haven't done this- have heard of it before though. I wouldn't have much of a problem doing it, but I'm probably not going to walk into my next shift ready to jump right to it for my next headache patient.

 

I definitely agree with RC in this statement:

It is AMAZING. How their "hard line " stance changes when you call at 2am with an admission for status migrainous in such a patient)

 

Even doing an injection in certain headache patients with ulterior motives may not likely change anything- pain relief is all subjective. I can completely foresee a situation where no matter what I use, whether non-narcotic cocktail or trigger point injection, nothing helps until the nurse comes in with that "D" drug.

 

There's such a laundry list of migraine abortives, and our neurology group is on board with admissions for refractory patients. Those who want relief will get it. Those who don't can simply choose to walk out the door and find someone more willing to give them their drug of choice.

 

I have no doubt jmj has done these before

[MedicinePower]

Two videos from an ER doc on this very topic:

 

 

 

[adubitzky]

I've seen it done. There's no anatomy in the area you could harm. Patient had a refreactory headache. The shot didnt provide any relief btw

[donwinder]

I have done countless extracranial nerve blocks with moderate success. I have some patients come in every 4 or 6 or 12 weeks for repeat blocks and love it. TPI's work great as well. I recommend them all the time to my ED friends. The nerve blocks numb it all away instantly if done right. Patient is happy enough to move along. Jmj11 knows all about the greater occipital nerve stimulator we placed for a patient. Dramatic results.

[SCHMITTIE120]

I have actually done these as a student but not as a PA-C. One of the EM attendings I rotated with loved these and would offer them to a majority of headache patients in the ED (I think he actually just loved doing any sort of procedure). We would usually see about 50 percent success.

[jmj11]

I have done countless extracranial nerve blocks with moderate success. I have some patients come in every 4 or 6 or 12 weeks for repeat blocks and love it. TPI's work great as well. I recommend them all the time to my ED friends. The nerve blocks numb it all away instantly if done right. Patient is happy enough to move along. Jmj11 knows all about the greater occipital nerve stimulator we placed for a patient. Dramatic results.

I've hadn't heard from her yet, although I emailed her today. I hope she is doing well. I have patient 2 lined up. He is Canadian and it will be ricky a he will have to pay cash.