ISSN 0017-8748 0017-8748 ISSN doi: 10.1111/head.12607 10.1111/head.12607 doi: Published Inc. Published by by Wiley Wiley Periodicals, Periodicals, Inc.
Headache Headache C 2015 American Headache Society V © 2015 American Headache Society
Brief Communication Communications Greater Occipital Nerve Blockade: A Safe and Effective Option for the Acute Treatment of Hemiplegic Aura Javier Casas-Limón, MD; Ángel Aledo-Serrano, MD; Belén Abarrategui, MD; María-Luz Cuadrado, MD, PhD
Background.—Prolonged auras such as those of hemiplegic migraine or migraine with brainstem aura may be extremely disabling. The availability of effective treatments is limited, but two case reports described cessation of the aura symptoms after a greater occipital nerve (GON) blockade. Case.—A 26-year-old woman with a history of hemiplegic migraine with prolonged auras came to our office with an episode of motor and sensory aura 1 hour after onset. Both muscle strength and sensory function started to improve immediately after a GON anesthetic blockade, and the patient was fully relieved in 50 minutes. Conclusion.—GON blockade may be an effective option for the acute treatment of hemiplegic aura or other prolonged migraine auras. Key words: greater occipital nerve, nerve blockade, migraine aura, hemiplegic migraine, treatment Abbreviations: CSD cortical spreading depression, GON greater occipital nerve, MRI magnetic resonance imaging
(Headache 2015;••:••-••) 2015;55:1000-1003)
The most frequent types of migraine aura are the visual, sensory, or aphasic ones, lasting less than 60 minutes in most cases. Prolonged auras such as the ones seen in hemiplegic migraine or in migraine with From the Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain (J. Casas-Limón, Á. Aledo-Serrano, B. Abarrategui, and M.L. Cuadrado); Department of Neurology, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain (J. Casas-Limón); Department of Neurology, Hospital Quirón Madrid, Pozuelo de Alarcón, Madrid, Spain (J. Casas-Limón); Department of Medicine, Universidad Complutense, Madrid, Spain (M.L. Cuadrado). Patient Consent Informed consent was obtained from the patient included in this case report.
brainstem aura are by far much less common. This long-lasting phenomenon may be truly disabling, and can range from some hours to several days. Apart from a single inconclusive randomized controlled trial with intranasal ketamine,1 only few reports have found evidence of possible effectiveness of some drugs (valproic acid,2 acetazolamide,3 intravenous furosemide,4 lamotrigine,5 and magnesium,6 among others) for the acute treatment of prolonged auras. The greater occipital nerve (GON) blockade is a different option. So far, only two case reports have described cessation of these episodes with this procedure.7,8 We present a new case of rapid alleviation of the motor and sensory aura symptoms after GON blockade.
Address all correspondence to J. Casas-Limón, Department of Neurology, Hospital Universitario Fundación Alcorcón, Budapest 1, Alcorcón, Madrid 28922, Spain. Conflict of Interest: No conflict. Accepted for publication April 1, 2015.
Financial Support: None.
1000 1
Headache 2
1001
CASE REPORT A 26-year-old woman with personal and family history of migraine without aura suffered her first hemiplegic aura 3 years before assessment. The episode consisted of a right-sided headache, preceded by a feeling of glare lasting 15 minutes, along with manifest weakness and tingling in her left arm and leg. These motor and sensory symptoms disappeared spontaneously in 5 hours. Brain magnetic resonance imaging (MRI) taken at that time was normal. During the next 3 years the patient was on topiramate, but still had three more episodes with the motor symptoms lasting about 5 hours. Lamotrigine was added as a preventive, but had to be ended in less than 1 month because of a skin reaction. The day when our blockade took place, once again she had a progressive weakness in her left limbs and tingling in her left arm. She also had a severe right-sided headache scored as 9 out of 10 accompanied by photophobia and phonophobia. She came to our office 65 minutes after symptom onset. Ten minutes later, an anesthetic blockade of both GON was performed by injecting 2.5 cc of bupivacaine 0.5% with a 30 gauge, 0.5 inch (0.3 mm × 13 mm) needle. On each side, the needle was inserted one third of the distance on a line drawn from the external
occipital protuberance to the mastoid, just medial to the occipital artery.9 After the procedure, we assessed muscle strength and sensory function in the affected limbs every 5 minutes, as shown in Tables 1 and 2. She was paucisymptomatic in 15-25 minutes, and fully relieved in 50 minutes. Together with the aura symptoms, the pain decreased and vanished in less than 25 minutes. A new MRI did not show any abnormalities. In the subsequent months, she came to the emergency room with the same symptoms twice again 2 hours after onset, obtaining complete relief few minutes after GON blockade on both occasions.
DISCUSSION In our patient, GON blockade was followed by rapid and complete resolution of the aura symptoms, just as occurred to the prior cases of hemiplegic and brainstem migraine auras published by Rozen7 and Baron et al.8 It could have been natural history that the aura stopped, but most likely it was the procedure that stopped the aura. Indeed, all her previously untreated auras lasted about 5 hours, and this one ceased in less than 2 hours. Moreover, there was a consistency of response to the GON blockade on two more occasions.
Table 1.—Strength of Different Muscles on the Left Side of the Body After the Occipital Nerve Block (Time Course)†
Time
0 5 10 15 20 25 30 35 40 45 50 minute minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes
Upper Arm abduction limb Elbow flexion Elbow extension Wrist flexion Wrist extension Thumb opposition Finger abduction
4 44443 3
4 4 4 4 4 3 3
4 4 4+ 4 4 3 4-
4 4 5 5 5 44-
4+ 4+ 5 5 5 44-
4+ 4+ 5 5 5 4 4
5 5 5 5 5 4 4
5 5 5 5 5 4 4+
5 5 5 5 5 4 4+
5 5 5 5 5 4+ 4+
5 5 5 5 5 5 5
Lower Hip flexion limb Knee flexion Knee extension Foot plantar flexion Foot dorsiflexion
4 4 4 4 3
4 5 4 4 4
5 5 5 5 5
5 5 5 5 5
5 5 5 5 5
5 5 5 5 5
5 5 5 5 5
5 5 5 5 5
5 5 5 5 5
5 5 5 5 5
5 5 5 5 5
†Muscle strength is graded on a scale of 0-5 (5: muscle contracts normally; 4: muscle strength is reduced but muscle contraction can still move joint against resistance; 3: muscle strength is further reduced such that the joint can be moved only against gravity).
1002 Headache
July/August 2015 3 Table 2.—Sensory Function of the Left Upper Limb After the Occipital Nerve Block (Time Course)†
Time
0 5 10 15 20 25 30 35 40 45 50 minute minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes
Touch
Proximal Distal Position Distal
↓ ↓↓ ↓↓
↓ ↓↓ ↓
N ↓ N
N ↓ N
N ↓ N
N ↓ N
N N N
N N N
N N N
N N N
N N N
†N: normal; ↓: mildly affected; ↓↓: severely affected.
The mechanism of action of the GON anesthetic blockade is unclear. There is evidence of a functional connection between the trigeminal nerve and the upper cervical sensory fibers, where the GON is originated.10 Modifying the activity in the trigeminocervical complex might abort the cortical spreading depression (CSD) and thus, make the aura symptoms disappear. Both CSD and trigeminal activation are important facts in migraine pathophysiology, and they must be connected in some way. Experimental data have demonstrated that CSD can activate the trigeminal system.11,12 On the other hand, there seems to be a feedback loop from the trigeminal nucleus caudalis with both activation and suppression capabilities on CSD generation;7 this could explain why the aura typically stops as the headache begins, and why some nociceptive inputs may provoke aura.13 GON blockade could theoretically activate the trigeminal nucleus suppression arm of CSD with termination of the aura. It is also possible that GON blockade has no direct modulation of CSD. Instead, it may initiate a diffuse inhibitory process over the entire cascade of migraine, including the pain and the aura.7 In fact, other symptoms of the migraine complex such as allodynia and photophobia can also respond to the anesthetic blockade of the GON.14 In conclusion, GON blockade is an easy, fast and safe procedure that we can use for the acute treatment of hemiplegic aura or other prolonged migraine auras. We believe it should be considered in this kind of migraine episodes, due to the lack of effective alternatives.
STATEMENT OF AUTHORSHIP Category 1 (a) Conception and Design Javier Casas-Limón, María-Luz Cuadrado (b) Acquisition of Data Javier Casas-Limón, Angel Aledo-Serrano, Belén Abarrategui (c) Analysis and Interpretation of Data Javier Casas-Limón, María-Luz Cuadrado Category 2 (a) Drafting the Manuscript Javier Casas-Limón, Angel Aledo-Serrano (b) Revising It for Intellectual Content María-Luz Cuadrado Category 3 (a) Final Approval of the Completed Manuscript Javier Casas-Limón, Angel Aledo-Serrano, Belén Abarrategui, María-Luz Cuadrado
REFERENCES 1. Afridi SK, Giffin NJ, Kaube H, Goadsby PJ. A randomized controlled trial of intranasal ketamine in migraine with prolonged aura. Neurology. 2013;80: 642-647. 2. Rothrock JF. Successful treatment of persistent migraine aura with divalproex sodium. Neurology. 1997;48:261-262. 3. Haan J, Sluis P, Sluis LH, Ferrari MD. Acetazolamide treatment for migraine aura status. Neurology. 2000;55:1588-1589.
Headache 4 4. Rozen TD. Treatment of a prolonged migrainous aura with intravenous furosemide. Neurology. 2000; 55:732-733. 5. Chen WT, Fuh JL, Lu SR, Wang SJ. Persistent migrainous visual phenomena might be responsive to lamotrigine. Headache. 2001;41:823-825. 6. Rozen TD. Intravenous prochlorperazine with magnesium sulfate can abort a prolonged migrainous aura during pregnancy. Headache. 2003;43:901-903. 7. Rozen T. Cessation of hemiplegic migraine auras with greater occipital nerve blockade. Headache. 2007;47:917-928. 8. Baron EP, Tepper SJ, Mays M, Cherian N. Acute treatment of basilar-type migraine with greater occipital nerve blockade. Headache. 2010;50:10571069. 9. Blumenfeld A, Ashkenazi A, Napchan U, et al. Expert consensus recommendations for the performance of peripheral nerve blocks for headaches – A narrative review. Headache. 2013;53:437-446.
1003 10. Busch V, Jakob W, Juergens T, Schulte-Mattler W, Kaube H, May A. Functional connectivity between trigeminal and occipital nerves revealed by occipital nerve blockade and nociceptive blink reflexes. Cephalalgia. 2006;26:50-55. 11. Moskowitz MA, Nozaki K, Kraig RP. Neocortical spreading depression provokes the expression of c-fos protein-like immunoreactivity within trigeminal nucleus caudalis via trigeminovascular mechanisms. J Neurosci. 1993;13:1167-1177. 12. Bolay H, Reuter U, Dunn AK, Huang Z, Boas DA, Moskowitz MA. Intrinsic brain activity triggers trigeminal meningeal afferents in a migraine model. Nat Med. 2002;8:136-142. 13. Husid MD. New onset migraine with aura following head injury: A case report. Headache. 2004;44:10481050. 14. Young W, Cook B, Malik S, Shaw J, Oshinsky M. The first 5 minutes after greater occipital nerve block. Headache. 2008;48:1126-1139.
Headache Headache C 2015 American Headache Society V © 2015 American Headache Society
Brief Communication Communications Greater Occipital Nerve Blockade: A Safe and Effective Option for the Acute Treatment of Hemiplegic Aura Javier Casas-Limón, MD; Ángel Aledo-Serrano, MD; Belén Abarrategui, MD; María-Luz Cuadrado, MD, PhD
Background.—Prolonged auras such as those of hemiplegic migraine or migraine with brainstem aura may be extremely disabling. The availability of effective treatments is limited, but two case reports described cessation of the aura symptoms after a greater occipital nerve (GON) blockade. Case.—A 26-year-old woman with a history of hemiplegic migraine with prolonged auras came to our office with an episode of motor and sensory aura 1 hour after onset. Both muscle strength and sensory function started to improve immediately after a GON anesthetic blockade, and the patient was fully relieved in 50 minutes. Conclusion.—GON blockade may be an effective option for the acute treatment of hemiplegic aura or other prolonged migraine auras. Key words: greater occipital nerve, nerve blockade, migraine aura, hemiplegic migraine, treatment Abbreviations: CSD cortical spreading depression, GON greater occipital nerve, MRI magnetic resonance imaging
(Headache 2015;••:••-••) 2015;55:1000-1003)
The most frequent types of migraine aura are the visual, sensory, or aphasic ones, lasting less than 60 minutes in most cases. Prolonged auras such as the ones seen in hemiplegic migraine or in migraine with From the Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain (J. Casas-Limón, Á. Aledo-Serrano, B. Abarrategui, and M.L. Cuadrado); Department of Neurology, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain (J. Casas-Limón); Department of Neurology, Hospital Quirón Madrid, Pozuelo de Alarcón, Madrid, Spain (J. Casas-Limón); Department of Medicine, Universidad Complutense, Madrid, Spain (M.L. Cuadrado). Patient Consent Informed consent was obtained from the patient included in this case report.
brainstem aura are by far much less common. This long-lasting phenomenon may be truly disabling, and can range from some hours to several days. Apart from a single inconclusive randomized controlled trial with intranasal ketamine,1 only few reports have found evidence of possible effectiveness of some drugs (valproic acid,2 acetazolamide,3 intravenous furosemide,4 lamotrigine,5 and magnesium,6 among others) for the acute treatment of prolonged auras. The greater occipital nerve (GON) blockade is a different option. So far, only two case reports have described cessation of these episodes with this procedure.7,8 We present a new case of rapid alleviation of the motor and sensory aura symptoms after GON blockade.
Address all correspondence to J. Casas-Limón, Department of Neurology, Hospital Universitario Fundación Alcorcón, Budapest 1, Alcorcón, Madrid 28922, Spain. Conflict of Interest: No conflict. Accepted for publication April 1, 2015.
Financial Support: None.
1000 1
Headache 2
1001
CASE REPORT A 26-year-old woman with personal and family history of migraine without aura suffered her first hemiplegic aura 3 years before assessment. The episode consisted of a right-sided headache, preceded by a feeling of glare lasting 15 minutes, along with manifest weakness and tingling in her left arm and leg. These motor and sensory symptoms disappeared spontaneously in 5 hours. Brain magnetic resonance imaging (MRI) taken at that time was normal. During the next 3 years the patient was on topiramate, but still had three more episodes with the motor symptoms lasting about 5 hours. Lamotrigine was added as a preventive, but had to be ended in less than 1 month because of a skin reaction. The day when our blockade took place, once again she had a progressive weakness in her left limbs and tingling in her left arm. She also had a severe right-sided headache scored as 9 out of 10 accompanied by photophobia and phonophobia. She came to our office 65 minutes after symptom onset. Ten minutes later, an anesthetic blockade of both GON was performed by injecting 2.5 cc of bupivacaine 0.5% with a 30 gauge, 0.5 inch (0.3 mm × 13 mm) needle. On each side, the needle was inserted one third of the distance on a line drawn from the external
occipital protuberance to the mastoid, just medial to the occipital artery.9 After the procedure, we assessed muscle strength and sensory function in the affected limbs every 5 minutes, as shown in Tables 1 and 2. She was paucisymptomatic in 15-25 minutes, and fully relieved in 50 minutes. Together with the aura symptoms, the pain decreased and vanished in less than 25 minutes. A new MRI did not show any abnormalities. In the subsequent months, she came to the emergency room with the same symptoms twice again 2 hours after onset, obtaining complete relief few minutes after GON blockade on both occasions.
DISCUSSION In our patient, GON blockade was followed by rapid and complete resolution of the aura symptoms, just as occurred to the prior cases of hemiplegic and brainstem migraine auras published by Rozen7 and Baron et al.8 It could have been natural history that the aura stopped, but most likely it was the procedure that stopped the aura. Indeed, all her previously untreated auras lasted about 5 hours, and this one ceased in less than 2 hours. Moreover, there was a consistency of response to the GON blockade on two more occasions.
Table 1.—Strength of Different Muscles on the Left Side of the Body After the Occipital Nerve Block (Time Course)†
Time
0 5 10 15 20 25 30 35 40 45 50 minute minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes
Upper Arm abduction limb Elbow flexion Elbow extension Wrist flexion Wrist extension Thumb opposition Finger abduction
4 44443 3
4 4 4 4 4 3 3
4 4 4+ 4 4 3 4-
4 4 5 5 5 44-
4+ 4+ 5 5 5 44-
4+ 4+ 5 5 5 4 4
5 5 5 5 5 4 4
5 5 5 5 5 4 4+
5 5 5 5 5 4 4+
5 5 5 5 5 4+ 4+
5 5 5 5 5 5 5
Lower Hip flexion limb Knee flexion Knee extension Foot plantar flexion Foot dorsiflexion
4 4 4 4 3
4 5 4 4 4
5 5 5 5 5
5 5 5 5 5
5 5 5 5 5
5 5 5 5 5
5 5 5 5 5
5 5 5 5 5
5 5 5 5 5
5 5 5 5 5
5 5 5 5 5
†Muscle strength is graded on a scale of 0-5 (5: muscle contracts normally; 4: muscle strength is reduced but muscle contraction can still move joint against resistance; 3: muscle strength is further reduced such that the joint can be moved only against gravity).
1002 Headache
July/August 2015 3 Table 2.—Sensory Function of the Left Upper Limb After the Occipital Nerve Block (Time Course)†
Time
0 5 10 15 20 25 30 35 40 45 50 minute minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes
Touch
Proximal Distal Position Distal
↓ ↓↓ ↓↓
↓ ↓↓ ↓
N ↓ N
N ↓ N
N ↓ N
N ↓ N
N N N
N N N
N N N
N N N
N N N
†N: normal; ↓: mildly affected; ↓↓: severely affected.
The mechanism of action of the GON anesthetic blockade is unclear. There is evidence of a functional connection between the trigeminal nerve and the upper cervical sensory fibers, where the GON is originated.10 Modifying the activity in the trigeminocervical complex might abort the cortical spreading depression (CSD) and thus, make the aura symptoms disappear. Both CSD and trigeminal activation are important facts in migraine pathophysiology, and they must be connected in some way. Experimental data have demonstrated that CSD can activate the trigeminal system.11,12 On the other hand, there seems to be a feedback loop from the trigeminal nucleus caudalis with both activation and suppression capabilities on CSD generation;7 this could explain why the aura typically stops as the headache begins, and why some nociceptive inputs may provoke aura.13 GON blockade could theoretically activate the trigeminal nucleus suppression arm of CSD with termination of the aura. It is also possible that GON blockade has no direct modulation of CSD. Instead, it may initiate a diffuse inhibitory process over the entire cascade of migraine, including the pain and the aura.7 In fact, other symptoms of the migraine complex such as allodynia and photophobia can also respond to the anesthetic blockade of the GON.14 In conclusion, GON blockade is an easy, fast and safe procedure that we can use for the acute treatment of hemiplegic aura or other prolonged migraine auras. We believe it should be considered in this kind of migraine episodes, due to the lack of effective alternatives.
STATEMENT OF AUTHORSHIP Category 1 (a) Conception and Design Javier Casas-Limón, María-Luz Cuadrado (b) Acquisition of Data Javier Casas-Limón, Angel Aledo-Serrano, Belén Abarrategui (c) Analysis and Interpretation of Data Javier Casas-Limón, María-Luz Cuadrado Category 2 (a) Drafting the Manuscript Javier Casas-Limón, Angel Aledo-Serrano (b) Revising It for Intellectual Content María-Luz Cuadrado Category 3 (a) Final Approval of the Completed Manuscript Javier Casas-Limón, Angel Aledo-Serrano, Belén Abarrategui, María-Luz Cuadrado
REFERENCES 1. Afridi SK, Giffin NJ, Kaube H, Goadsby PJ. A randomized controlled trial of intranasal ketamine in migraine with prolonged aura. Neurology. 2013;80: 642-647. 2. Rothrock JF. Successful treatment of persistent migraine aura with divalproex sodium. Neurology. 1997;48:261-262. 3. Haan J, Sluis P, Sluis LH, Ferrari MD. Acetazolamide treatment for migraine aura status. Neurology. 2000;55:1588-1589.
Headache 4 4. Rozen TD. Treatment of a prolonged migrainous aura with intravenous furosemide. Neurology. 2000; 55:732-733. 5. Chen WT, Fuh JL, Lu SR, Wang SJ. Persistent migrainous visual phenomena might be responsive to lamotrigine. Headache. 2001;41:823-825. 6. Rozen TD. Intravenous prochlorperazine with magnesium sulfate can abort a prolonged migrainous aura during pregnancy. Headache. 2003;43:901-903. 7. Rozen T. Cessation of hemiplegic migraine auras with greater occipital nerve blockade. Headache. 2007;47:917-928. 8. Baron EP, Tepper SJ, Mays M, Cherian N. Acute treatment of basilar-type migraine with greater occipital nerve blockade. Headache. 2010;50:10571069. 9. Blumenfeld A, Ashkenazi A, Napchan U, et al. Expert consensus recommendations for the performance of peripheral nerve blocks for headaches – A narrative review. Headache. 2013;53:437-446.
1003 10. Busch V, Jakob W, Juergens T, Schulte-Mattler W, Kaube H, May A. Functional connectivity between trigeminal and occipital nerves revealed by occipital nerve blockade and nociceptive blink reflexes. Cephalalgia. 2006;26:50-55. 11. Moskowitz MA, Nozaki K, Kraig RP. Neocortical spreading depression provokes the expression of c-fos protein-like immunoreactivity within trigeminal nucleus caudalis via trigeminovascular mechanisms. J Neurosci. 1993;13:1167-1177. 12. Bolay H, Reuter U, Dunn AK, Huang Z, Boas DA, Moskowitz MA. Intrinsic brain activity triggers trigeminal meningeal afferents in a migraine model. Nat Med. 2002;8:136-142. 13. Husid MD. New onset migraine with aura following head injury: A case report. Headache. 2004;44:10481050. 14. Young W, Cook B, Malik S, Shaw J, Oshinsky M. The first 5 minutes after greater occipital nerve block. Headache. 2008;48:1126-1139.
