Original Article

Cephalalgia
0(0) 1–9
Preventive effect of greater occipital ! International Headache Society 2021
Article reuse guidelines:
nerve block on patients with episodic sagepub.com/journals-permissions
DOI: 10.1177/03331024211058182
migraine: A randomized double-blind journals.sagepub.com/home/cep

placebo-controlled clinical trial

Nazila Malekian1, Pouya B Bastani1 , Shahram Oveisgharan2,

Ghaemeh Nabaei1 and Siamak Abdi3

Abstract
Objective: Since the data regarding the efficacy of greater occipital in episodic migraines are rare, we aimed to examine
the efficacy of greater occipital block in the prophylaxis of episodic migraines without aura and compare different
injectable drug regimens.
Methods: In a randomized, double-blind placebo-controlled trial, adult patients suffering from episodic migraines
without aura were randomized to one of the following: triamcinolone, lidocaine, triamcinolone plus lidocaine, and
saline. Patients were assessed at baseline, one week, two weeks, and four weeks after the injection for severity and
duration of headaches and side effects.
Results: Fifty-five patients completed the study. Repeated measures ANOVA indicated that the severity and duration
decreased significantly after the greater occipital block (P < 0.001, P ¼ 0.001 respectively) in all four groups. However,
there was no difference between groups at any study time points (P > 0.05). In paired sample T-test, only groups 2 and 3
with lidocaine as a part of the injection showed a significant decrease in frequency compared to the baseline (P ¼ 0.002,
P ¼ 0.019). Three patients reported side effects with a possible association with triamcinolone.
Conclusion: Greater occipital block with a local anesthetic significantly decreases the number of attacks in episodic
migraine, whereas no injection was superior to the placebo in regards to the duration and severity of the headaches.
Trial Registration Information: Iranian Registry of Clinical Trials (IRCT). Registration number:
IRCT2017070334879N1. https://www.irct.ir/trial/26537.

Keywords
Greater occipital nerve block, migraine, prophylaxis, lidocaine, triamcinolone
Date received: 26 July 2021; revised: 18 October 2021; accepted: 19 October 2021

Introduction treatments are also required, as there are patients

Migraine headaches, affecting more than one billion
people globally, are responsible for a tremendous
amount of decreased productivity and lost working
days, roughly five times more than that of tension-
type headaches (1). Therefore, a great deal of emphasis
is put on developing and evaluating novel treatments
that would address the disability caused by migraine.
Prophylactic treatment with antidepressants, antiepi-
leptics, calcium channel blockers, beta-blockers, and
most recently with monoclonal antibodies against cal-
citonin gene related peptide (CGRP) have shown dif-
ferent efficacies in reducing the attack frequency,
severity, and duration (2,3). However, alternative
who do not achieve adequate pain relief or who devel-
op side effects of migraine prophylactic agents. Greater
1
Neurology Department, Shariati Hospital, Tehran University of Medical
Sciences, Tehran, Iran
2
Rush Alzheimer’s Disease Center, Rush University Medical Center,
Chicago, IL, USA
3
The Iranian Center of Neurological Research, Neuroscience Institute,
Tehran University of Medical Sciences, Tehran, Iran
Corresponding author:
Siamak Abdi, Fourth Floor, Iranian Center of Neurological Research
Building, Imam Khomeini Hospital, Keshavarz Blvd., Tehran, Iran.
Email: Siamak.Abdi@yahoo.com
2 Cephalalgia 0(0)
occipital nerve (GON) block with local anesthetics and
steroids has been used to treat several types of head-
aches (4–7). Peripheral nerve blocks, including GON
block, have been used for many years (8) as an acces-
sory treatment option in patients with migraine – espe-
cially those with chronic migraine. There have been
several proposed mechanisms in the literature that
could partly explain the possible underlying pathophys-
iology of the effect of GON block on migraine head-
aches. The main focus in these studies has been on the
central nervous system (CNS) connections of GON and
trigeminal afferent fibers, which are believed to be the
prime origin of migraine headaches (9–11). On the
other hand, neither the results from available clinical
trials nor the experts are in full agreement regarding
this method’s efficacy in reducing the frequency or
intensity of the headaches in patients with migraine
(4–6,12–15). Furthermore, the medications used for
the GON block (16) and the putative duration (7) of
effect have been topics of interest in this field. Given
the research gaps and paucity of evidence for the use of
GON block as a prophylactic treatment in episodic
migraine, we aimed to evaluate the efficacy of GON
blocks in the prophylaxis of headaches in patients suf-
fering from episodic migraine without aura (MwoA).
Our main goal was to determine whether GON block
would be effective in reducing the severity and duration
of the headache episodes that patients experienced and
whether this method would be superior to the placebo
in decreasing the number of attacks in patients with
episodic MwoA in a month. Additionally, to determine
the most effective regimen for the GON block, we
decided to use three different regimens and one placebo
injection.
Method and materials
We conducted a randomized, double-blind placebo-
controlled trial on adult patients suffering from episod-
ic MwoA. These subjects were sequentially chosen
from patients referred to the Neurology Clinic at
Tehran’s Shariati Hospital between 2018–2019. The
episodic migraine headache without aura diagnosis
was initially made according to the International
Headache Society’s ICHD-3 beta version published in
2013 (17). Since the final version of ICHD-3 was pub-
lished in 2018, the diagnosis was made in accordance
with the most recent guideline (18). The study protocol
was approved by the Ethics Committee of Tehran
University of Medical Sciences (Approval ID: IR.
TUMS.MEDICINE.REC.1397.130), and written
informed consents were acquired from all the partici-
pants before entering the study. This study was regis-
tered in the Iranian registry of clinical trials
(Registration number: IRCT2017070334879N1).
Inclusion and exclusion criteria
The study’s inclusion criteria were as follows: 18 to
65 years of age and a history of MwoA with a frequen-
cy of at least four attacks per month. The exclusion
criteria included: 1) less than fifteen headache-free
days per month, 2) start or change of prophylactic
migraine treatments within the last month, 3) hypersen-
sitivity to lidocaine or triamcinolone, 4) history of sei-
zure, 5) local infection on the injection site, 6) history
of craniotomy, 7) medication overuse headache based
on ICHD-3, and 8) a migraine disability assessment
score (MIDAS) greater than twenty-one (17–19).
Sample size and randomization
The calculated sample size for the study was 80 patients
(20 patients in each group). However, due to the dis-
ruption of routine clinic visits during the COVID-19
pandemic and to avoid unnecessary exposure of
patients, we stopped recruiting patients after 55 patients
were registered. For randomization, we used computer-
generated blocks of four in random order. Based on
this method, patients were assigned to one of the fol-
lowing groups: 1) Triam (triamcinolone): 20 mg
(0.5 ml) of triamcinolone and 2 ml of saline (n ¼ 10),
2) Lido (lidocaine): 2.0 ml of lidocaine 2% and 0.5 ml
of saline (n ¼ 16), 3) Lido þ Triam (lidocaine plus tri-
amcinolone): 20 mg (0.5 ml) of triamcinolone and
2.0 ml of lidocaine 2% (n ¼ 13), and 4) NS (normal
saline): 2.5 ml of 0.9% saline solution (n ¼ 16).
Method of intervention
Each patient underwent a single injection session after
registration. The injections were given bilaterally at a
point 2 cm lateral on the line that connects the occipital
protuberance to the mastoid process and medial to the
occipital artery pulse with 22-gauge needles (20). The
person responsible for preparing and administrating
injections was not blinded to the intervention but had
no contact with the patients or the research team
during registration or follow-up. The patients were
kept under observation for 30 minutes after receiving
injections to note possible immediate side effects.
Outcomes and patient evaluation
A neurologist blinded to the type of treatment was
assigned to evaluate the patients at the first and
follow-up visits. The patients were assessed at baseline,
one week, two weeks, and four weeks after the injection
for pain severity and duration. The frequency of head-
aches was assessed as the number of attacks in four
weeks; the baseline was the number of attacks patients
experienced in the four weeks preceding the study, and
Malekian et al.
the outcome was assessed as the number of attacks
patients experienced in the four-week-period following
the intervention. Patients were asked to record every
headache episode and rate the severity by the Visual
Analogue Scale (VAS) of pain. The duration of head-
aches was recorded in hours. We used the number of
attacks and the average of headache severity and dura-
tion in our final analysis.
Adverse events
Three of the patients reported side effects associated
with the injection site. Upon examination, cutaneous
atrophy and alopecia were observed and recorded in
these patients. In order to review the incidence, after
halting the study, an independent party was asked to
review the type of injection that these patients received.
After reviewing the groups, it was noted that two
patients were in the group Triam (triamcinolone), and
one patient was in the group Lido þ Triam (lidocaine
plus triamcinolone). As a result, considering the possi-
ble association of local corticosteroids with mentioned
side effects, we stopped recruiting patients in these two
groups. The blinding and recruitment were maintained
for the other two groups. We included the patients who
already received either of the mentioned injections in
our final analysis.
Statistical analysis
Statistical analysis was performed using IBM SPSS
Statistics 26.0. The results were presented as means 
standard deviations (SD) for quantitative variables and
were summarized by frequency (percentage) for cate-
gorical variables. T-tests and repeated measures analy-
sis of variance (ANOVA) were used to compare the
groups’ means. Chi-square was used to compare vari-
able frequencies in different groups, and where the cell
size requirements for chi-square were not met, Fisher’s
exact test was used instead. Paired sample T-tests were
used for variables for comparisons within the groups.
Profile plots were produced using the repeated
measures ANOVA model for each of the variables.
P-value <0.05 was considered as significant.
Results
In total ninety-five patients were considered for the
study; 8 patients were excluded due to the previous
history of seizure, and 32 patients declined to consent
for the study. Fifty-five patients completed the study
and were included in the analysis (Figure 1). The mean
age of the participants was 40.42  12.23, and 72.7% of
the patients were female. The baseline characteristics
of the patients in all four groups, as summarized in
Table 1, show no significant difference between the
3
groups at baseline. Sixteen patients were already on
preventive migraine medications with a stable dose
for at least two months. There was no significant dif-
ference between groups in regards to the number of
patients receiving prophylactic medication (P ¼ 0.442).
The data regarding headache severity and duration
were collected in four different time points, and the
frequency was assessed once in baseline and once
four weeks after intervention. Supplemental Table 1
outlines mean measures and standard deviations for
severity, duration, and frequency in each time point.
Headache severity and duration
Repeated measure analysis of variance (ANOVA) with
time as within-subject factor and group as a between-
subject factor was conducted to analyze the effect of
different interventions through time on headache sever-
ity and duration. The analysis shows that all four
groups experience a significant reduction in headache
severity and duration with a P-value <0.001 and
P-value ¼ 0.001 for severity and duration, respectively.
On the other hand, there was no significant interaction
between group and time; as a result, no significant dif-
ference was observed between groups at any of the time
points (P-value ¼ 0.871, P-value ¼ 0.819 for severity
and duration, respectively) (Table 2, Figure 2, and
Figure 3). Supplemental Table 2 summarizes the pair-
wise comparison of the estimated means for each time
point with Bonferroni adjustment of confidence inter-
vals. This shows that compared to baseline, headache
severity was significantly lower at all three time points
(P < 0.001), and while at the end of the fourth week, the
mean severity was still lower compared to baseline, it
had significantly increased compared to the end of
the second week (mean difference ¼ 1.537  0.421,
P-value ¼ 0.004). In the case of headache duration, in
pairwise comparison with Bonferroni adjustment, only
the mean duration of headache at the end of the first
and second week were significantly lower than the base-
line (P-value ¼ 0.003, P-value ¼ 0.007 respectively), and
compared to the baseline, the mean duration of head-
ache was not significantly different at the end of the
fourth week (P-value ¼ 0.196).
Headache frequency
We analyzed the before and after data for headache
frequency with paired sample T-test and used one-
way ANOVA to compare the data between groups at
baseline and at the end of week 4. Although there was
no significant difference between groups at the end of
the 4th week (P-value ¼ 0.306), groups 2 and 3 had a
significantly lower frequency of headaches compared to
the baseline. Patients in group 2 who received lidocaine
4 Cephalalgia 0(0)

Assessed for eligibility

(n = 95)

Excluded (n = 40)
History of seizure (n = 8)
No consent (n = 32)

Randomized
n = 55

Allocated to triamcinolone
Allocated to triamcinolone Allocated to lidocaine Allocated to 0.9% saline
+ lidocaine
n = 10 n = 16 n = 16
n = 13

Received triamcinolone +
Received triamcinolone Received lidocaine Received 0.9% saline
lidocaine
n = 10 n = 16 n = 16
n = 13

Lost to follow-up = 0 Lost to follow-up = 0 Lost to follow-up = 0 Lost to follow-up = 0

Analyzed Analyzed Analyzed Analyzed

n = 10 n = 16 n = 13 n = 16

Figure 1. Flow chart of the study.

Table 1. Baseline characteristics.

Groups Group 1* Group 2† Group 3‡ Group 4§

Number of Participants 10 16 13 16 P Value

Sex (M:F) (1:9) (5:11) (3:10) (6:10) 0.480–0.500**

Age Mean  SD 38.30  14.85 40.94  10.79 42.85  11.70 39.25  13.07 0.814††
Severity‡‡ Mean  SD 7.00  1.94 6.69  1.44 7.23  1.92 6.38  1.66 0.580††
Duration§§ Mean  SD 25.60  23.01 9.07  11.18 18.62  20.83 11.60  15.29 0.093††
Frequency*** Mean  SD 8.40  6.86 10.00  6.12 9.85  6.01 9.44  6.99 0.936††
Preventive Medication††† N (%) 5 (50%) 3 (18.75%) 4 (30.76%) 4 (25%) 0.442‡‡‡
*Triamcinolone: 20 mg (0.5 ml) of triamcinolone and 2 ml of 0.9% saline.
†
Lidocaine: 2.0 ml of lidocaine 2% and 0.5 ml of 0.9% saline.
‡
Lidocaine Plus triamcinolone: 20 mg (0.5 ml) of triamcinolone and 2.0 ml of lidocaine 2%.
§
Saline solution: 2.5 ml of 0.9% saline solution.
**Calculated by Fisher’s Exact test.
††
Calculated by one-way analysis of variances (ANOVA).
‡‡
Mean headache severity in the preceding week assessed by visual analogue scale (VAS).
§§
Mean headache duration in the preceding week in hours.
***Number of attacks in the preceding month.
†††
Number of patients who were already on preventive medication.
‡‡‡
Calculated by Chi Square.
Malekian et al.
injection experienced a significant average decrease of
5.81 attacks per month compared with the baseline
(95% CI of the difference ¼ 2.52–9.09) (Figure 4).
In group 3, where patients received a combination of
lidocaine and triamcinolone, compared to the baseline,
the number of attacks dropped significantly by an aver-
age of 5.69 attacks per month (95% CI of the differ-
ence ¼ 1.11–10.27) (Figure 4). Despite a downward
trend in the number of attacks in group 1
(P-value ¼ 0.266) and group 4 (P-value ¼ 0.085), the reduc-
tion was deemed statistically insignificant (Figure 4).
Discussion
Although there are several randomized placebo-
controlled studies on this subject, the main focus of
the previous studies has been on patients with chronic
migraine, and the data on patients with episodic
migraine is scarce (21). Apart from this, to evaluate
Table 2. Results obtained from repeated measure ANOVA for
the effect of time and interaction of Group and Time on
headache severity and duration.
Severity* Duration†
F (df), P value F (df), P value
Time 19.98 (3,153), P < 0.001 5.45 (3,153), P ¼ 0.001
Time  Group 0.503 (9,153), P ¼ 0.871 0.57 (9,153), P ¼ 0.819
*Assumption of sphericity was tested using Mauchly’s test of sphericity
and the null hypothesis was rejected with a P value of 0.069.
†Assumption of sphericity was tested using Mauchly’s test of sphericity
and the null hypothesis was rejected with a P value of 0.194.
8 3
Estimated marginal means
Baseline
Figure 2. Profile plot of headache severity by time where each line represents the changes of a group within time. Error bars
represent 95% confidence interval.
5
the efficacy of GON block, patients should avoid the
use of new prophylactic medication, which makes it
difficult to conduct studies with a longer duration of
follow-up. Unlike other available studies, which com-
prised only two groups, this study had four groups,
including a group with just triamcinolone as the inter-
vention. The results of this study demonstrate that
there is a significant improvement in the mean severity
and duration of headaches in all four groups through
time, with no injection being superior to the placebo.
Within-subject changes during the time show a sus-
tained effect of GON block on the severity and dura-
tion of the headaches beyond the duration of the effect
of each of the agents in the solution (7,22). These find-
ings are in keeping with previous studies, which found
GON block to have a duration of effect for as long as
four weeks (15). Furthermore, the number of the
attacks in the four-week period following the interven-
tion was significantly lower compared to the number of
headaches in the four-week period preceding the inter-
vention in groups that had lidocaine in their injections.
In a systematic review published in 2019, Shauly
et al. (23) pooled the data of nine placebo-controlled
studies on GON block from 2006 to 2018 with a total
number of 440 patients. The meta-analysis showed that
GON block significantly decreased headache days per
month (95% CI ¼ 1.39 to 5.81 days) and VAS (95%
CI ¼ 1.56 to 2.84) (23). When considering the ran-
domized clinical trials, there were some differences
regarding timing of injection, duration of follow-up,
and the volume of injection. Each of these could poten-
tially influence the results. We evaluated the effect of a
Estimated marginal means of severity
Group
1
2
4
One week Two weeks One month
Time
6 Cephalalgia 0(0)

Estimated marginal means of duration

40.00 Group
1
2
3
4
30.00

Estimated marginal means

20.00

10.00

.00

Baseline One week Two weeks One month

Time

Figure 3. Profile plot of headache duration by time where each line represents the changes of a group within time. Error bars
represent 95% confidence interval.

Estimated marginal means of frequency

Group
10
1
2
3
4
Estimated marginal means

Baseline One month

Time

Figure 4. Profile plot of headache frequency by time where each line represents the changes of a group within time.

single injection session, while some studies had weekly
(24) or monthly (25) injections with follow-ups as long
as six months (13). This difference in the method and
timing of intervention is notable in the context of clin-
ical practice, especially when patients are to refrain
from prophylactic treatment; thus, we considered a
single injection with shorter follow-up. The volume of
injection also varies between studies, ranging from
1.5 ml (26) of total injection volume to 3 ml (21) in
studies that we reviewed. To bring it into the context
of our study, one of the hypotheses that we find plau-
sible for the observed results from this study is that the
compression itself plays an important role in the
observed effects; hence the greater the volume of injec-
tion, the greater the effect of compression and the
better the outcomes. This hypothesis is in concordance
with clinical and functional connections of upper cer-
vical afferents and trigeminal nuclei known as
trigeminal-cervical convergence (9–11) in the medulla
and can explain the lack of significant between-group
Malekian et al.
difference in our study while a positive effect is seen
among all of the groups. Similar findings have been
previously reported. In a study published in 2017,
Gul et al. (24) compared the efficacy of weekly GON
block using 1.5 ml of Bupivacaine þ 1 ml of saline with
2.5 ml of saline as a placebo. There was no significant
difference between placebo and GON block at the end
of the first month. However, both groups experienced a
significant reduction of headache days per month (24).
These findings raise the possibility that at least some
degree of the improvement experienced after GON
block could be attributed to the injection itself rather
than the medication that is used. Nevertheless, the role
of the placebo effect in the treatment of migraine has
been previously raised in the literature, and it is
believed that the more invasive the placebo (e.g., injec-
tion), the more the placebo effect it might exert (27).
Even so, these findings are insufficient to draw such a
conclusion with an acceptable degree of certainty, and
there is a need for further studies where the placebo
group receives no amount of injection and needling is
done in order to maintain the blinding. The
Trigeminocervical complex is also of importance in
explaining the role of local anesthetic in reducing the
frequency of migraine attacks as this complex acts as a
bridge between peripheral nociceptive stimuli and the
intracranial nociceptive receptors (28). Lidocaine’s
effect in blocking voltage-gated sodium channels has
been well established in previous studies; hence, it is a
plausible assumption that by suppressing peripheral
triggers, lidocaine decreases the number of migraine
attacks (29,30).
There is one issue regarding the blinding when some
groups do not receive anesthetics as a part of their
intervention. One might argue that given the hypoes-
thesia expected after the injection of the local anesthet-
ic, the patients in the intervention group would not be
properly blinded to the treatment. In one of the studies,
in order to overcome this issue, a small amount of lido-
caine (0.25 ml of 1% solution) was mixed with 2.75 ml
of saline solution to mimic the hypoesthesia; this study
was unable to find any difference between the interven-
tion (2.5 ml of 0.5% Bupivacaine solution þ 0.5 ml of
methylprednisolone) and the placebo in terms of head-
ache duration and severity. The authors of this article
believed the lack of difference to be partly due to the
small amount of anesthetic in the placebo group (21).
Given this and the lack of significant documented dif-
ference between active and placebo groups in terms of
hypoesthesia in other studies (23), we did not believe
that the use of local anesthetic in all groups was neces-
sary to maintain the blinding.
The use of corticosteroids as a part of the regiment is
also debated. In this study, we had to stop recruiting
patients in groups receiving triamcinolone - alone or in
7
combination with local anesthetic - following adverse
effects, including cutaneous atrophy and alopecia, that
were reported in these patients. Although there has
been no report of such adverse events in the previous
randomized clinical trials, there have been case reports
of alopecia and skin atrophy in the use of local corti-
costeroid injection in combination with local anesthetic
in GON block. These adverse effects have been previ-
ously reported both in the use of triamcinolone and
methylprednisolone (31,32). Studies on the side effects
of the local corticosteroid injection in other sites of the
body have found these side effects to be reversible, but
there has been no study on the duration and reversibil-
ity of these side effects following GON block (33).
Corticosteroids have been added to the GON block
solution due to the understanding that the added ben-
efit weighed more than the local reversible side effects.
However, in our study, there was no difference between
triamcinolone combination with lidocaine and lido-
caine alone. This has been previously studied in
patients with chronic migraine, and no significant dif-
ference was observed in those studies with addition of
20 mg of methylprednisolone or 40 mg of triamcino-
lone as well (16,34). However, this lack of significance
should be considered with caution as the sample size of
these groups was smaller in our study, and the dose of
triamcinolone was relatively low (20 mg). Considering
adverse events associated with local triamcinolone
injection, until further studies confirm the efficacy of
local injection of corticosteroids in GON block and a
preferred agent and dose with least complication is
established, their routine use is rather discouraged.
Limits of the study
We intended to conduct the study with 80 patients, but
due to the COVID-19 pandemic, considering the
patient and staff safety, we decided to stop recruiting
patients. In addition to that, given the observed adverse
events with a possible link to local corticosteroids, we
had stopped recruiting patients in the groups receiving
triamcinolone as a part of their injection. Since the
desired sample size was not met in each group, the
study is prone to being underpowered in finding
between-group differences. Nevertheless, one must con-
sider that despite the smaller sample size, all of the
groups experienced significant improvements over time.
As we mentioned earlier, there are some challenges
that limit the follow-up time. Besides, we included
patients whose preventive medications have not been
changed in the month preceding the registration, but
guidelines recommend a three-month period of stable
preventive treatment (35). However, given the even dis-
tribution of patients on preventive medication between
all groups and the fact that none of the patients
8 Cephalalgia 0(0)
registered in the study had a change in their preventive
medication in the two months leading to the study, the
confounding effect of preventive medication would be
attenuated. Nevertheless, one must bear in mind this
possible overlap.
The issue we raised in regards to the hypoesthesia
experienced over the area of GON following the infil-
tration with a local anesthetic still persists and must be
considered as a possible confounder to the blinding.
We mainly evaluated the effect of GON block on the
headache, but the amount of the medication used
during attacks was not recorded and analyzed. This
issue should be addressed in future studies.
Furthermore, we did not study the effect of GON
block on other symptoms, including nausea and vom-
iting, photophobia, and phonophobia. It would be log-
ical if future studies take these symptoms into account
as well since the data around this issue is less
developed.
While we used a 20 mg triamcinolone solution as our
corticosteroid agent, equivalent to 20 mg of methyl-
prednisolone, some studies used higher doses (16).
Considering the use of a different corticosteroid like
Clinical implications
• GON block with a local anesthetic significantly reduces the number of headaches per month in patients
with episodic migraine without aura.
• GON block, regardless of the type of injection medication, significantly reduces the severity and duration
of headaches for at least two weeks.
• With current data at hand, the use of local corticosteroids for GON is not recommended.
Data availability
All the data pertaining to the published work would be made
available upon reasonable request from the corresponding
author.
Declaration of conflicting interest
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The authors disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this
article: This study did not receive any funding from sources
outside Tehran University of medical sciences (TUMS).
Iranian center of neurological research (ICNR) in affiliation
with TUMS provided the funding for the equipment and
medications used in this research, and the compensation of
non-medical staff.
methylprednisolone with a higher dose (40-80 mg) in
future studies might yield a significant effect and lower
complication. Nevertheless, until further studies could
provide us with more concrete evidence, caution must
be taken in using adjunctive local corticosteroids.
Conclusion
Our study concludes that all of the four types of injec-
tions used were effective in reducing the severity and
the duration of headaches in episodic migraines, and
no block solution was superior to the 0.9% saline solu-
tion as a placebo at any of the time points. Further
studies are needed to explore whether these results
were caused by the compressive effect of injected solu-
tion or by the placebo effect. On the other hand, there
was a significant decrease in the number of headaches
in patients receiving lidocaine alone or in combination
with triamcinolone as opposed to 0.9% saline injection
or triamcinolone. Overall, the findings of this study
support use of lidocaine as an agent for greater occip-
ital nerve block should one be considered.
ORCID iDs
Pouya B Bastani https://orcid.org/0000-0002-5884-2126
Siamak Abdi https://orcid.org/0000-0002-1339-346X
Supplemental material
Supplemental material for this article is available online.
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