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Ultrasound guided greater occipital nerve blocks for post-traumatic occipital neuralgia.


The patient described in this case report developed post-traumatic headaches following a motor vehicle collision with head injuries. After non-invasive approaches to the management of his occipital neuralgia failed, bilateral greater occipital nerve blocks conferred symptom relief in a matter of hours. This case report highlights an interesting presentation of post-traumatic occipital neuralgia and underscores the utility of occipital nerve block as a therapeutic modality.

Case Presentation

A 45 year old, 127 kg male was hospitalized following a motor vehicle accident. He struck a tree while driving home from work and sustained multiple injuries including traumatic ventral hernia, traumatic left testicular hematoma, open bilateral superior and inferior pubic rami fractures, scalp laceration, nasal bone fractures, and bilateral occipital condyle fractures. During his four week hospital stay, he developed headaches which became more frequent and severe. His past medical history was only remarkable for type II diabetes mellitus. Hospital medications consisted of alprazolam, duloxetine, sustained release morphine, oxycodone/ acetaminophen, cyclobenzaprine, tramadol, metoprolol, simvastatin, and metformin. The headaches were characterized by sharp pain radiating in a posterior to anterior direction. His typical headache episode was characterized with severe intensity that often lasted several hours. There were no associated symptoms such as nausea, emesis, photophobia, or aura. Neurology was consulted for evaluation and management of these headaches. The diagnosis of occipital neuralgia was made with recommendations for bilateral occipital nerve blocks and the addition of gabapentin to his regimen. Bilateral greater occipital nerve blocks were performed under ultrasound guidance with 3 mL of 0.25% bupivacaine and epinephrine. The patient reported relief of his headaches and had no complaints of lingering headaches upon hospital discharge or at his outpatient follow-up visit.


When evaluating a patient with a post-traumatic headache, it is important to differentiate between a primary and the more worrisome secondary headache. (1) Primary headaches, idiopathic in nature, can also occur following trauma. Common types in this setting include cluster and migraine headaches which are defined by their symptoms. Other etiologies that can be an imminent threat to the patient must be considered such as intracranial hemorrhage and post-dural puncture headache. As emphasized by this case report, our patient's occipital neuralgia would be classified as a secondary headache (identifiable cause; occipital condyle fractures). The International Classification of Headache Disorders (ICHD) 2004 algorithm classifies headaches into primary, secondary, and not yet defined headaches. (2) Each class has many sub-classifications. (2) Although the etiology of headaches in this presentation was identified radiographically, trauma induced headaches might have less obvious causes like post-concussive and cervicogenic sources.

Occipital neuralgia can occur spontaneously or result from underlying disease, hence--it can be classified as either primary or secondary. Often though, we see it manifested after physical insult to the greater or lesser occipital nerve pathways i.e. direct trauma or compression. (3) Symptoms range from throbbing, burning, migraine-like pain which typically originates near the base of the skull. The headaches can localize to one or both sides and are often agitated with movement or pressure on the nerve(s). Diagnosis is challenging and conservative treatment modalities are recommended before the more invasive approaches. (4) One should be aware that there is literature supporting the successful use of occipital nerve blocks to interrupt primary headaches such as cluster and migraine. In this instance, the occipital nerve block might be therapeutic rather than diagnostic. Thus, the diagnostic utility of occipital nerve blocks has been questioned. Regardless, occipital nerve blocks may break the headache cycle and provide long-term headache relief.

The dorsal rami of C2 gives rise to the greater occipital nerve, while the lesser occipital nerve is a combination of both the C2 and C3 ventral rami. (1) They emerge from the suboccipital triangle and provide cutaneous innervations to the majority of the scalp. In most situations, the procedure is very easy to perform. A variety of approaches have been described. Common landmark-based techniques utilize the external occipital protuberance or superior nuchal line. The occipital artery, if palpable, is a reliable landmark. Very few complications have been reported following greater occipital nerve blocks. Intravascular injection, hematoma, and allergic reaction are possible. Cushing syndrome can be seen with repeated injections containing corticosteroids. (5) Okuda et al reported sudden unconsciousness following lesser occipital nerve block in a patient with a bony defect. (5) Occipital nerve blocks can be performed in the sitting, lateral, or prone position. In this case, positioning was difficult because our patient was in a bulky external fixator for his pelvic fractures. The above mentioned positions were not possible. For the blocks described in this case report, the patient was positioned as close to lateral as possible and the head was turned to the contralateral side.

The patient's body habitus and scalp swelling rendered landmark palpation difficult. For this reason, we elected to use an ultrasound-guided perivascular technique. The occipital artery was identified at a level 1.5 cm caudad to the external occipital protuberance. (At this location, the GON lies medial to the occipital artery, see figures 1 and 2). (1) Bilateral greater occipital nerve blocks were performed by injecting 3ml of 0.25% bupivicaine with 1:200k epinephrine medial to the greater occipital artery. A 22 GA needle was inserted until contact with the occipital bone was made. The needle was withdrawn slightly and the injection proceeded following negative aspiration. The injection sites were massaged to help spread the anesthetic and decrease tension from developing within the noncompliant connective tissue.

Follow-up with the patient was made roughly six hours later and then again the next morning. He reported that the headache subsided within several hours after injection. He remained headache-free for the remainder of his hospital stay. He did not complain of any headaches at his outpatient follow-up several months later.


Our patient presented with trauma induced occipital neuralgia which failed conservative treatments. The patient was successfully managed with ultrasound guided bilateral greater occipital nerve blocks. These nerve blocks are safe, technically easy to perform and should be considered in a variety of clinical situations.


(1.) Benzon H, Rathmell J, Wu C, Turk D, Argoff C. Raj's Practical Management of Pain. 3rd ed. Philadelphia: Mosby Elsevier, 2008. 480, 856. HIS Classification ICHD-II. Web. Jan 2013 <>

(2.) National Institute of Neurologic Disorders and Stroke. Web. Jan 2013 < /disorders/occipitalneuralgia/occipitalneuralgia.htm>

(3.) American Association of Neurologic Surgeons. "Occipital Neuralgia." 2006. Web. Jan 2013.>

(4.) Lavin PJ, Workman R. Cushings syndrome induced by serial occipital nerve blocks containing corticosteroids. Headache. 2001;41:902-904

(5.) Okuda Y, Matsumoto T, Shinohara M, Kitajima T, Kim P. Sudden unconsciousness during a lesser occipital nerve block in a patient with the occipital bone defect. Eur J Anaesthesiol. 2001;18:829-832.

Jeremie Walker, MD MBA

Stephen Howell, MD

West Virginia University School of Medicine Department of Anesthesiology

Corresponding Author: Jeremie Walker, MD, MBA, WVU School of Medicine, Dept. of Anesthesiology, 1 Medical Center Dr., Morgantown, WV 26506;
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Title Annotation:Case Report
Author:Walker, Jeremie; Howell, Stephen
Publication:West Virginia Medical Journal
Article Type:Case study
Date:Mar 1, 2014
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