For Headache--Peripheral Nerve Block, Steroids, or Both?

A Poster Brief

Bret S. Stetka, MD


April 27, 2017

Peripheral nerve blocks (PNBs) have been used for decades to treat various forms of headache, but only recently have clinical experience and data been reported on in the literature. While on site at the 2017 American Academy of Neurology Annual Meeting, Medscape interviewed Matthew S. Robbins, MD, associate professor of clinical neurology at Albert Einstein College of Medicine, and director of inpatient services at the Montefiore Headache Center. We spoke about his two new studies exploring the use of PNBs in older patients suffering from headache disorders.

Matthew S. Robbins, MD

Medscape: In what types of headaches have PNBs been shown to be most effective?

Dr Robbins: PNBs have been shown to be effective for a variety of headache disorders, but the highest-quality and perhaps clearest evidence is for the short-term preventive treatment of cluster headache, with single or repeated unilateral occipital nerve injections with a corticosteroid.

Medscape: What was the goal of your new PNB research?

Dr. Robbins: In the first study,[1] we reported our experience with PNBs in patients age 65 years or older, who often have contraindications to many therapies for headache disorders and also take more medications in general, raising concern for drug interactions and polypharmacy. Therefore, PNBs are an appealing therapy to use in this demographic as a potentially safe and effective treatment option.

In the second study,[2] we studied short-term preventive treatments in patients seen at our center with cluster headache, which mainly compared a course of oral steroid versus a single occipital nerve injection with a steroid. These are the two main treatments used as "bridge" treatments, which work rapidly to suppress a cluster headache attack period while a longer-term preventive therapy is initiated and titrated.

Medscape: What did you find? And how might clinicians incorporate your findings into practice?

Dr. Robbins: In the first study, PNBs for older patients seemed to be an effective, well-tolerated treatment option for a variety of headache disorders. The study also demonstrated that patients with headache disorders who are older often have a lot of comorbidities and take numerous medications, including those that are on the Beers list of potentially inappropriate medications prescribed to older adults—medications that can place these patients at risk for falls, cognitive impairment, and other side effects.

In the second study, patients with cluster headache seemed to fare well when treated with either oral steroids or an occipital injection with steroid, but those on oral steroids seemed on the whole to do better. However, it was not a randomized clinical trial and it may be that the occipital nerve injection with steroid is a safer therapy in many patients, so both seem to be good choices. In fact, in the latest American Headache Society cluster headache treatment guidelines, an occipital nerve injection with steroid was given a Level A recommendation.

Medscape: Where are PNBs typically placed in the treatment algorithms for various headache disorders?

Dr Robbins: This is very individualized and it depends on the type and severity of the headache disorder being treated. In addition, nerve blocks are generally used for two purposes. The first approach, which is better studied, is to use PNBs as a short-term preventive treatment strategy. The second approach is to use PNBs as a treatment for an incessant particular headache attack that is not responding to other therapies. In migraine, for example, when a single attack lasts more than 72 hours, we call this status migrainosus, and PNBs may be used in such a circumstance.

Follow Bret Stetka on Twitter: @BretStetka
And for more Neurology news: @MedscapeNeuro


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