Occipital Nerve Blocks: When and What to Inject?

Joshua Tobin, MD; Stephen Flitman, MD


Headache. 2009;49(10):1521-1533. 

In This Article

Abstract and Introduction


Introduction.—Occipital nerve block (ONB) is a promising treatment for headaches. Its indications, selection criteria, and best techniques are not clear, however.
Objective.—To summarize in narrative format what is known about ONBs and what needs to be learned.
Methods.—MD Consult and Google Scholar were searched using the terms occipital, suboccipital, block, and injection to identify relevant articles that were reviewed. This process was repeated for all additional pertinent articles identified from these articles, and so on, until no additional articles were identified.
Results.—A total of 21 articles were identified.
Conclusions.—Occipital nerve block is an effective treatment for cervicogenic headache, cluster headache, and occipital neuralgia. While a double blinded randomized placebo controlled clinical trial is lacking, multiple open label studies reported favorable results for migraine. Two other possible uses of ONB worthy of further study are use as a rescue treatment and as an adjunctive treatment for medication overuse headache. ONB may be effective for tension headache, but only under very specific circumstances. ONB is either ineffective or only effective under as yet unstudied circumstances for hemicrania continua and chronic paroxysmal hemicrania. Some practitioners use occipital nerve (ON) tenderness to palpation (TTP) or reproduction of headache pain with ON pressure (RHPONP) as selection criteria for identifying appropriate patients. While only a clinical trial can produce a definitive answer, current evidence suggests that these selection criteria are not necessary for cervicogenic headache or cluster headache. Occipital neuralgia by definition involves TTP of the ONs. Whether RHPONP or ON TTP predicts success in migraine is unclear, and may relate to whether steroids are used. A single blinded randomized controlled trial evaluating local anesthetic with steroids vs local anesthetic alone for transformed migraine reported slightly worse results with steroids, but there are several alternate explanations for this finding other than steroids being counterproductive. The technique of repetitive ONBs deserves further study.


The purpose of this narrative review is to summarize what is known about occipital nerve blocks (ONBs) and what needs to be learned. In particular, the Table summarizes the published case reviews and clinical trials evaluating ONB for various headache disorders. As there is no standard procedure for performing an ONB,[1] and only rudimentary algorithms for selecting appropriate candidates, we compare and contrast published results for different headache disorders, different selection criteria, and different medications used. We propose several possible future indications. We compare results obtained when pressure on an occipital nerve reproduces a patient's headache pain (RHPONP) vs when occipital nerve (ON) tenderness to palpation (TTP) is present vs when neither is used as selection criteria. Whether steroids should be used depends on how one interprets available data. A technique with the potential to produce especially long lasting effects is performing repetitive ONBs without steroid.


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