Nerve Block: Occipital

Background

• Therapeutic and diagnostic for occipital neuralgia
• Nerve is between ~8-18 mm deep

Indications

• Suspected or confirmed occipital neuralgia
• Migraine refractory to conservative treatment
• Post-lumbar puncture headache refractory to conservative treatment

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, but efficacy has not been proven.

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)

Procedure

• Traditionally done "blindly" with palpation of occipital protuberance
  • Then palpate laterally to find the tender nerve on the side of the headaches
  • Palpate the occiptal artery above the superior nuchal line, and inject 2-3cc of anesthetic just medially to that

Complications

• Damage to surrounding structures
• Bleeding
• Infection

Follow-up

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

See Also

• Nerve Blocks (Main)
• Local Anesthetic Systemic Toxicity (LAST)