C 2 / C 3 N E RVE BLOCKS AND GREATER OCCIPITAL NERVE BLOCK IN CERV I C O G E N I C HEADACHE TREATMENT

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1 C 2 / C 3 N E RVE BLOCKS AND GREATER OCCIPITAL NERVE BLOCK IN CERV I C O G E N I C HEADACHE TREATMENT N u rten Inan, Aysegul Ceyhan, Levent Inan*, Ozlem Kavaklioglu, Alp Alptekin, Nurten Unal Ministry of Health, Department of Anaesthesiology, Ankara Training and Research Hospital; *Ministry of Health, Department of Neurology, Ankara Training and Research Hospital, Turkey Reprint requests to: Dr Nurten Inan, Esat Caddesi 60/3, Küçükesat 06660, Ankara, Turkey nurteninan@yahoo.com In the diagnosis of cervicogenic headache, greater occipital (GON), cervical, minor occipital, and cervical facet joint blocks are used. In our study we compared the GON and C 2 /C 3 blocks in the diagnosis and treatment of cervicogenic headache. In both cases, repeated blocks proved to have a long-lasting effect in the treatment of this disorder, with both GON and C 2 /C 3 blocks being found to be equally effective. KEY WORDS: Cervicogenic headache, C 2 n e r v e block, C 3 block, greater occipital block, regional anaesthesia. FUNCT NEUROL 2001;16: INTRODUCTION Cervicogenic headache differs from other headaches in its diagnosis and treatment. Diagnostic criteria for cervicogenic headache were introduced by Sjaastad et al. (1). In accordance with these criteria undiagnosed patients are blocked with local anaesthetics and the subsequent diagnosis is based on the relief of pain obtained. Greater occipital (GON) block, cervical (especially C 2 / C 3 s) blocks, minor occipital (MON) block and cervical facet joint blocks are used for the diagnosis and treatment of cervicogenic headache (1-6). Presented as an oral presentation at the 13 t h I n t e r n a- tional Cervicogenic Study Group Meeting in Rome and as a poster at the 7 t h ESA Annual Meeting, Amsterdam In mild cases, non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics are effective. In the treatment of the disorder, repeated local anaesthetic injections are also used, given at weekly intervals. For long-lasting response, local anaesthetics and steroid combinations are used (7). More invasive procedures, used in patients with neurological deficits, include cervical epidural steroid injections (8), liberation operations (9), neurectomies, and stabilization operations (3). Radiofrequency coagulation and epidural spinal cord stimulation are the other invasive procedures used in the treatment of cervicogenic headache (1). We set out to compare C 2 /C 3 blocks and GON blocks as diagnostic tools and also to compare the long-lasting effect of repeated C 2 /C 3 and GON blocks with bupivacaine in the treatment of cervicogenic headache. FUNCTIONAL NEUROLOGY (16)

2 N. Inan et al. MATERIALS AND METHODS With the approval of the ethics committee, 28 patients diagnosed with cervicogenic headache on the basis of the cervicogenic headache diagnostic criteria (5) were enrolled in the study. Physical and neurological examinations of all the patients were performed, as were X-rays of the cervical spine. Prior to the diagnostic block, patients were monitored for a month to establish pain frequency and degree. The degree of pain was measured by visual analogue scale ( VAS) and patients were informed about the VA S procedure. Two groups (GON and C 2 / C 3 ) were randomly formed. Both the diagnostic and the therapeutic blocks were performed unilaterally. GON blockade group The diagnostic block of the GON was performed 2 cm laterally and 2 cm below the protuberantia occipitalis externa by using 2 ml 1% lidocaine in a painful period (10). Patients were observed for 30 minutes to monitor possible side effects of the block and degree of pain. The block was considered successful in the presence of sensory deficit in the innervation area of the and a VAS score decrease of >50%. After the diagnostic block the patients were monitored for a week to establish frequency and degree of pain. Then, the therapeutic block was performed using 2 ml 0.25% bupivacaine. The patients were observed for 45 minutes, again for possible side effects. After this procedure, the patients were again monitored for a week to establish the frequency and degree of pain. After a week, the blocks were repeated with 2 ml 0.25% bupivacaine and patients were followed up for a further two months to monitor pain frequency and degree. C 2 /C 3 blockade group The diagnostic block of the C 2 / C 3 n e r v e s was carried out as described in detail elsewhere (11). The positions of the transverse processes were marked. C 2 is approximately 1.5 cm below the mastoid process and C 3 is a further 1.5 cm below C 2. The needle was angled slightly in the caudal direction. Paraesthesias were elicited before each injection. During a painful period, 2 ml 1% lidocaine was deposited at each point. In the presence of an appropriate sensory deficit and of VAS score decreases >50%, blockade was regarded as successful. Patients were observed for 30 minutes for possible side effects of the block and to monitor the degree of pain. After the diagnostic block the patients were monitored for a week to establish the frequency and degree of pain. Then, the first therapeutic block was performed using 2 ml 0.25% bupivacaine. Patients were observed for 45 minutes, again to monitor possible side effects. They were then followed up to monitor the frequency and degree of pain for a week. Then, the C 2 /C 3 block with 2 ml 0.25% bupivacaine was repeated and patients were followed up for a period of two months to monitor pain frequency and degree. The first and the second groups were compared to each other. The results were evaluated statistically according to the Mann Whitney U and Wilcoxon matched pairs signed rank tests. RESULTS In both groups a considerable decrease in the frequency and degree of pain was seen in the first week after the diagnostic block, in the first week after the first therapeutic block, and in the first and second months following the second therapeutic block. Comparison of the two groups revealed no significant statistical differences, except for pain frequency in the first week following the first therapeutic block, which was significantly reduced in the C 2 / C 3 group compared with the GON group (p<0.005). The results are shown in Tables I and II. 240 FUNCTIONAL NEUROLOGY (16)3 2001

3 C 2 /C 3 and GON blocks in cervicogenic headache treatment Table I - Frequency of pain (mean ± SD) GON (no. = 14) C 2 /C 3 (no. = 14) Before the diagnostic block 27.1 ± ± st week after the diagnostic block 3.2 ± 2.3* 3.8 ± 2.4* 1 st week after the 1 st therapeutic block 2.4 ± 1.9* 1.3 ± 1.3*,** 1 st month after the 2 nd therapeutic block 3.6 ± 3.0* 2.1 ± 1.7* 2 nd month after the 2 nd therapeutic block 2.3 ± 2.1* 1.6 ± 1.6* * p < 0.005; ** p < 0.05 (compared to GON group). Table II - Degree of pain (mean ± SD) (VAS = 0-10) GON (no. = 14) C 2 /C 3 (no. = 14) Before diagnostic block 5.8 ± ± st week after the diagnostic block 4.0 ± 1.7* 3.8 ± 2.7* 1 st week after the 1 st therapeutic block 3.4 ± 1.8** 2.7 ± 2.7*** 1 st month after the 2 nd therapeutic block 3.3 ± 2.4* 2.1 ± 1.4*** 2 nd month after the 2 nd therapeutic block 2.7 ± 2.2* 1.8 ± 1.8*** * p < 0.05; ** p < 0.01; *** p < Occipital Semispinalis Lesser occipital Fig. 1 - GON blockade technique. Fig. 2 - C 2 /C 3 blockade technique. FUNCTIONAL NEUROLOGY (16)

4 N. Inan et al. DISCUSSION Cervicogenic headache is a syndrome. There are very many causes of the pain, which may originate at various levels including the lower part of the neck. The clinical picture and diagnostic criteria for cervicogenic headache were defined by Sjaastad et al. These criteria were accepted by the International Association for the Study of Pain (IASP) (1,4,5,12-16,17). Bovin et al. (16) researched the eff i c a c y of GON, C 2, C 3, C 4, C 5 and C 2 / C 3 f a c e t joint blocks in the diagnosis of cervicogenic headache. In this study, GON blockade was completely effective in 4 of the 5 responders to C 2 blockade; and 6 of the 9 cervicogenic headache patients had partial pain relief following C 3 block. No patients responded completely to isolated blockade of the C 3, C 4, or C 5 s. The C 2 / C 3 facet joint injection gave relief from pain in only 2 out of 9 patients. They argued that the GON is composed of the medial fibres from the dorsal ramus of the C 2 and that a blockade of the C 2 should relieve the pain in all patients who experience relief following a GON blockade. The C 2 blockade should also be effective whether the pain is mediated through the lesser occipital (ventral ramus of C 2 ) or originates from deeper structures innervated by C 2 fibres (periosteum of the occiput, vertebrae, etc.) or from the C 2 itself (16). Their results (with complete effect of GON blockade in 4 of the 5 patients showing the same response to C 2 blockade) suggest that the simpler GON blockade may be suff i- cient in many patients with cervicogenic h e a d a c h e. According to Bovim et al. (16), no patients responded completely to isolated blockades of the C 3, C 4 and C 5 s. Combined C 2 and C 3 blocks provided effective pain relief and C 2 /C 3 facet joint block was partially effective in providing pain relief (16). Bogduk performed a C 2 ganglion block using 1% lidocaine and the patient s pain was completely relieved for 3 hours. After this procedure, follow-up of the patient for four months showed that the patient experienced pain (treated with dextropropoxiphene) once a week, lasting three hours (18). The results of other studies (1,7) revealed that in the occasional patient there was a protracted effect lasting not only for days, but also for weeks and this situation can be utilised therapeutically by giving local anaesthetic injections at set, e.g. weekly, intervals. P f a ffenrath performed C 2 block 5 times at weekly intervals and the results were successful. In this study 17 months pain relief was observed (14). The results may be even more favourable by combining the local anaesthetics with corticosteroids (1,7). Anthony (7) has speculated that repeated combined injections may give results comparable to some degree of demyelinisation. In our study the C 2 /C 3 blockade group did not fare better than the GON blockade group. Both blocks were effective in the diagnosis and the treatment of cervicogenic headache. We also found that repeated GON or C 2 / C 3 n e r v e blocks using 2 ml 0.25% bupivacaine are effective in cervicogenic headache treatment. REFERENCES 11. Sjaastad O, Fredriksen TA, Nielsen AS et al. A clinical review with special emphasis on therapy. Funct Neurol 1997;12: Bovim G, Sand T. Cervicogenic headache, migraine without aura and tension-type headache. Diagnostic blockade of greater occipital and supra-orbital s. Pain 1992;51: Aprill C, Bogduk N. The prevalence of cervical zygoapophyseal joint pain. A first approximation. Spine 1992;17: Sjaastad O, Saunte C, Hovdol H, Breivik 242 FUNCTIONAL NEUROLOGY (16)3 2001

5 C 2 /C 3 and GON blocks in cervicogenic headache treatment H, Gronback E. Cervicogenic headache. An hypothesis. Cephalalgia 1983;3: Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: Diagnostic criteria. Headache 1990;30: Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: Diagnostic criteria. Headache 1998;38: Anthony M. The role of the occipital in unilateral headache. In: Clifford Rose ed Advances in Headache Research. London; John Libbey 1987; Ö z y a lçýn S. Epidural steroid injection in cervicogenic headache. International Monitor of Regional Anaesthesia 1996;16 (abstract) 19. Bovim G, Fredriksen TA, Stolt-Nielsen A, Sjaastad O. Neurolysis of the greater occipital in cervicogenic headache. A follow up study. Headache 1992;32: M o rgan E, Mikhail MS. Pain management. In: Clinical Anesthesiology 2nd Ed, Stamford; a Lange Medical Book 1996: Moore DC. Regional Block. Springfield Illinois; Charles C, Thomas 1973: P f a ffenrath V, Dandekar R, Pöllmann W. Cervicogenic headache: the clinical picture radiological findings and hypothesis on its pathophysiology. Headache 1987; 27: Fredriksen TA, Hovdal H, Sjaastad O. Cervicogenic headache: clinical manifestations. Cephalalgia 1987;7: P f a ffenrath V, Kaube H. Diagnostics of cervicogenic headache. Funct Neurol 1990;5: Inan LE, Mihoglu H. Cervicogenic headache. Journal of Turkish Neurology 1996;2: Bovim G, Berg R, Dale LG. Cervicogenic headache, anesthetic blockades of cervical s (C 2 - C 5 ) and facet joint (C2/C3). Pain 1992;49: Mersky H, Bogduk N. Classification of chronic pain. Seattle; IASP Press Bogduk N. The anatomy and physiology of the vertebral in relation to cervical migraine. Cephalalgia 1981;1:11-24 FUNCTIONAL NEUROLOGY (16)