Headache Medicine 2021, 12(3): 231-234 p-ISSN 2178-7468, e-ISSN 2763-6178
DOI: 10.48208/HeadacheMed.2021.33
Headache Medicine
© Copyright 2021
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
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
Edited by:
Marcelo Moraes Valença
Neck pain
Physical therapy modalities
Nerve block
Received: October 16, 2021
Accepted: November 24, 2021
Botelho WGN, Signori LS, César ARA
Occipital nerve block and Maitland physiotherapy: review of treatment techniques based on positive results
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
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.
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
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.
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.
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.
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
5. Apply the substance subcutaneously with a 26 G 13
mm needle.
The effect is immediate, and a reassessment is
recommended after 20 days.
Regarding the Maitland physiotherapy protocol, there are
basic characteristics of the mobilization degree.
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
Based on previous studies, it is possible to conclude that,
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
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
Alcântara Ramos de Assis César: Advisor.
Conflict of interests
This study is free from conict of interest.
Own nancing.
Wesley Gabriel Novaes Botelho
Laura Suelen Signori
Alcântara Ramos de Assis César
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