View source for Nerve Block: Occipital

===Background===
[[File:Gray800.png|thumb|Posterior primary divisions of the upper three cervical nerves. (Great occipital nerve labeled at center top.)]]
[[File:Gray790.png|thumb|Lateral view (greater occipital nerve posterior)]]
*Therapeutic and diagnostic for occipital neuralgia
*Nerve is between ~8-18 mm deep<ref>M. Greher, B. Moriggl, M. Curatolo, L. Kirchmair and U. Eichenberger. Sonographic visualization and ultrasound-guided blockade of the greater occipital nerve: a comparison of two selective techniques confirmed by anatomical dissection. Br. J. Anaesth. (2010) 104 (5): 637-642.</ref>

==Indications==
*Suspected or confirmed occipital neuralgia
*[[Migraine]] refractory to conservative treatment
*[[Post-lumbar puncture headache]] refractory to conservative treatment
*Cluster headache, occipital neuralgia, cervicogenic headache, or migraine with occipital nerve irritation or tenderness <ref>https://www.nuemblog.com/blog/occipital-nerve-block</ref>

==Contraindications==
*Infection overlying injection site

==Equipment Needed==
*PPE
*Syringe and 27-30ga needle
*Betadine or chlorhexidine
*Local anesthetic
**40mg of methylprednisolone or triamcinolone may be mixed with the local anesthetic<ref name="Brock">Brock G. The occasional greater occipital nerve block. Can J Rural Med. 2014 Fall;19(4):152-5.</ref>, but efficacy has not been proven.

==Procedure==
*Patient in position of comfort allowing access to posterior head and neck. (laying prone or sitting with head down in arms)
*Identify Greater Occipital Nerve (GON).
**May be palpated 1.5-2.5 cm inferior to occipital protuberance and ~1.5-2 cm lateral to midline<ref name="Dach">Dach F, Éckeli ÁL, Ferreira Kdos S, Speciali JG. Nerve block for the treatment of headaches and cranial neuralgias - a practical approach. Headache. 2015 Feb;55 Suppl 1:59-71.</ref>
**Alternatively, may be ultrasound guided - look for occipital artery in medial third of the line from occipital tubercle to mastoid process<ref name="Palamar">Palamar D, Uluduz D, Saip S, et al. Ultrasound-guided greater occipital nerve block: an efficient technique in chronic refractory migraine without aura? Pain Physician. 2015 Mar-Apr;18(2):153-62.</ref>
***GON will be located medial to artery.
*Cleanse skin with betadine or chlorhexidine and allow to dry
*Insert needle over nerve at 90 degrees to skin until hit bone, then withdraw slightly<ref>Inan LE, Inan N, Karadaş Ö, et al. Greater occipital nerve blockade for the treatment of chronic migraine: a randomized, multicenter, double-blind, and placebo-controlled study. Acta Neurol Scand. 2015 Mar 13. doi: 10.1111/ane.12393</ref>
**If using ultrasound, insert needle at 45 degrees to skin and advance toward nerve under direct ultrasound guidance
*Aspirate to ensure not in vessel.
*Inject ~1-3 mL of local anesthetic. (may inject small amount medial and lateral to nerve to ensure adequate block)<ref name="Brock" />
*Repeat on contralateral side, if indicated.

{{Maximum doses of anesthetic agents}}

==Complications==
''Complications are rare due to superficial location and lack of major surrounding structures.<ref name="Brock" />''
*Damage to surrounding structures
*Bleeding
*Infection

==Follow-up==
*Follow up with appropriate specialist for the indication for nerve block.

==See Also==
*[[Nerve Blocks (Main)]]
*[[Local Anesthetic Systemic Toxicity (LAST)]]
*[[Headache]]
*[[Migraine_headache|Migraine]]

==External Links==

===Videos===
{{#widget:YouTube|id=6Dj5zYbvLxo}}


==References==
<references/>

[[Category:Procedures]]
[[Category:Neurology]]