Another Arrow for Your Headache Quiver: Cervical Injections

People don’t come to the emergency department for treatment of headaches unless their headache severity or duration is intolerable or the headache is frighteningly different. (Neurol Clin 1998 May;16[2]:285.) Usually, these headaches have failed to respond to their usual and standard therapies. In fact, those who market the migraine-specific triptan drugs recognize that headaches that have progressed to the state of central sensitization simply don’t respond well to their drugs. (Ann Neurol 2004;55[1]:27; Ann Neurol 2004;55[1]:19; Clin Ther 2000;22[9]:1035.) Central sensitization is an increased response to stimulation that is mediated by amplification of signaling in the central nervous system. It is primarily demonstrated by allodynia, a painful response to a stimulus that does not normally cause pain. (Clin Ther 2000;22[9]:1035; Funct Neurol 2000;15[Suppl 3]:28; Ann Neurol 2000;47[5]:614.) In other words, headaches in the emergency department are not your garden-variety headaches. We are dealt the most difficult headaches to treat and need as many therapeutic arrows in our quiver as possible. The injection of small amounts of 0.5% bupivacaine bilaterally in the paraspinous muscles at the C6 or C7 level of the posterior neck was first recognized in 1996, and the first case series was published in 2003. It also appears to have a role in managing orofacial pain. (Headache 2003;43[10]:1109.) A 1.5-inch 25-gauge needle is used to inject 1.5 mL of 0.5% bupivacaine HCl approx...
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