Nerve Block: Occipital

Background

Posterior primary divisions of the upper three cervical nerves. (Great occipital nerve labeled at center top.)
Lateral view (greater occipital nerve posterior)
  • Therapeutic and diagnostic for occipital neuralgia
  • Nerve is between ~8-18 mm deep[1]

Indications

  • Suspected or confirmed occipital neuralgia
  • Migraine refractory to conservative treatment
  • Post-lumbar puncture headache refractory to conservative treatment
  • Cluster headache, occipital neuralgia, cervicogenic headache, or migraine with occipital nerve irritation or tenderness [2]

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[3], but efficacy has not been proven.

Procedure

  • Patient in position of comfort allowing access to posterior head and neck. (laying prone or sitting with head down in arms)
  • Identify Greater Occipital Nerve (GON).
    • May be palpated 1.5-2.5 cm inferior to occipital protuberance and ~1.5-2 cm lateral to midline[4]
    • Alternatively, may be ultrasound guided - look for occipital artery in medial third of the line from occipital tubercle to mastoid process[5]
      • GON will be located medial to artery.
  • Cleanse skin with betadine or chlorhexidine and allow to dry
  • Insert needle over nerve at 90 degrees to skin until hit bone, then withdraw slightly[6]
    • If using ultrasound, insert needle at 45 degrees to skin and advance toward nerve under direct ultrasound guidance
  • Aspirate to ensure not in vessel.
  • Inject ~1-3 mL of local anesthetic. (may inject small amount medial and lateral to nerve to ensure adequate block)[3]
  • Repeat on contralateral side, if indicated.

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)

Complications

Complications are rare due to superficial location and lack of major surrounding structures.[3]

  • Damage to surrounding structures
  • Bleeding
  • Infection

Follow-up

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

See Also

References

  1. M. Greher, B. Moriggl, M. Curatolo, L. Kirchmair and U. Eichenberger. Sonographic visualization and ultrasound-guided blockade of the greater occipital nerve: a comparison of two selective techniques confirmed by anatomical dissection. Br. J. Anaesth. (2010) 104 (5): 637-642.
  2. https://www.nuemblog.com/blog/occipital-nerve-block
  3. 3.0 3.1 3.2 Brock G. The occasional greater occipital nerve block. Can J Rural Med. 2014 Fall;19(4):152-5.
  4. Dach F, Éckeli ÁL, Ferreira Kdos S, Speciali JG. Nerve block for the treatment of headaches and cranial neuralgias - a practical approach. Headache. 2015 Feb;55 Suppl 1:59-71.
  5. Palamar D, Uluduz D, Saip S, et al. Ultrasound-guided greater occipital nerve block: an efficient technique in chronic refractory migraine without aura? Pain Physician. 2015 Mar-Apr;18(2):153-62.
  6. Inan LE, Inan N, Karadaş Ö, et al. Greater occipital nerve blockade for the treatment of chronic migraine: a randomized, multicenter, double-blind, and placebo-controlled study. Acta Neurol Scand. 2015 Mar 13. doi: 10.1111/ane.12393