Headache Medicine, v.10, n.2, p.37-40, 2019

ABSTRACT

RESUMO

Descritores: Bloqueios nervosos; Nervo occipital; Nervo auriculotemporal;

Nervo supraorbital; Nervo supratroclear; Nervo zigomático; Cefaleias

ORIGINAL ARTICLE

Full Head Block for headache treatment:

technical description, indications and mechanisms

Bloqueio completo da cabeça no tratamento das cefaleias:

Descrição técnica, indicações e mecanismos

Bruna de Freitas Dias

Thiago Nouer Frederico

Iron Dangoni Filho

Mario Fernando Prieto Peres

HIAE - Hospital Israelita Albert Einstein¹

FICSAE – Faculdade Israelita de Ciências e

Saúde Albert Einstein

*Correspondence

Mario F P Peres

E-mail: mariop3r3s@gmail.com

Received: June 2, 2019.

Accepted: June 8, 2019.

Headache is a most prevalent neurological condition in the world and has a

major impact on quality of life. The causes are usually multifactorial and may

have a chronic character. Headache management involves pharmacological

and non-pharmacological approach; invasive and noninvasive. Peripheral

nerve block is already a viable, safe, and effective treatment option, such as

major occipital nerve block. Full head block is a minimally invasive proposal

of peripheral pain neuromodulation for the treatment of refractory or severe

headache, mainly. The aim of this paper is to describe a technique and discuss

the role of full head block in the headache management. The proposal is

bilaterally anesthetizing the following nerves: major and minor occipital,

supraorbital, supratrochlear, zygomatic-temporal and auriculo-temporal with

local anesthetic and a corticosteroid. Many aspects should be studied: efcacy

and safety of the technique, clinical indications, professional training, need

for USG guidance, adequate dose of anesthetic and corticosteroids. In order

to further evaluate the role of peripheral blocks in headaches randomized

controlled trials are required.

Keywords: Nerve blocks; Occipital nerve; Auriculotemporal nerve; Supraorbital

nerve; Supratrochlear nerve; Zygomatic nerve; Primary headache

Cefaleias primárias são condições neurológicas prevalentes no mundo com

grande impacto na qualidade de vida. As causas são geralmente multifatoriais

e podem ter caráter crônico. O gerenciamento da dor de cabeça envolve

abordagem farmacológica e não farmacológica; invasivo e não invasivo.

O bloqueio do nervo periférico já é uma opção viável, segura e ecaz de

tratamento, como o bloqueio do nervo occipital maior. O bloqueio cefálico

completo é uma proposta minimamente invasiva da neuromodulação da

dor periférica, principalmente para o tratamento de cefaleias refratárias

ou intensas. O objetivo deste artigo é descrever uma técnica e discutir o

papel do bloqueio cefálico completo no manejo das cefaleias. A proposta é

uma anestesia local bilateraldos seguintes nervos: occipital maior e menor,

supraorbital, supratroclear, zigomático-temporal e aurículo-temporal com

anestésico local associado a corticoide. Muitos aspectos devem ser estudados:

ecácia e segurança da técnica, indicações clínicas, treinamento prossional,

necessidade de orientação por ultrassonograa, dose adequada de anestésico e

corticosteróide. Para melhor avaliação do papel dos procedimentos periféricos

nas cefaleias, ensaios clínicos randomizados e robustos são necessários.

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Headache Medicine, v.10, n.2, p.37-40, 2019

INTRODUCTION

Headache is the most prevalent neurologic condition

in the world

. It most affects patient in productive age

and is associated with a substantial personal and societal

burden. Migraine represents the rst highest cause

of disability under 50 years of age and the second

worldwide

. Migraine, the most common primary

headache, has been found in 15,2% in Brazil

, followed

by tension-type headache (13%)

and chronic headaches

(6,9%)

. They are frequently multifactorial and have a

chronic character. Its treatment can be challenging and

involves pharmacological and non-pharmacological,

invasive and non-invasive approaches, as well as acute

and prophylactic therapy

There are now several non-invasive and invasive

options to manage headache. Peripheral nerve block

is a minimally invasive therapy and represents an

excellent alternative to conventional drugs (responsible

for a wide range of side effects due to its action on

several neurotransmitters) and to non-pharmalogical

neuromodulation, like Transcranial Magnetic Stimulation

(TMS) and Transcranial Direct Current Stimulation

(tDCS)

. The nerve block can be used in primary

(migraine, cluster headache, and nummular headache)

and secondary headaches (cervicogenic headache and

headache attributed to craniotomy), as well in cranial

neuralgias (trigeminal neuropathies, glossopharyngeal

and occipital neuralgias)

. Nerve block provides rapid

pain relief to patients and its analgesic effect often

long-lasting (sometimes for weeks to months). The

mechanism includes an interruption of neural conduction

in peripheral nerves and nerve trunks by the injection of

a local anesthetic agent (e.g., lidocaine, bupivacaine).

However, it is still incomplete understood, but is likely

secondary to effects on central pain modulation via

second order neurons in the trigeminocervical complex

Several peripheral cranial nerve targets have been

aimed in this approach. Greater occipital nerve is the

most studied peripheral nerve block, but there are

some others sites already tested, such as lesser occipital

nerve, supratrochlear nerve, supraorbital nerve and

auriculotemporal

. The procedure is fast, easy, generally

safe and well tolerated, becoming attractive for clinicians

and patients, especially for resistant headaches.

A similar procedure has been done in neurosurgical

anesthesia where all peripheral nerves are blocked

to anesthetize the scalp, the so-called scalp block

Scalp block involves regional anesthesia to the nerves

that innervate the scalp, providing analgesia for tumor

excision, epilepsy surgery and deep brain stimulation

surgery

. Full head block is different from scalp block

because of its therapeutic target and technique.

Our study aimed to describe the technique and

discuss the role of a full head block in headache

management treatment.

METHODS

The proposal of full head nerve block is to

anesthetize bilaterally greater lesser and third occipital,

supraorbital, supratrochlear, zygomatic-temporal and

auriculotemporal nerves. The techniques of each nerve

block are detailed below.

Greater occipital nerve (GON) block.

GON is located approximately two thirds of the

distance on a line drawn from the center of the mastoid

to the external occipital protuberance. GON can also

be located palpating occipital artery; because of that,

care needs to be taken to avoid intra-arterial injection.

Another option is to inject approximately 2 cm lateral to

the external occipital protuberance

Lesser occipital nerve (LON) block.

LON is located approximately one third of the way

on a line drawn from the center of the mastoid to the

greater occipital protuberance

Third occipital nerve (TON) block.

TON is located deep to the semispinalis capitis

muscle and two anatomic landmarks are used: the tip of

the mastoid process and the C3 spinous process

. The

Figure 1. Topography of the nerve’s blockage in full head block propose

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Dias BF, et al.

Headache Medicine, v.10, n.2, p.37-40, 2019

third occipital nerve lies medial to great occipital nerve

and have bers communication between both, and is

blocked in the same injection of GON by the intimacy

proximity.

Auriculotemporal nerve (ATN) block

ATN is located at superior to the posterior portion

of the zygomatic bone just anterior to the ear. It follows

supercial temporal artery that can be palpated and

used as a reference for the block

Supraorbital nerve (SON) block

SON, which runs approximately 2 cm lateral to the

supratrochlear nerve, the injection can be done in this

point, or the needle can be advanced laterally through

the same puncture that was used for the STN

13,14

Supratrochlear nerve (STN) block

STN is blocked by inserting the needle just above

the eyebrow over its medial border

13,14

Zygomatic nerve (ZN) block

ZN is blocked by placing the index nger on ventral

rim of the orbit at the lateral canthus of the eye, and rmly

press against the supraorbital portion of the zygomatic

arch

12,14

POSSIBLE INDICATIONS

Full head block can be performed together with

botulinum toxin, as a bridge therapy, while waiting to

the toxin starting to work

15-17

. Refractory headache,

primary headache in pregnancy and the presence of

contraindications for other treatment’s options.

Peripheral nerve block has already been tested for

primary headache disorders like migraine prevention,

migraine acute treatment, cluster, neuralgia and tension-

type, as well as to secondary headache disorders such

posttraumatic headache, post-surgical headache

and scar related pain. It can also be considered as a

transitional treatment in chronic headaches.

LIMITATIONS

The major side effects occur due to local injection.

There are related cases of local infection, nerve damage

with later neuroma formation, hematoma, local injury to

adjacent structures and, rarely, systemic manifestations

due to absorption of local anesthetics (seizure, alteration

in consciousness and cardiac conduction effects when

high doses are used). Using small needles and aiming for

perineural sites are helpful in avoiding these side effects.

When patient has anatomic abnormalities, such as skull

defects, local infection or previous surgical scars, the

procedure is not indicated.

Assistant’s training about the location of structures,

technique and aseptic environment is necessary for

a great performance of the procedure. Studies must

be designed to identify the efcient amount of local

anesthetic, necessity of ultrasound guided

and

addition of corticosteroid (methylprednisolone or

betamethasone).

FUTURE DIRECTIONS

Thereby, clinical trials are important to assess the

role of the full head block for headache treatment. It

represents the combination of several well tolerated and

effective therapy, with a lack of side effects.

DISCUSSION

There are many examples of peripheral targeted

treatments, such as low-level laser therapy, topical

lidocaine, dry needling, electrical stimulation and

massaging

. There are other forms of inducing anesthesia

with nerve blocks, e.g., lidocaine transdermal patch

It has already been discussed through literature

about the role of peripheral nerve block on headache

management

21,22

. Peripheral nerve block can result in

rapid relief of pain and allodynia, reduce the number of

headache days and medication consumption

and its

effects may last for several weeks. Thereby, nerve block

is a viable and safe treatment option for selected groups

of headache patients, particularly those with intractable

headache.

Although there are many studies about effectiveness

of a specic nerve block

24-26

, especially greater occipital

nerve block

, there is no case report that apply full

head block for treatment of primary headache. Why

should we do a full head block? Due to: (1) distribution

nerve pain - headaches are not limited to one nerve; (2)

necessity of a complete peripheral detachment to arouse

neuromodulation; (3) acute response in headache attack;

and (4) refractory headaches to others procedures.

CONCLUSION

Considering this rational, structured scientic

evidence with blinded and sham-controlled studies is

needed to understand the action mechanism, validate

doses of the anesthetics, train professionals and establish

the efcacy of full nerve block in headache disorders.

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