Nerve Block: Occipital

Background

Posterior primary divisions of the upper three cervical nerves. (Great occipital nerve labeled at center top.)
Lateral view (greater occipital nerve posterior)
  • Therapeutic and diagnostic for occipital neuralgia
  • Nerve is between ~8-18 mm deep[1]

Indications

  • Suspected or confirmed occipital neuralgia
  • Migraine refractory to conservative treatment
  • Post-lumbar puncture headache refractory to conservative treatment
  • Cluster headache, occipital neuralgia, cervicogenic headache, or migraine with occipital nerve irritation or tenderness [2]

Contraindications

  • Infection overlying injection site

Equipment Needed

  • PPE
  • Syringe and 27-30ga needle
  • Betadine or chlorhexidine
  • Local anesthetic
    • 40mg of methylprednisolone or triamcinolone may be mixed with the local anesthetic[3], but efficacy has not been proven.

Procedure

  • Patient in position of comfort allowing access to posterior head and neck. (laying prone or sitting with head down in arms)
  • Identify Greater Occipital Nerve (GON).
    • May be palpated 1.5-2.5 cm inferior to occipital protuberance and ~1.5-2 cm lateral to midline[4]
    • Alternatively, may be ultrasound guided - look for occipital artery in medial third of the line from occipital tubercle to mastoid process[5]
      • GON will be located medial to artery.
  • Cleanse skin with betadine or chlorhexidine and allow to dry
  • Insert needle over nerve at 90 degrees to skin until hit bone, then withdraw slightly[6]
    • If using ultrasound, insert needle at 45 degrees to skin and advance toward nerve under direct ultrasound guidance
  • Aspirate to ensure not in vessel.
  • Inject ~1-3 mL of local anesthetic. (may inject small amount medial and lateral to nerve to ensure adequate block)[3]
  • Repeat on contralateral side, if indicated.

Maximum Doses of Anesthetic Agents

Agent Without Epinephrine With Epinephrine Duration Notes
Lidocaine 5 mg/kg (max 300mg) 7 mg/kg (max 500mg) 30-90 min
  • 1% soln contains 10 mg/ml
  • 2% soln contains 20 mg/ml
Mepivicaine 7 mg/kg 8 mg/kg
Bupivicaine 2.5 mg/kg (max 175mg) 3 mg/kg (max 225mg) 6-8 hr
  • 0.5% soln contains 5 mg/ml
  • May cause cardiac arrest if injected intravascularly
  • Do not buffer with bicarbonate
Ropivacaine 3 mg/kg
Prilocaine 6 mg/kg
Tetracaine 1 mg/kg 1.5 mg/kg 3hrs (10hrs with epi)
Procaine 7 mg/kg 10 mg/kg 30min (90min with epi)

Complications

Complications are rare due to superficial location and lack of major surrounding structures.[3]

  • Damage to surrounding structures
  • Bleeding
  • Infection

Follow-up

  • Follow up with appropriate specialist for the indication for nerve block.

See Also

External Links

Videos


References

  1. M. Greher, B. Moriggl, M. Curatolo, L. Kirchmair and U. Eichenberger. Sonographic visualization and ultrasound-guided blockade of the greater occipital nerve: a comparison of two selective techniques confirmed by anatomical dissection. Br. J. Anaesth. (2010) 104 (5): 637-642.
  2. https://www.nuemblog.com/blog/occipital-nerve-block
  3. 3.0 3.1 3.2 Brock G. The occasional greater occipital nerve block. Can J Rural Med. 2014 Fall;19(4):152-5.
  4. Dach F, Éckeli ÁL, Ferreira Kdos S, Speciali JG. Nerve block for the treatment of headaches and cranial neuralgias - a practical approach. Headache. 2015 Feb;55 Suppl 1:59-71.
  5. Palamar D, Uluduz D, Saip S, et al. Ultrasound-guided greater occipital nerve block: an efficient technique in chronic refractory migraine without aura? Pain Physician. 2015 Mar-Apr;18(2):153-62.
  6. Inan LE, Inan N, Karadaş Ö, et al. Greater occipital nerve blockade for the treatment of chronic migraine: a randomized, multicenter, double-blind, and placebo-controlled study. Acta Neurol Scand. 2015 Mar 13. doi: 10.1111/ane.12393