Modulation of Pain Areas by Greater Occipital Nerve Block

in Chronic Daily Headache

Diego Molina Ochoa1, Douglas Baughman1, Elisabeth Powelson1, Shellie A. Boudreau2, Lars Arendt-Nielsen2, Michele Curatolo1,2
(1) University of Washington, Department of Anesthesiology and Pain Medicine
(2) Center for Sensory-Motor Interaction, Department of Health Science and Technology, Aalborg University, Denmark

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INTRODUCTION PATIENT WITH REDUCTION IN PAIN AREA
> Sensitization of trigemino-cervical pathways (central sensitization) AFTER GON BLOCK
plays a crucial role in the pathophysiology of chronic headache. Pre-Injection Post-Injection
> One clinically relevant manifestation of central sensitization is 2000000
expansion of pain areas.
> Local anesthetic blocks of the greater occipital nerve (GON) reduce

Pain Area (# of Pixels)

pain in headache. The mechanisms underlying this effect are unclear. 1500000
> We tested the hypothesis that GON blockade reduces pain area in
patients with chronic daily headache. This would provide evidence that
reducing sensory input from the cervical system attenuates central
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sensitization.

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METHODS
> Twelve patients with chronic daily headache, undergoing ultrasound-
guided GON block with bupivacaine 0.25%, were studied.
> Patients drew pain localization on a high-resolution 3D body schema
on tablet, using the Navigate Pain App1, before and 30 minutes after
the injection. The pain area was quantified as number of pixels.
> The Patient Global Impression of Change (PGIC) was recorded 30
minutes after injection.
> Data were analyzed by paired t-test.
RESULTS
> The median pain area (interquartile range) was 622,271 (158,216-
795,912) and 104,961 pixels (27,466-488,391) pre- and post-
procedure, respectively (p = 0.0277) (figure).
> The reduction in pain area can occur at both cervical and trigeminal
distribution (diagram, top).
> The response was highly variable (diagrams).
> The PGIC showed very good improvement in 2 patients, good
improvement in 3 patients, minimal improvement in 2 patients, no
change in 2 patients, and minimally worsening in 3 patients.
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Pre-Procedure Post-Procedure
PATIENT WITHOUT REDUCTION IN PAIN AREA
AFTER GON BLOCK Figure. Pain areas before and 30 min after GON block.
Pre-Injection Post-Injection
CONCLUSIONS
> GON block can reduce the area of pain in chronic daily
headache, both at cervical and trigeminal distribution.
> This suggests that a sensory block at the cervical system
reduces sensitization of trigemino-cervical pathways.
> The mechanisms underlying this effect is unclear.
> There is substantial and unexplained inter-individual
variability in the effect of GON block on pain areas, potentially
reflecting variable modulatory effect on central sensitization.
Diagrams. Pain area before and after injection GON block as reported by a
patient with and without reduction in pain area (top and bottom diagram,
respectively). Darker red signifies higher frequency of selection as area where REFERENCES
pain is felt. (DIEGO – THIS IS UNCLEAR, AS PATIENTS DREW THE MAP ONLY 1. Boudreau SA, Badsberg S, Christensen SW, Egsgaard LL. Digital Pain Drawings: Assessing Touch-
ONCE FOR THIS ANALYSIS, PLEASE CLARIFY. Screen Technology and 3D Body Schemas. Clin J Pain 2016;32:139-145.