Pericranial Injection of Local Anesthetics for the Management of Resistant Headaches

Transcription

1 1224 BRIEF REPORTS BRIEF REPORTS I Pericranial Injection of Local Anesthetics for the Management of Resistant Headaches Headaches have become an increasingly common cause of ED presentations. In particular, migraine headaches have been reported to be increasing at an alarming rate, with a governmental study reporting a 77% increase in women during the 1980s. Patients presenting to the ED with headaches can be categorized in multiple ways. However, two separate syndromes receive the most attention2: The first or worst syndrome requires diagnostic consideration to rule out potentially life-threatening diseases such as intracranial bleeding, meningitis, and tumors. The second intractable syndrome consists of patients with a history of headache who present after their standard therapy failed to alleviate their symptoms. The majority of the ED patients with headaches belong in the second cate- g~ry.~.~ For this group of patients, the role of the emergency physician (EP) is both reassurance and symptom relief. The lack of consistently effective therapy for these patients is suggested by the varied and long list of therapeutic options, including: ketorolac, metocl~pramide,~ chlorpromazine,6 prochlorpera~ine,~ opiates: intranasal lidocaineg or butorphanol,i0 dihydroergotamine (DHE), and sumatriptan.i2 Despite the very wide range of treatment options, only two-thirds of patients have been reported to obtain complete or significant relief of symptoms in response to ED therapy.13 Even with effective initial treatment, headache relapses are common, and up to 67% of patients experience return of symptoms on hour follow-~p.~~~~~ A relatively small subset of patients with particularly resistant headaches generally account for this high failure rate; Salamone et al. reported that 11% of patients with migraine-like symptoms accounted for 43% of ED visit~.*~ There have been isolated reports of pericranial injection of local anesthetics as effective treatment for headaches resistant to conventional therapies. Successful injection ther- apy has been described for migraine,lb tension headache, cluster heada~he,~~.~~ cervicogenic headache,2o and neurotic headache.21 However, these have generally been isolated reports and have received little attention. As a result, the use and understanding of this alternative form of treatment by the medical community have been limited. To our knowledge, there has been no report of pericranial injection therapy (PIT) in the emergency medicine (EM) literature. A comprehensive EM procedural text mentions the use of myofascial trigger point injection for treatment of headaches, but it does not discuss indications and how patients or injection sites are selected.22 EPs treat patients with some of the most severe and resistant headache symptoms. Current therapeutic options are not consistently effective in these patients. We report a case series of patients in whom we found PIT to be an effective treatment for recurrent headache resistant to standard pharmacologic therapy. METHODS Study Design. Prospective case series. Population. Adult patients with highly resistant recurrent headaches. Setting. University hospital emergency department. Intervention. Pericranial injection of local anesthetics. The procedure involves steps: 1) identifying the correct site for injection and 2) performing the injection. Examination of the Head. Careful palpation of the patient s head and neck was performed using a firm circular pressure with the tip of the index or middle fingers. Particular attention was paid to the suboccipital and the anterior temporal areas (Fig. 1). When examining the suboc- I cipital area, anterior pressure was first applied to the general area where the greater occipital nerve penetrates the semispinalis capitis muscle (area B on Fig. 1). This area is located approximately two finger breadths inferior to the superior nuchal line and one to two finger breadths lateral to the occipital protuberance (area A). After first pressing directly onto this area, pressure was then applied in a more superior direction to compress the tissue against the horizontal portion of the occipital bone. Palpation was continued laterally until the posterior aspect of the mastoid bone was reached (area C). The anterior temporal area was examined by first identifying the applying pressure to a slight depression just posterior to the lateral orbital rim and superior to the zygomatic arch (area D). Pressure was then applied against the anterior fibers of the temporalis muscle before walking posteriorly across the temporal muscle along the zygomatic arch. Appropriate sites for injection of local anesthetics were identified when focal pressure reproduced or increased the patient s headache symptoms. A focal area that was simply tender, but where palpation did not augment the headache symptoms, was not considered an appropriate site for injection. Injection Technique. A mixture of 2% lidocaine and 0.25% bupivacaine was buffered using 140th volume of 8% sodium bicarbonate. This was drawn up in a 5-mL syringe. A #27-gauge needle was inserted through the area of maximal tenderness until making contact with the cranium. To make contact with the inferior portion of the occipital bone, which is almost horizontal, the needle must be directed degrees superiorly. Once contact with the periosteum was made, continuous pressure was applied on the syringe and each focally tender area was fanned with the 1-5 ml of local anesthetic mixture by moving the needle in multiple directions, in and out of the tender area. We did not aspirate before injecting. This was followed by at least 30 seconds of continuous massaging pressure to the area. A site was considered adequately anesthetized when the area

2 ACADEMIC EMERGENCY MEDICINE December Volume 5, Number was no longer tender and focal palpation no longer reproduced the headache symptoms. A maximum of 10 ml of anesthetic mixture was injected per patient. On discharge the patients were informed that the local injection sites might be tender and were instructed to stretch and massage the injected tissue. RESULTS Prospective data were collected for six patients with particularly intractable headaches who were treated with PIT in the ED. Each patient was followed up by phone or clinic visit within two weeks of PIT. The main features of each case are summarized individually below and in Table 1. Case 1. A 31-year-old woman with a history of migraine represented to the ED with severe leftsided retro-orbital pain, photophobia, and nausea with vomiting. Prior treatments with IM sumatriptan and prochlorperazine resulted in only partial relief. None of the patient s outpatient medications reliably worked. The patient was vomiting in the ED and using a towel to cover her face. She had exquisite tenderness over the left medial suboccipital area, which exacerbated her symptoms (area B, in Fig. 1). Two minutes after injection of 5 ml of local anesthetic into this site, all symptoms resolved. At 48-hour follow-up, the patient had returned to work and remained free of all her symptoms. Case 2. A 67-year-old woman with new and gradual-onset occipital headache, photophobia, and tinnitus presented for her third ED visit. Previous treatments with 30 mg of IV ketorolac and 75 mg of IM meperidine only partially and temporarily relieved her symptoms. Outpatient medications were ineffective. The patient s symptoms were reproduced by palpation of the medial bilateral suboccipital area (areas B, and B,) and along the right lateral aspect of the nuchal line (area C,). PIT of these areas resolved the headache, the photophobia, and the tinnitus in the right ear. The patient continued to be free of symptoms on follow-up two weeks Fiaure 1. Anatomic locations of pericranial injection therapy. Letters correspond to Table 1 s sites of injection; subscript L refers to the left side, and subscript R refers to the right side. later and has returned to normal daily activities. Case 3. A 59-year-old man with two and a half years of recurrent headaches presented with worsening right frontalltemporal headache and photophobia of three weeks duration. Multiple prior medications had been ineffective. Symptoms were reproduced by palpation of the anterior right temporalis muscle, just superior to the zygomatic arch (area DR). Injection of 3 ml of anesthetic mixture into this area, depositing some around both the deep temporal (close to the skull) and the zygomaticotemporal nerves (subcutaneously) resolved 90% of the patient s symptoms. At 24-hour followup he was without a headache but did mention local soreness at the injection site. Overall, he was pleased with the treatment. Case 4. A 44-year-old woman presented for her third ED visit since the onset of increasing right-sided occipital head pain with blurred vision and nausea. Previously prescribed medications did not resolve her symptoms. Symptoms were reproduced from a very tender central suboccipital area, greatest on the right (areas B, and B,). Injection of 4 ml of anesthetic into each area resolved all her symptoms. On a twoweek follow-up, she was without headache symptoms. Case 5. A 50-year-old woman with history of severe chronic head- aches presented with 35 days of constant holocephalic pain and recurrent photophobia, nausea, and vomiting. During this episode of headache she had been seen 25 times at various EDs and urgent care centers. Outpatient medications were all ineffective. She was given 60 mg of IM ketorolac and 10 mg of oral diazepam at another ED the same day without symptom relief. She was vomiting, complaining of severe retro-orbital pain and light sensitivity. She requested a shot of meperidine (Demerol) as the only thing that helps. Examination revealed bi-occipital tenderness (areas B, and B,) with exacerbation of symptoms. PIT to these areas resolved the patient s occipital and retro-orbital pain; however, milder headache symptoms could be reproduced from the bilateral temporal areas (areas D, and D,). Her remaining symptoms resolved after PIT to these areas. The patient then spontaneously stated, This is the first time in years that I have been completely free of pain. On followup the next day she had returned to normal daily activities and was very pleased with the treatment. She reported local soreness at the injection sites and only a mild headache without symptoms of nausea or photophobia. Case 6. A 31-year-old man with a history of intermittent migraine/ cluster-type headaches presented for his 13th ED visit in one month. His severe left-sided frontal headache

3 1226 BRIEF REPORTS BRIEF REPORTS was associated with photophobia, nausea, and left-sided rhinorrhea. Prior ED medications only partially and temporarily relieved his symptoms. The patient brought a large bag of ineffective medications that had been prescribed (Table 1). He held a wet towel over his left temple and requested a shot of meperidine (Demerol). On examination, the anterior aspect of the left temporalis muscle was exquisitely tender to palpation, which exacerbated the patient s headache symptoms (area DL). Partial symptoms also could be reproduced closer to his ear (area EL). Injection of 7 ml of anesthetic mixture was directed at three areas: the deep temporal nerve close to the periosteum, the superficial fascia of the temporalis muscle (area D, deep and superficial), and the area of the auriculotemporal nerves (area EL). All symptoms resolved within 1 minute and the patient dropped all requests for meperidine. On follow-up his headache remained well controlled on amitriptyline 50 mg/day and prn ibuprofen. DISCUSSION Effective evaluation and treatment of headaches are an important function of the EP. Because patients generally do not visit the ED for their normal headaches, they are more likely to present with their worst or most difficult kind of headache. When indicated, EPs must consider and rule out a serious source of their patients headache symptoms. However, in the vast majority of these cases the diagnostic studies are normal and the patients are considered to have benign primary headache~.~.~.~~ A relatively small subset of these patients have headaches that are resistant to standard medical management, which can result in repeat visits to the ED.I3 Management of this group of patients can be particularly frustrating for both patients and the EP who may think there is little to offer after standard medication has failed. We report a series of patients with highly resistant headaches who obtained symptomatic relief with PIT. Two-thirds experienced complete and persistent relief. This degree of treatment success is noteworthy given the recurrent, severe, and resistant nature of their symp-

4 ACADEMIC EMERGENCY MEDICINE December 1998, Volume 5, Number 12 toms. One-third of the patients obtained complete initial relief but experienced some recurrence of symptoms. Even in those cases, the recurrent symptoms were less intense and the patients were happy with their treatment. These results should be considered in the context of data showing that more than twothirds of ED headache patients have symptom recurrence regardless of treatment used.is We believe that PIT is an effective treatment option for a subset of patients with particularly resistant headaches. In some regards, our findings are similar to reports of injection therapy from other settings. However, it is difficult to directly compare our findings with previous reports for several reasons. First, it appears that our patients experienced greater severity of head pain and associated symptoms than did those in the other reports. Second, we report experience with injections performed at a single visit, whereas others reported the response to mul- D are the most frequently used actiple treatment~.~~j~~~~~~l Third, our upuncture sites for treatment of injection technique may be signifi- headaches.21 cantly different from that used by Interestingly, several of our paothers. Other articles reporting ben- tients experienced relief of pain eficial effect with local anesthetic in- symptoms relatively remote from jections generally describe anesthe- the site of injection. For example, tizing superficial nerves such as the some experienced resolution of foresupra-orbital and occipital nerves.16-*0 head pain in response to local anes- However, in our experience, a simple thetic injection into the suboccipital nerve block may cause localized area. Though this may be surprisnumbness, but not effective relief of ing, prior work has demonstrated headache symptoms. We have ob- that pain originating in the upper served that with local nerve blocks neck can be referred to the forehead. the tissue proximal and deep to the Specifically, nociceptive stimulation nerve often remains tender, and lo- of the suboccipital area has been cal pressure at the site is still capa- shown to result in pain symptoms in ble of reproducing the headache the orbit and frontal region^.^^.^^ symptoms. We have found that there This kind of referred pain also has is more complete relief when suffi- been reported to be blocked by injeccient anesthetics are injected to ren- tion of local anesthetics into the subder the entire local area anesthetic. occipital a~ea.2~ It is postulated that Therefore, our injection technique may be more than a simple superficial nerve block. It also may interrupt nociceptive signals originating from underlying structures, such as blood vessels and myofascia. In this regard our technique is more similar to trigger point inje~tion. ~.~~ We believe this may be an important difference from previous reports of injection treatment for headaches and may help explain the success observed in our patients with the most intractable symptoms. Most articles and textbook chapters on the ED evaluation of headaches include little discussion of ex- amining the head However, to use PIT, a careful examination of the head and neck, together with understanding of the local anatomy, is important. Even though we examined the whole head and the upper neck in our patients, we found that headache symptoms could be reproduced from only two general anatomic sites: the temporal and the suboccipital areas. Therefore, all injections of local anesthetics were performed at these sites. Slightly more of the injections (seven of 12) were placed in the suboccipital areas (Fig. 1). These sites are similar to the injection sites sometimes recommended for trigger point therapy for headache^.'^,^^ Both the temporal and the suboccipital locations have long been shown to participate in both tension and migraine type headaches.26 In addition, in traditional Chinese medicine, sites B and this referred pain is due to nociceptive impulses originating from the upper neck that converge onto the sensory nucleus of the trigeminal nerve (nucleus caudalis), which is continuous with the upper cervical dorsal h0rn.3~,~~ Another interesting observation is that after PIT treatment, our patients experienced resolution of their other associated symptoms such as nausea, photophobia, and visual and auditory changes. This can perhaps be explained by two separate exper iments performed more than 50 years ago. In 1944 Campbell and Parson demonstrated that injecting hypertonic saline (a tissue irritant) into the suboccipital area (area B) in human volunteers resulted in retroorbital pain, nausea, and visual and balance disturbance^.^^ In a separate study by Ray and Wolff, nociceptive stimulation of the exposed superficial temporal artery (area D) resulted in spreading headache pain that was associated with nausea and visual disturbances. They demonstrated that all of these symptoms could be blocked by local anesthet- i c ~ Therefore,. ~ ~ it is likely that the resolution of our patients associated symptoms was also due to interrupting nociceptive signals originating in the temporal and the suboccipital areas. We did not observe any complications associated with our technique of injection (PIT). However, since the anesthetic mixture is being injected in the anatomic locations of the superficial temporal and the occipital arteries, a local hematoma is possible. To decrease the likelihood of this, we apply firm constant pressure for a minimum of 30 seconds after injection. This should probably be maintained longer if local swelling is observed after PIT. Intravascular injection is also possible. However, since the technique involves using only a #27-gauge needle that is continuously moved, the amount of local anesthetic that would be injected intravascularly would likely be quite small. For that reason, we do not advocate aspirating before injection. Although PIT could potentially result in infection or trauma to the pericranial nerves, we are unaware of either of these complications in our group of patients. However, not all of our patients were examined or specifically followed up for these possibilities. The evaluation and treatment of difficult headache patients, many of whom return to the ED with persistent symptoms, can he a frustrating experience for both the EP and the patient. It is tempting to consider the patient s request for opioids as a sign of drug-seeking behavior. However, it is likely that for some of these patients, high-dose opioids may have been one of the few, or only, treatments that have

5 1228 BRIEF REPORTS BRIEF REPORTS reliably provided at least temporary relief. We were impressed by the fact that all of our patients who initially requested meperidine were fully satisfied when PIT alone relieved their symptoms. They then dropped all requests for opioids. Most of our patients had a history of migraines and presented to the ED with a symptom complex generally consistent with a diagnosis of migraine. However, none of them strictly fit the International Headache Classification Committee (IHCC) criterion for migraine, since their symptoms persisted longer than 72 hours.34 They also do not fit the category of chronic tension headache, because their symptoms were both too severe (vomiting, or both nausea and photophobia) and aggravated by routine physical activity. In many ways our patients best fit into what is called category 11, headache or facial pain associated with disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, and other facial or cranial ~tructures. ~~ As a result, we are in agreement with Thomas and Stone, who state that attempting to classify ED patients with headaches according to the IHCC criterion is of- ten ~nrewarding.~~ This raises the question of the need for a new category or system of headache classification for the ED setting. LIMITATIONS AND FUTURE QUESTIONS Though prospective, this is a simple case series report. It does not represent a consecutive series of headache patients. Whether the same results could be obtained by other physicians, in other settings, or in other headache patients is not clear. It is possible that side effects and complications with PIT also would become apparent with further use. Even in the subset of patients with highly resistant headaches, it is unclear whether PIT is any more effective than other therapies. This was not a comparative study. However, all of these patients had already recently received multiple headache therapies that are considered common, acceptable, or even standard, without adequate relief. They did experience improvement with PIT. Therefore, it appears that PIT warrants further investigations as a potential therapeutic option for ED treatment of resistant or otherwise problematic headaches. CONCLUSION In this prospective case series of ED patients with highly resistant headache symptoms, pericranial injection therapy with local anesthetics provided relief after failure of common pharmacologic treatments. Resolution of other associated headache symptoms in addition to the pain also was observed after PIT. No complications of PIT were observed. PIT may represent an additional therapeutic option for a subset of ED patients with difficult headaches and warrants further investigation. - Bo T o w BROFELDT, MD (deceased), and EDWARD A. PANACEK, MD, Division of Emergency Medicine, UC Davis Medical Center, Sacramento, CA References 1. CDC study: prevalence of chronic migraine headaches-united States, MMWR. 1990; 40: Edmeads J. Emergency management of headaches. Headache. 1988; 28: Diamond ML. Emergency department treatment of the headache patient. Headache Q. 1992; 3(suppl 1): Davis CP. Torre PR, Williams C, et al. Ketorolac versus meperidine-plus-promethazine treatment of migraine headache: evaluations by patients. Am J Emerg Med. 1995; 13: Ellis GL, Delaney J, DeHart DA, et al. The efficacy of metoclopramide in the treatment of migraine headache. Ann Emerg Med. 1993; 22: Bell R, Monotoya D, Shuaib A, et al. A comparative trial of three agents in the treatment of acute migraine headache. Ann Emerg Med. 1990; 19: Jones EB, Gonzalez ER, Boggs JG, et al. Safety and efficacy of rectal prochlorperazine for the treatment of migraine in the emergency department. Ann Emerg Med. 1994; 24: Carleton S, Shesser R, Pietrzak M, et al. Double-blind comparison of dihydroergotamine with hydroergotamine with hydroxyzine versus meperidine with hydroxyzine for the emergency department treatment of acute migraine headache [abstract]. Ann Emerg Med. 1993; 22: Maizels M, Scott B, Cohen W, Chen W. Intranasal lidocaine for treatment of migraine: a randomized double-blind controlled trial. JAMA. 1996; 276: Elenbass RM, Iacono CU, Koellner KJ, et al. Dose effectiveness and safety of butorphanol in acute migraine headache. Pharmacotherapy. 1991; 11: Klapper JA, Stanton JS. Ketorolac versus DHE and metoclopramide in the treatment of migraine headaches. Headache. 1991; Akpunonu BE, Mutgi AB, Federman DJ, et al. Subcutaneous sumstriptan for treatment of acute migraine in patients admitted to the emergency department: a multicenter study. Ann Emerg Med. 1995; 26: Salomone JA, Thomas RW, Watson WA. An evaluation of the role of the ED in the management of migraine headaches. Am J Emerg Med. 1994; 12: McEwen JI, O Connor HM, Dinsdale HB. Treatment or migraine with intramuscular chlorpromazine. Ann Emerg Med. 1987; 16: Bell R, Montoya D, Shuaib A, et al. A comparative trial of three agents in the treatment of acute headache. Ann Emerg Med. 1990; 19: Caputi CA, Firetto V. Therapeutic blockade of greater occipital and supraorbital nerves in migraine patients. Headache 1997; 37(3): Sola AE. Myofascial trigger point therapy. Resident & Staff Physician. 1981; 8: Anthony M. Headache and the greater occipital nerve. Clin Neurol. Neurosurg. 1992; 94: Antonaci F, Pareja JA, Caminero AB, Sjaastad 0. Chronic paroxysmal hemicrania and hemicrania continua: anaesthetic blockades of pericranial nerves. Funct Neurol. 1997; 12(1): Gawel MJ, Rothbart PJ. Occipital nerve block in the management of head- ache and cervical pain. Cephalalgia ; 2: Shuqin W, Wei W, Lingzhi L. Treating neurotic headache by point-injection wsh Novocain. J Tradit Chin Med: 1990; 10: Sola AE, Anders E. Trigger point therapy. In: Roberts JR, Hedges JR (eds). Clinical Procedures in Emergency Medicine 2nd ed. Philadelphia: W. B. Saunders, 1991, pp Thomas SH, Stone CK. Emergency department treatment of migraine, tension, and mixed-type headache. J Emerg Med. 1994; 12: Travel1 J. Myofascial trigger points: In: Bonica JJ, Albe-Fessard DG (eds). Advances in Pain Research and Therapy, Vol. 1. New York: Raven Press, American College of Emergency Physicians. Clinical policy for the initial approach to adolescents and adults presenting to the emergency department with a chief complaint of headache. Ann Emerg Med. 1996; 27: Wolff HG. Headache and cranial arteries. Trans Assoc Am Physicians. 1938; 53~ Hunter CR, Mayfield FH. Role of the upper cervical roots in the production of pain in the head. Am J Surg. 1949; 78: Bogduk N. Greater occipital neuralgia. In: Long DM (ed). Current Therapy in Neurological Surgery. Toronto: B. C.

6 ACADEMIC EMERGENCY MEDICINE December Volume 5, Number Decker, 1985, pp Ellis BD. Kosmorsky GS. Referred ocular pain relieved by suboccipital injection. Headache. 1995; 35:lOl Sessle BJ. The neurobiology of facial and dental pain: present knowledge, future directions. J Dent Res. 1987; 66: Kerr FWL. A mechanism to account for frontal headache in cases of posterior fossa tumors. J Neurosurg. 1961; 18: Campbell DG, Parson CM. Referred head pain and its concomitants: report of preliminary experimental investigation with implications on post-traumatic head syndrome. J Nerv Ment Dis. 1944; 99: Ray BS. Wolff HG. Experimental studies on headache. Arch Surg. 1940; 41~ Headache Classification Committee of the International Headache Society. Classification and Diagnostic Criteria for Headache Disorders, Cranial Neuralgias and Facial Pain. Copenhagen: Norwegian University Press, 1988, p 19. IN M MORIAM Bo Toms BROFELDT, MD Only days after submitting the manuscript describing his innovative injection therapy for the management of headaches, Dr. Bo Tomas Brofeldt tragically died. He suffered sudden cardiac death after playing tennis with one of our emergency medicine residents. Resuscitative efforts were continued at the very emergency department where he served as a faculty attending. He died later that evening. Tomas was a very beloved physician by the residents, emergency department staff, and throughout the entire hospital. His death had a profound effect on us all. Tomas was renowned for his creativity and intellectual curiosity. He enthusiastically pursued innovative approaches, even when they were relatively unpopular. Unfortunately, only recently have some of his innovative ideas received full attention. One example is the pericranial injection therapy technique for resistant headaches, described in the preceding article. In addition, he was the first to develop the rapid four-step cricothyrotomy technique first published in Academic Emergency Medicine in Many have now come to calling that technique the Brofeldt technique of cricothyrotomy. Tomas also developed a unique burn cream that contained local anesthetics and was designed to help treat the pain of the burn, while also decreasing infection and promoting healing. Because of his Swedish background, this cream continues to be called the Swedish burn cream at UC Davis Medical Center. On behalf of my colleagues at UC Davis, we very much miss our beloved and admired colleague Bo Tomas Brofeldt. I also believe that the speciality of emergency medicine has lost one of its most creative and innovative academicians. Hopefully his enthusiasm and unique approach to problem solving will continue to serve as an inspiration to us in the future. EDWARD A. PANACEK, MD