Headache Medicine 2021, 12(3): 231-234 p-ISSN 2178-7468, e-ISSN 2763-6178

231

ASAA

DOI: 10.48208/HeadacheMed.2021.33

Headache Medicine

Opnion

Occipital nerve block and Maitland physiotherapy: review of

treatment techniques based on positive results

Wesley Gabriel Novaes Botelho , Laura Suelen Signori , Alcântara Ramos de Assis César

Universidade Federal do Parana, Parana, Brazil

Abstract

Cervicogenic headache is a clinical condition that has a direct impact on quality of life and

labor productivity and its underdiagnosis and lack of consensus on the appropriate treatment

aggravates even more the condition. This work aims to systematize the protocol that has the

highest success rate so far, based on the study carried out in Pindamonhangaba, São Paulo,

Brazil. The results demonstrated with the occipital block and Maitland physiotherapy were

exceptional and its methodology will be carried out as performed during the study.

Conclusion: Regardless of the substance used for the blockade, its combination with Maitland's

physiotherapy was shown to be favorable and its description can help other professionals

and also enable reproduction in other studies.

Wesley Gabriel Novaes Botelho

wesleygabrielnovaesbotelho@

gmail.com

Edited by:

Marcelo Moraes Valença

Keywords:

Neck pain

Physical therapy modalities

Nerve block

Received: October 16, 2021

Accepted: November 24, 2021

232

ASAA

Botelho WGN, Signori LS, César ARA

Occipital nerve block and Maitland physiotherapy: review of treatment techniques based on positive results

Introduction

eadache is one of the most prevalent conditions in the

population, resulting in quality of life impairment and

reduced labor productivity. Headaches can be divided into

several groups, and these groups are classied as primary

and secondary headaches, according to the International

Headache Society.

Symptomatic overlap leads to an un-

derdiagnosis of cervicogenic headache, and 50% of cases

have inadequate diagnosis and treatment.

Cervicogenic headaches are classically included in a

large group of secondary headaches associated with

neck disorders because their symptomatology and

etiology is characterized by a different pattern from

migraine and tension headache, not being considered

in an isolated category according to the International

Headache Society.

The pain has a variable intensity,

usually moderate, lasting from a few hours to weeks,

with a pattern of higher incidence from 1 to 3 days, not

throbbing and not excruciating. It may present prodromes

related to the C2-C3 nerve roots, such as throbbing and

pinching in the neck and occipital region ipsilateral to

pain, hypoesthesia, dysphagia, xerostomia, and stiffness

in the passive movement of the neck.

Currently, there are two diagnostic criteria panels, the one

adapted by Antonaci and colleagues

and the International

Headache Society.

Diagnostic criteria adapted by Antonaci and colleagues:

1. Unilateral headache without lateral displacement.

2. Symptoms and signs of neck involvement: pain triggered

by neck movement or inadequate sustained posture, and/

or external pressure on the posterior region of the occipital

neck; ipsilateral neck or occiput pain; ipsilateral neck,

shoulder, and arm pain; reduced range of motion.

3. Pain episodes with variable duration or continuous and

uctuating pain.

4. Moderate pain, not throbbing and not excruciating.

5. Pain starting in the neck, radiating to the orbital, frontal,

and temporal regions.

6. Temporary relief of pain with anesthetic blocks provided

that a complete anesthesia or sustained cervical trauma

occurs shortly before onset.

7. Several events related to the attack: autonomic signs

and symptoms, nausea, vomiting, ipsilateral edema and

redness in the periocular area, dizziness, phonophobia,

photophobia, or ipsilateral blurred vision.

For the diagnosis, it is necessary the presence of items 1

and 5, and any other three.

Diagnostic criteria of the International Headache Society

A. Any headache that meets criterion C.

B. Clinical and/or imaging evidence of a cervical spine

or neck soft tissue disorder or injury known to cause

headache.

C. Evidence of causality demonstrated by at least two of

the following ndings:

1. The headache developed in a temporal relation

with the cervical disorder or lesion onset

2. The headache signicantly improved or resolved in

parallel with the recovery or resolution of the cervical

disorder or injury.

3. Cervical range of motion is reduced and headache

is signicantly aggravated by provocative maneuvers

4. Headache is abolished after diagnostic blockage of

a cervical structure or its nerve supply

D. Not better explained by another diagnosis.

Notes:

1. High cervical spine imaging ndings are common in

patients without a headache; they are suggestive but not

solid evidence of causality.

2. Upper cervical spine tumors, fractures, infections, and

rheumatoid arthritis have not been formally validated as

causes of headache, but are accepted to meet criterion B in

individual cases. Cervical spondylosis and osteochondritis

may or may not be valid causes that meet criterion B,

again depending on the individual case.

3. When cervical myofascial pain is the cause, the

headache should probably be classied as tension-

type headache; however, awaiting more evidence, an

alternative diagnosis of headache attributed to cervical

myofascial pain can be raised.

4. Headache caused by upper cervical radiculopathy

has been postulated and, considering the now well-

understood convergence between upper cervical and

trigeminal nociception, this is a logical cause of headache.

Depending on other evidence, this diagnosis has as

a differential one the headache attributed to superior

cervical radiculopathy.

5. Features that tend to distinguish cervicogenic from

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ASAA

Botelho WGN, Signori LS, César ARA

Occipital nerve block and Maitland physiotherapy: review of treatment techniques based on positive results

migraine and tension-type headache include sideways

pain, typical headache provocation by digital pressure

on neck muscles and head movement, and posterior-

anterior radiation of the pain. However, while these

may be features of cervicogenic headache, they are

not exclusive to it and do not necessarily dene causal

relation. Migraine features such as nausea, vomiting,

and photo/phonophobia may be present in cervicogenic

headaches, although to a generally lower degree than in

migraine, and may differentiate some cases of tension-

type headaches.

Regarding the treatments, several methods and suggested

pharmacology, all with limited success were found.

Among

the used drugs there are muscle relaxants, antidepressants,

and neuromodulators.

Non-pharmacological therapies

are currently the most accepted treatment for cervicogenic

headache, with effective and timely restricted remission.

The isolated blockade had an immediate response in 94%

of patients, however, the mean pain-free duration was

23.5 days.

Excision of the major occipital nerve and

radiofrequency neurotomy were not shown as effective,

even with the average of 244 days and 297 days with

pain reduction, respectively, the studies are inconclusive.

A study conducted in Brazil, with solid methodology and

statistical signicance, associated the Maitland technique

with the occipital nerve block on a scale from 1 to 10),

with a score of 1.6 for combined treatment with Maitland

technique and block, 3.7 for conventional physical

therapy combined with block and 5.2 for isolated block 6.

The goal of this paper is to systematize block and physical

therapy techniques, based on work of CÉSAR and

colleagues (2021), to better guide the effective treatment

of cervicogenic headaches.

Methodology

The present study used the systematization of the techniques

used by CÉSAR and colleagues (2021), in the study carried

out at the 10 de Julho Hospital, in Pindamonhangaba, São

Paulo, Brazil, from January 2017 to February 2018.

Protocols

The etiology of cervicogenic headache is secondary

to several disorders that affect cervical and trigeminal

afferent nerve roots in the trigemiocervical nucleus. In

the nucleus, nociceptive afferents from spinal roots C1-

C2-C3 converge to second-order neurons that also receive

afferents from cervical nerves and from the rst division of

the trigeminal nerve. These convergences allow high neck

pain to be referred in the domain regions of the cervical

nerves (occipital and auricular) and also in the path and

the region innervated by the rst division of the trigeminal

(parietal, frontal and orbicular).

Considering the anatomical and drug features, we will

describe the protocol:

1. Prepare material for sterilization, syringe, 2 needles, 1%

lidocaine without vasoconstrictor, 2mg dexamethasone.

2. Aspirate 1ml of 2mg dexamethasone and 2ml of 1%

lidocaine without vasoconstrictor.

3. Perform local antisepsis.

4. Identify the path of the major occipital nerve, which is

located on the lateral third of the occipital protrusion in

a line going from the occipital protrusion to the mastoid

process.

5. Apply the substance subcutaneously with a 26 G 13

mm needle.

The effect is immediate, and a reassessment is

recommended after 20 days.

8,9

Regarding the Maitland physiotherapy protocol, there are

basic characteristics of the mobilization degree.

10,11

Grade I - small amplitude movement close to the starting

position of the path;

Grade II - large amplitude movement within the path. It

can take any part of the path that is free of any muscle

stiffness or spasm;

Grade III - large amplitude movement, but within muscle

stiffness or spasm, at the range end;

Grade IV - small range movement forced into muscle

stiffness or spasm at the range end.

Grades I and II are indicated in the initial therapy to

reduce pain and irritation, grades III and IV are used in

more advanced therapies to increase the range of motion,

stabilization, and stretching of the joint capsule.

The mobilization rate must be 2Hz and the period of 30

to 60 seconds per manipulation.

The recommended physiotherapy period is 8 weeks.

These protocols are prepared by the authors of the study

based on clinical practice and are supported by scientic

evidence.

Conclusion

Based on previous studies, it is possible to conclude that,

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ASAA

Botelho WGN, Signori LS, César ARA

Occipital nerve block and Maitland physiotherapy: review of treatment techniques based on positive results

regardless of the substance used, the isolated blockade

has a limited improvement in cervicogenic headache

symptoms.

6,7,12

The association of major occipital nerve

block with simple physical therapy demonstrated more

efcacy than the simple block and less than the block

associated with the Maitland technique.

The work concludes its goal of systematizing the technique

used in the research, for protocol use by other professionals.

It is important in the medical eld to improve the diagnosis

and treatment rates of cervicogenic headache. Furthermore,

it enables the reproducibility of the method for conducting

studies by other professionals in the eld.

Autor contributions

Wesley Gabriel Novaes Botelho: First author, elaboration

of protocols following the primary study, elaboration of the

base text.

Laura Suelen Signori: Co-author, review of protocols and

translation.

Alcântara Ramos de Assis César: Advisor.

Conflict of interests

This study is free from conict of interest.

Financing

Own nancing.

Wesley Gabriel Novaes Botelho

https://orcid.org/0000-0001-7315-4201

Laura Suelen Signori

https://orcid.org/0000-0002-9397-6605

Alcântara Ramos de Assis César

https://orcid.org/0000-0002-7390-7282

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