Treatment of disabling headache with greater occipital nerve injections in a large population of childhood and adolescent patients: a service evaluation

DOI: https://doi.org/10.1186/s10194-018-0835-5

Abstract-Summary Evidenced-based options for the treatment of primary headache disorders with pre- ventive medication is limited and clinical outcomes are often unsatisfactory.

Greater occipital nerve injections represent a rapid and well-tolerated therapeutic option, which is widely used in clinical practice in adults, and has previously shown a good outcome in a pediatric population.

This service evaluation reviewed greater occipital nerve injections performed unilaterally with 30 mg 1% lidocaine and 40 mg methylprednisolone, to treat dis- abling headache disorders in children and adolescents.

Of the population, 79% had chronic migraine, 14% new daily persistent head- ache, 4% a trigeminal autonomic cephalalgia, 3% secondary headache and one patient had chronic tension-type headache.

Improvement was seen in 68% of patients with chronic migraine, 67% with a

trigeminal autonomic cephalalgia and 59% with new daily persistent headache.

This large single centre service evaluation confirms that unilateral injection of the greater occipital nerve is a safe, rapid-onset and effective treatment strategy in disabling headache disorders in children, with a range of diagnoses and severity of the condition, and with minimal side effects.

Extended: Greater occipital nerve (GON) injections have shown to provide a quick onset of therapeutic response, which is also sustained [637], while avoiding the common side effects of classic migraine preventives or more invasive treat- ments [638].

Greater occipital nerve injections are a safe, effective and useful strategy for

disabling primary headache disorders in children.

Improvement was seen in 68% of the chronic migraine population (n = 85) and

59% (n = 13) in the NDPH subgroup.

A binary logistic regression analysis was performed in order to determine the effect of several predictor variables on the dichotomous primary outcome measure of improvement.

Research should focus on performing large randomized controlled studies in

paediatric subjects to establish how objectively effective this approach may be.

4.9 Childhood and Adolescent

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Background Headache disorders with high frequency of attacks in children and adolescents can be extremely disabling.

Infiltration of the area around the greater occipital nerve with a mixture of local anesthetic and corticosteroids is a well-established therapy for primary headache prevention in adults [639, 640] that has been recently reported in children to have excellent results [641].

The mechanism of action is linked to the anatomical overlap between spinal afferents providing sensory innervation from the C2 occipital region and trigeminal afferents at the trigeminocervical complex, a complex brain area involved in the pathophysiology of primary headache disorders [67].

Our objective was to determine the efficacy and safety of greater occipital nerve

injections in a large population of paediatric headache patients.

Methods A retrospective chart review was performed on all letters and clinical correspon- dence for patients who received a greater occipital nerve injection between 2009 and 2016.

For each patient who received a GON injection, information on age (measured as a continuous variable), gender, headache diagnosis, date of first visit, time from first visit to injection, site of injection, past and current medication, effects of injection and eventual follow-up treatment was collected using a standardized pro forma.

The clinician palpated over the greater occipital nerves and injected the side that

was most tender.

The primary outcome of ‘improvement’ from the injection was defined as either a significant, more than one third, decrease in headache frequency or intensity or by a documented headache improvement in the clinical notes.

A binary logistic regression analysis was performed in order to determine the effect of several predictor variables on the dichotomous primary outcome measure of improvement.

Results Of these, 159 patients with follow-up, 79% (n = 126) had chronic migraine, 15% (n = 24) with aura, 14% (n = 22) new daily persistent headache (NDPH), 4% (n = 6) a trigeminal autonomic cephalalgia (TAC), 3% (n = 4) a form of secondary headache and one patient had chronic tension-type headache.

Of patients who had subsequent injections n = 15 were headache free and n = 67

had a general benefit after treatment.

A binary logistic regression model was created in order to examine the effect of age, gender, medication overuse, headache diagnosis and frequency, years of dis- ease, number of past preventives used and presence of side effects, on the primary outcome measure of improvement for the first GON injection.

No specific variable was responsible for significantly predicting a positive out- come, although a diagnosis of migraine and a trigeminal autonomic cephalalgia increased the odds of having an improvement from the injection by 4 and 3 times, respectively.

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4 Treatment

Discussion Our study found no significant difference with regards to response to treatment in different headache phenotypes, even if we observed an increased likelihood of response in migraineurs and patients with TACs.

Conditions normally associated with a more severe clinical picture, such as an increased number of headache preventive medications used in the past and a diag- nosis of medication overuse, not only did not predict a poorer response to treatment but on the contrary were linked with a higher likelihood of improvement.

It is therefore possible to infer that greater occipital nerve injections are a valid therapeutic approach even in refractory headache patients who would normally be bound to fail normal preventives [642] patients should also be informed that side effects are not to be considered as a marker of poor outcome.

It is worth noting this is a relatively invasive procedure and the proportion of patients showing a placebo response in headache studies is well estab- lished [643].

Conclusions Greater occipital nerve injections are a safe, effective and useful strategy for dis- abling primary headache disorders in children.

Presence of side effects and refractory headache does not predict poor treatment

outcome.

In the clinical approach to the treatment of chronic primary headache disorders in a paediatric setting, GON injections should be considered as first line manage- ment alongside the classic medications, which are often more side-effect prone.

Acknowledgement A machine generated summary based on the work of Puledda, Francesca; Goadsby, Peter J.; Prabhakar, Prab. 2018 in The Journal of Headache and Pain.

Paracetamol versus Ibuprofen for the Acute Treatment of Migraine Headache in Children: A Blinded Randomized Controlled Trial