EM:RAP Emergency Medicine: Reviews and Perspectives

2012  ›  August Episode

Cervical Injection for Headache

Larry and Al chat about the effectivness of a cervical injection to alleviate migraine pain. 

Contributor

  • Al Sacchetti, MDOur Lady of Lourdes Hospital Camden New Jersey

Comments on Cervical Injection for Headache

Larry M.

This injection technique is an excellent adjunct for treating headaches and many face pain conditions. However, even though it is good, intravenous compazine and benadryl are better. Additionally, be aware that "bad", well entrenched headaches that are difficult to treat with your favorite cocktails will also frustrate you with the cervical injections. Nevertheless, you can start with either compazine or reglan (whatever isn't in shortage status) OR the cervical injection and let either one be the rescue medication that finally conquers the headache.

Kevin M., MD

Had a guy that had a history of migraines and a similar HA last night. The HA had been going on for 3 days. I did the procedure of the discussion, 20 minutes later, his HA went from 9/10->3/10. Not bad for a first attempt. I'll give it a trial run although I still don't really know how this works.

Kevin M., MD

I've used this technique 5 times for all sorts of pain from the neck up. Four of them have had considerable improvement including a woman who had neck, head, ear and jaw pain for 7 weeks. I injected her last night and within 20 minutes her pain went from 8/10 to less than 1/10.

I'm not sure I'm buying the explanation of the pathophysiology, and it might be just placebo effect, but it has given me four encounters where my patients have left the ER considerably better than they arrived and I didn't have to give them any opiates.

That's good enough for me for now.

Ahmed M.

Used it today for a patient who was a bounceback from the night before. Received IV opioid pain meds and came back in the morning for "cervical dystonia". History of same treated with botox. Triggering a headache asst'd with vomiting. She left last night with best pain at 6/10. After injection she got immediate improvement and we were able to achieve 5/10, but appeared much more comfortable.

Vomiting proved to be difficult to control but we were able to discharge her feeling better after 2nd visit. She did receieve IV opioid meds on the 2nd visit as well.

For now, I will put this in the success column although the vomiting and the need for parenteral opioids keeps me from saying that it was a runaway success.

Larry M.

Remember that in our series of over 417 patients 65% got complete relief, 20% got partial relief and needed additional therapy and 15% didn't get any relief. It's not always a run away success, but it is a nice additional therapeutic adjunct. As far as placebo effect is concerned, it is far more successful (85% getting benefit) than you would see with placebo (about 25%).

Mellick LB, McIlrath ST, Mellick GA. Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 417 patients. Headache. 2006 Oct;46(9):1441-9.

If anyone wants the published articles on this topic, feel free to write me at lmellick@georgiahealth.edu.

Abel T.

If it works for neck pain has there been thought of trying it in the lumbar region for people with lumbar pain exacerbations?

AKERDoc

I just tried this on 2 patients yesterday that had severe intractible headaches and neck pain. They had almost immediate relief of their pain, Amazing!!! Great technique

Yvonne B., M.D.

I have a personal friend who has bilateral trigeminal neuralgia treated surgically, but now has developed recurrent chronic facial pain and headache. After listening to this audio I had one of my partners do this injection for him. His pain went from a 6 to a 2, but recurred after about 12 hours. He develops 10/10 pain that lasts for days whenever he flies, which his work requires. Due to this he has had to limit his work. He asked for an injection prior to flying, and it again reduced his pain to a 2 or 3 and allowed him to fly with the pain never getting over a 5. The relief seemed again to last less than a day. He weighs 400 pounds. I have since performed another injection but delivered it 2 inches deep into the muscle because of his size. He has now had relief lasting several days after that injection. I have two questions. 1. How frequently can these injections be repeated? 2. Do you recommend giving the injection deeper on obese patients?

Larry M.

We communicated by e-mail, but I pretty much bury the needle into the muscle. You might not go to the hilt on a small thin person, but otherwise go deep. We don't know how often they can be given, but there is going to me some microscopic muscle injury with any injection. Nevertheless, I have had occasional patients get monthly or a little more frequent injections for chronic orofacial pain. One of the nurses I work with hits me up for an injection while we are working together every 3 to 4 months. She finds the injections help here with her recurrent migraine headaches.

Francois L., M.D.

This technique is intriguing, (and is quite useful I think) but not too dissimilar to what some of us who are familiar with prolotherapy have been doing for years. I think that we are causing sodium channel blockade mediated decrease of neuronal activity in the medial branches of the dorsal rami. Since all these nerves are interconnected in the C-spine, it affects a much bigger region than what one would expect from a single level injection. I would suggest that, for facial pain, one should consider doing this technique at the C2/3 level, because afferents from this region converge on the same second order neurons in the trigeminocervical complex in the brain (so will decrease trigeminal nerve area pain). Adding 5 % dextrose to lidocaine / bupivacaine increases the length of clinical effect in my experience.
Thanks again for this.
A GP/Anesthetist

John L., M.D.

Listened to this in August and tried it. First attempt was toothache for 3 weeks 10/10 down to 0/10 in ~3 minutes. So I figured I would give it a try. Now end of December; n of ~20; mostly headaches with about 7 or 8 toothaches. My results are a lot like the study. 10-14 100% relief; all but 3 had significant relief (10/10 down to 3-4/10). 2 had no effect.

One pt became much worse: "oh, my God, what have you done to me?!? It is much worse!! I'm calling my lawyer!! I want to speak to your manager!!" and the only thing that ever worked for their headache was a medicine that began with "D... dem.... dema-something" review of the pharmacy board revealed multiple Rx from multiple MDs for opiods- ~700 opiod pills Rx'd in past 2 months with 5 providers and 4 pharmacies. I might throw that one out.

Howard L.

0/3 - no relief at all. Frustrating. Thoughts?

Kirk H., IV

Why wouldn't you do dental blocks for dental pain? They ALWAYS work.

Lynne F., MD

I just started using this. I've done one "migraine", one toothache, and one headache associated with influenza. All three got significant relief, and the flu guy's headache was completely relieved. I'm very pleased with this! And personally, I'd much rather have someone put a needle into the base of my neck, than into my gums. I HATE dental injections!

Scott M., M.D.

I have performed 18 injections since listening to that particular lecture and watching the video on YouTube. I have had success in 17 of the 18 patients. The degree of relief varied from complete relief to good relief, but none of the patients required additional meds or narcotics.

Cortney S.

I was also really excited to try this after seeing the YouTube video, but I have unfortunately not had the amazing results that everyone else seems to have had. I think I have been using it only for the patients with complex pain (e.g. bad chronic daily headaches), so a much more difficult to treat population. Still, I would have liked to see a partial improvement this group of patients (I didn't tell them I was expecting 100% resolution of pain). As of yet I have not had any of them report a significant improvement. Maybe I will try to give it a try for some regular old migraines.

warren j.

i have had 5/6 success, did not need any other treatments. 2 of those were screaming in triage, so very surprised it worked so well.

Ruby R., M.D.

Has anyone had any medical/legal concerns about doing the procedure in your dept? If there was a complication or bad outcome, are we "protected" under the scope of our practice to perform these procedures in general? I'd like to try it but not sure if my hospital would approve of me doing a "pain management" procedure without their approval or do we need approval?? Any suggestions would be much appreciated, thanks.

Larry M.

This week had known glaucoma patient present with 9/10 pain. Eye pressure was 80 in the ophthalmology clinic. Resident had given two Percocet tablets an hour or so before and the pain was 6/10. After the cervical injection the pain went away completely. The pain had returned several hours later after being manipulated in the Ophthalmology clinic...it always does. Also as long as the inciting event is still there, the chances of return pain exists. Nevertheless, it was a nice reminder that this works on patients with eye pain.

robert j.

Have you ever added a steriod like kenalog to the local anaesthetic?

Larry M.

Yes, when I do a steroid there usually is a cervical muscle component or a chronic daily headache. I usually use 40 mg of Solu-Medrol as it comes out of the Pyxis machine in an easy to use 125 mg 2 mL bottle. I just add 0.6 mL of steroid to the 2.5 mL of bupivacaine in the syringe.

The question above about medical/legal concerns is also noted. There is nothing anatomically except muscle (and veins) in the areas being injected. I have done hundreds of these injections and the risks pretty much boil down to allergy to meds (very rare), intravenous administration (not good), vasovagal syncope and sore muscles. That's about it. Compared to some of the other stuff we do, this is really, really benign and safe.

Melissa Y.

Worked once amazingly for dental pain. Second patient vasovagaled on me.

Jonathan G.

Just used technique on pt w/ persisting tenstion headache refractory to meds. She feels much improved!

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