Efficacy of the Greater Occipital Nerve Block for Cervicogenic Headache: Comparing Classical and Subcompartmental Techniques.

AIM: The aim of the study was to compare the efficacy of the greater occipital nerve (GON) block using the classical technique and different volumes of injectate with the subcompartmental technique for the treatment of cervicogenic headache (CH). METHODS: Thirty patients acted as his/her own control. All patients were submitted to the GON block by the classical technique with 10 mg dexamethasone, plus 40 mg lidocaine (5 mL volume). Patients were randomly allocated into 1 of 3 groups (n = 10) when pain VAS was > 3 cm. Each group was submitted to a GON subcompartmental technique (10 mg dexamethasone + 40 mg lidocaine + nonionic iodine contrast + saline) under fluoroscopy using either 5, 10, or 15 mL final volume. Analgesia and quality of life were evaluated. RESULTS: The classical GON technique resulted in 2 weeks of analgesia and less rescue analgesic consumption, compared to 24 weeks after the subcompartmental technique (P < 0.01). Quality of life improved at 2 and 24 weeks after the classical and the suboccipital techniques, respectively (P < 0.05). The data revealed that groups were similar regarding analgesia when compared to volume of injection (P > 0.05). CONCLUSIONS: While the classical technique for GON block resulted in only 2 weeks of analgesia, the subcompartmental technique resulted in at least 24 weeks of analgesia, being 5 mL volume sufficient for the performance of the block under fluoroscopy.

Cervicogenic headache: a review comparison with migraine, tension-type headache, and whiplash.

Cervicogenic headache (CEH) is a well-recognized syndrome. Proposed diagnostic criteria differentiate CEH from migraine and tension-type headache (TTH) in most of the cases. The best differentiating factors include side-locked unilateral pain irradiating from the back and evidence of neck involvement--attacks may be precipitated by digital pressure over trigger spots in the cervical/nuchal areas or sustained awkward neck positions. Migrainous traits may be present in some cases. Cervical lesions are not necessarily seen, and most common cervical lesions do not produce CEH. Whiplash may occasionally induce headaches. This is suspected when the pain onset and the whiplash trauma are close in time. Whiplash-related headaches tend to be short-lasting, admitting mostly a TTH or a CEH-like phenotype. Neuroimaging abnormalities are not necessarily expected in CEH. Whiplash patients must undergo cervical imaging mostly in connection with the trauma, as no abnormalities are pathognomonic in chronic cases.

Aspectos clínicos e epidemiológicos da cefaleia pós-traumática crônica / Clinical and epidemiological aspects of chronic post-traumatic headache

Contexto: Existem muitas controvérsias acerca da patogênese da cefaleia pós-traumática, se vem de alterações orgânicas devidas a um trauma cranioencefálico ou se os acometidos dessa condição buscam um ganho secundário. Objetivo: Descrever os aspectos clínicos e epidemiológicos da cefaleia pós-traumática crônica (CPTC) em pacientes atendidos em dois hospitais de referência de Salvador, BA. Métodos: Foram estudados 33 pacientes que preencheram os critérios estabelecidos para CPTC. Resultados: Seis por cento apresentaram frequência de cefaleia inferior a 1 dia por mês; 49%apresentaram frequência de 1 a 7 dias por mês; 30%, de 8 a 14 dias por mês; 6%, por mais de 14 dias por mês, e 9% apresentaram cefaleia diariamente. Quanto à intensidade, 3% dos pacientes classificaram a cefaleia como leve, 30% como moderada e 67% como grave. Vinte e sete por cento caracterizaram sua cefaleia como “em pressão”, 61% como “pulsátil” e 12% como “em pontada”. O diagnóstico da CPTC foi migrânea em 79% dos pacientes e cefaleia tensional em 21% dos pacientes. Conclusão: A maior prevalência de migrânea nesses pacientes se deve ao fato de o trabalho ter sido realizado em um dos centros especializados. A uniformidade do padrão manifestado de cefaleia e a média de idade do aparecimento da cefaleia também falam a favor de uma causa orgânica para a CPTC, entretanto faz-se necessária a realização de estudos experimentais que possam comprovar essa teoria analisando os pacientes mais graves para reforçar a hipótese orgânica para origem da CPTC.

Background: Current data describes 75% to 85% of chronic post-traumatic headaches (CPTH) have a clinical presentation of tension-type headache. Pathogenesis of post-traumatic headache has been controversial; is it an organic secondary lesion due to head trauma or is simulated on aim of a secondary gain. Objective: To describe the clinical and epidemiological aspects of CPTH in two headache centers in Salvador city (Bahia, Brazil). Method: We studied 33 patients that fulfilled the established criteria for CPTH. Results: The frequency of headache was less than 1 day/month in 6% of the patients, 1 to7 days/month in 49%, 8 to 14 days/month in 30%, more than 14 days/month in 6% and 9% had daily headache. Intensity was analyzed and 3% of the patients referred mild headache, 30% moderate and67% referred severe headache. Twenty-seven per cent characterized the headache as “pressing”,61% as “pulsating” and 12% referred the pain manifesting like “sharp “. Migraine type was diagnosed in 79% of the patients and tension-type headache in 21%. Conclusion: A high prevalence of migraine may be explained by the recruitment of more severe patients in specialized centers and it supports the hypothesis of an organic pathogenesis for the CPTH. The uniformity of the pattern of headache and the average age of onset of headache also suggest an organic cause for the CPT, however it is necessary to perform experimental studies that can prove this theory.

O efeito do laser de baixa intensidade no tratamento das cefaleias cervicogênicas: apresentação de sete casos / Low-intensity laser to treat cervicogenic headaches: presentation of seven cases.

JUSTIFICATIVA E OBJETIVOS: A cefaleia cervicogênica é caracterizada por dor nucal e/ou fronto-temporal desencadeada por distúrbio na região do pescoço, C1, C2 ou C3. A dor é unilateral, iniciada na região da nuca e referida na região fronto-temporal sendo episódica ou crônica. O bloqueio do nervo occipital maior ou menor é feito com duas finalidades: terapêutica e diagnóstica. O objetivo deste estudo foi verificar o efeito do laser de baixa intensidade (GaAlAs) aplicado na região do nervo occipital maior e menor e/ou da raiz C2 do lado sintomático no tratamento das cefaleias cervicogênicas, substituindo o bloqueio convencional.RELATOS DOS CASOS: Foram encaminhados para o procedimento sete pacientes, do Ambulatório de Cefaleia do Hospital de Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo. Esses pacientes foram submetidos às aplicações com o laser (D = 60J/cm², 1 vez/semana durante 4 semanas) do lado sintomático em 8 pontos-gatilho localizados através da palpação na região dos nervos occipital maior e menor. Esses pacientes preencheram um diário de dor e foram feitas 4 avaliações: A0 (antes da 1a aplicação), A1 (logo após a última aplicação), A2 e A3 (30 e 60 dias após a última aplicação). CONCLUSÃO: Laser de baixa intensidade promoveu a diminuição da intensidade e frequência da sintomatologia, mas de acordo com os resultados sugere-se que alterações na potência e doses sejam feitas a fim de se buscar um protocolo mais exato.

BACKGROUND AND OBJECTIVES: Cervicogenic headache is characterized by nuchal and / or fronto-temporal pain triggered by neck region disorder, C1, C2 or C3. Pain is unilateral, starts in the nuchal region and refers to fronto-temporal region, being episodic or chronic. Major or minor occipital nerve block is performed with two goals: therapeutic and diagnostic. This study aimed at observing the effect of low-intensity laser (GaAIAs) applied to major and minor occipital nerve and / or C2 root at the symptomatic side to treat cervicogenic headaches, replacing conventional block.CASE REPORTS: Seven patients of the Headache Ambulatory, Clinicas Hospital, School of Medicine of Ribeirão Preto, University of São Paulo, were referred to the procedure. Patients were submitted to laser applications (D = 60J/cm², once a week for four weeks) at the symptomatic side in 8 trigger-points identified through palpation of major and minor occipital nerves region. Patients filled a pain log and 4 evaluations were made: A0 (before first application), A1 (soon after last application), A2 and A3 (30 and 60 days after last application). CONCLUSION: Low-intensity laser has decreased symptoms intensity and frequency, but according to results we suggest that changes in potency and dosages are made to look for a more accurate protocol.

Post-traumatic headache.

The onset of post-traumatic headache (PTC) occurs in the first seven days after trauma, according to the International Headache Society (IHS) classification. The objective of this study was to evaluate the several forms of headache that appear after mild head injury (HI) and time interval between the HI and the onset of pain. We evaluated 41 patients with diagnosis of mild HI following the IHS criteria. Migraine without aura and the chronic tension-type headache were the most prevalent groups, occurring in 16 (39%) and 14 (34.1%) patients respectively. The time interval between HI and the onset of headache was less than seven days in 20 patients (48.7%) and longer than 30 days in 10 (24.3%) patients. The results suggest that PTC may arise after a period longer than is accepted at the present by the IHS.

Post-traumatic headache / Cefaléia após traumatismo cranioencefálico

The onset of post-traumatic headache (PTC) occurs in the first seven days after trauma, according to the International Headache Society (IHS) classification. The objective of this study was to evaluate the several forms of headache that appear after mild head injury (HI) and time interval between the HI and the onset of pain. We evaluated 41 patients with diagnosis of mild HI following the IHS criteria. Migraine without aura and the chronic tension-type headache were the most prevalent groups, occurring in 16 (39 percent) and 14 (34.1 percent) patients respectively. The time interval between HI and the onset of headache was less than seven days in 20 patients (48.7 percent) and longer than 30 days in 10 (24.3 percent) patients. The results suggest that PTC may arise after a period longer than is accepted at the present by the IHS.

O início da cefaléia pós-traumática (CPT) ocorre dentro de sete dias após o trauma, de acordo com a classificação da Sociedade Internacional de Cefaléia (SIC). O objetivo deste estudo foi avaliar as diversas formas de cefaléia que surgem após o traumatismo cranioencefálico (TCE) leve e o intervalo de tempo entre o TCE e o início da dor. Foram avaliados 41 pacientes com diagnóstico de cefaléia pós-traumática leve segundo os critérios da SIC. Migrânea sem aura e cefaléia do tipo tensional crônica foram os tipos de cefaléia mais comuns, ocorrendo em 16 (39 por cento) e 14 (34,1 por cento) dos pacientes respectivamente. O intervalo de tempo entre o TCE e o início da cefaléia foi menor que sete dias em 20 pacientes (48 por cento) e maior que 30 dias em 10 (24,3 por cento) pacientes. Estes resultados sugerem que a CPT pode surgir após período maior do que é aceito atualmente pela SIC.

Cervicogenic headache.

The connection between headache and the cervical spine has been a theme of debate for decades. Cervicogenic headache is a headache related to the cervical spine that often is misdiagnosed and treated inadequately because of confusing and varying terminology. In this article, we discuss our experience in diagnosing and treating cervicogenic headache.