Coverage Policy Manual
Policy #: 2017018
Category: Medicine
Initiated: May 2017
Last Review: May 2024
  Sphenopalatine Ganglion and Occipital Nerve Block for Headache

Description:
HEADACHES AND HEADACHE
Headaches are common neurologic disorders and are among the top reasons that patients seek medical care. Headaches affect approximately 50% of the general population in a given year and over 90% of people have a lifetime history of headache (IASP, 2011). The 2 most common types of headache are tension-type headaches and migraines. Tension-headaches have a prevalence of approximately 40% (Singh, 2012). They are diagnosed when patients report at least 2 of the following characteristics: bilateral headache location, nonpulsating pain, mild to moderate intensity and headache not aggravated by physical activity (Cephalalgia, Jul 2013;33). Migraines are the second-most common headache disorder with 1-year prevalence of migraine in the United States of approximately 12% (Singh, 2012).  They are characterized by severe pain on 1 or both sides of the head, an upset stomach, and, at times, disturbed vision, Migraines can be categorized by headache frequency. According to the Third Edition of the International Headache Classification (ICHD-3), migraine without aura (previously known as common migraine) is defined as at least 5 attacks per month meeting other diagnostic criteria (Cephalaglia, Jul 2013;33).  Chronic migraine is defined as attacks on at least 15 days per month for more than 3 months, with features of migraine on at least 8 days per month. Cluster headaches are less common than tension or migraine headaches, with an estimated prevalence of 0.1% of the population (Singh, 2012).  Cluster headaches are characterized by severe unilateral orbital, supraorbital and/or temporal pain that also includes other symptoms in the eye and/or nose on the same side such as rhinorrhea and eyelid edema or drooping. Due to the severity of pain associated with cluster headaches, patients may seek emergency treatment.
 
Treatment
A variety of medications are used to treat acute migraine episodes. They include medications taken at the onset of an attack to abort the attack (triptans, ergotamines), and medications to treat the pain and other symptoms of migraines once they are established (nonsteroidal anti-inflammatory drugs, narcotic analgesics, antiemetics). Prophylactic medication therapy may be appropriate for people with migraines that occur more than 2 days per week. In addition to medication, behavioral treatments such as relaxation and cognitive therapy are used in the management of migraine headache. Moreover, botulinum toxin type A injections are a U.S. Food and Drug Administration (FDA)-approved treatment for chronic migraine. Severe acute cluster headaches may be treated with abortive therapy including breathing 100% oxygen, and triptan medications. Other medications used to treat cluster headaches include steroids, calcium channel blockers and nerve pain medications. Tension-type headaches are generally treated with over the counter pain medication.
 
Sphenopalatine Ganglion Block
Sphenopalatine ganglion (SPG) nerve blocks are a proposed treatment option for chronic migraines and some severe non migraine headaches. The SPG is a group of nerve cells that is located behind the bony structures of the nose. The nerve bundle is linked to the trigeminal nerve, the primary nerve involved in headache disorders. The SPG has both autonomic nerves, which in this case are associated with functions such as tearing and nasal congestion, and sensory nerves, associated with pain perception. SPG nerve blocks involve topical application of local anesthetic to mucosa overlying the SPG. The rationale for using SPG blocks to treat headaches is that local anesthetics in low concentrations could block the sensory fibers and thereby reduce pain while maintaining autonomic function. The currently proposed procedure for SPG nerve blockade is to insert a catheter intranasally that is attached to a syringe carrying local anesthetic (eg, lidocaine or bupivacaine). Once the catheter is in place, the local anesthetic is applied to the posterior wall of the nasal cavity and reaches the SPG. Some form of SPG blocking procedure has been used for many years. Originally, SPG blocks were done by inserting a cotton-tipped applicator dabbed with local anesthetic into the nose; this technique may be less accurate and effective than the currently proposed procedure. Another variation is to insert a needle into the cheek and inject local anesthetic but this no longer appears to be used since it is more invasive and can be painful. Neurostimulation of the SGB and SGB blockade with radiofrequency lesioning have been used outside of the United States but these treatments are not FDA-cleared or approved.
 
Three catheter devices are currently commercially available in the United States for performing SPG blocks. The catheters have somewhat different designs but all are attached to syringes that contain local anesthetic. The catheters are inserted intranasally and once in place, the local anesthetic is applied through the catheter. With 2 of the 3 commercially available catheters, the SpenoCath® or Allevio , patients are positioned on their back with their nose pointed vertically and their head turned to the side. With the Tx360® device, patients remain seated.4 The company marketing the Tx360® device is proposing its use in the context of a protocol called the MiRx protocol. This 2-part protocol includes a medical component for immediate pain relief and a physical component to reduce headache recurrences. The medical component involves clinical evaluation and, if the patient is considered eligible, an SPG block procedure. The physical component can include any of a number of approaches such as physical therapy, ergonomic modifications, massage and dietary recommendations.
 
The optimal number and frequency of SPG treatments is unclear. Information from the American Migraine Foundation states that the procedure can be repeated as often as needed to control pain (AMF, 2016). An RCT described a course of treatment for migraines consisting of SPG blocks twice a week for 6 weeks (total of 12 treatments).
 
Occipital Nerve Block
Occipital nerve blocks (also referred to as Greater Occipital nerve blocks or GONB) involve injection of a local anesthetic with or without steroid around the greater and lesser occipital nerves located in the back of the head just above the neck area. Occipital nerve block injections have been studied for the treatment of various headache syndromes and occipital neuralgia.
 
REGULATORY STATUS
The Tx360® Nasal Applicator (Tian Medical), the Allevio SPG Nerve Block Catheter (JET Medical), and the SpenoCath® (Dolor Technologies) are considered class I devices by the U.S. Food and Drug Administration (FDA) and are exempt from 510(k) requirements. This classification does not require submission of clinical data regarding efficacy but only notification of FDA prior to marketing. These 3 devices are all used to apply numbing medication intranasally.
 
Coding
It has been mentioned that this procedure is sometimes reported with CPT code 64505 Injection, anesthetic agent; sphenopalatine ganglion but it is felt that in the absence of an actual injection, that code is incorrect. The American Medical Association recommends using an unlisted code 64999, Unlisted procedure, nervous system to report this procedure. There is a specific procedure code for occipital nerve block, CPT code 64405 Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve.

Policy/
Coverage:
Effective August 01, 2024
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Sphenopalatine ganglion blocks does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for all indications, including but not limited to the treatment of migraines and non-migraine headaches.
 
For members with contracts without primary coverage criteria, sphenopalatine ganglion blocks are considered investigational.  Investigational services are specific contract exclusions in most member benefit certificates of coverage
 
Occipital nerve block does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for the treatment of occipital neuralgia and headache syndromes including, but not limited to, chronic migraine, chronic daily headache, cervicogenic and cluster headache.
 
For members with contracts without primary coverage criteria, Occipital nerve block is considered investigational for the treatment of occipital neuralgia and headache syndromes including, but not limited to, chronic migraine, chronic daily headache, cervicogenic and cluster headache. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Effective May 2017 to July 2024
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Sphenopalatine ganglion blocks does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes  for all indications, including but not limited to the treatment of migraines and non-migraine headaches.
 
For members with contracts without primary coverage criteria, sphenopalatine ganglion blocks are considered investigational.  Investigational services are specific contract exclusions in most member benefit certificates of coverage.      

Rationale:
Rationale
This evidence review was originally created in May 2017 based on a search of the MEDLINE database. The most recent literature search was conducted through March 23, 2017.
 
Assessment of efficacy for therapeutic interventions involves a determination of whether the intervention improves health outcomes. The optimal study design for this purpose is a randomized controlled trial (RCT) that includes clinically relevant measures of health outcomes. Intermediate outcome measures, also known as surrogate outcome measures, may also be adequate if there is an established link between the intermediate outcome and true health outcomes. Nonrandomized comparative studies and uncontrolled studies can sometimes provide useful information on health outcomes, but are prone to biases such as noncomparability of treatment groups, placebo effect, and variable natural history of the condition. Because the placebo response rate is typically high in patients with headache, assessment of evidence focuses on randomized, placebo-controlled trials.
 
CHRONIC MIGRAINE
The published literature on SGB blocks to treat chronic migraine consists of 1 double-blind placebo controlled RCT (Cady, 2015,Jan; Cady, 2015, Apr) and a small case report with 3 patients (Candido, 2013).
 
Findings of the RCT were published in two 2015 publications by Cady and colleagues. The first publication reported on the primary outcome measure and key secondary outcomes, and the subsequent publication reported on supplemental secondary outcomes and longer term follow-up. The trial included patients who met International Classification of Headache Disorders (ICHD-2) diagnostic criteria for chronic migraine headache (Cephalalgia, 2004) and had CM for at least 3 months. Patients could use concomitant headache medication, but needed to agree not to make changes in medication use during the study period. Following an initial 28-day baseline period to confirm the diagnosis of CM, patients were randomized 2:1 to receive treatment with 0.5% bupivacaine or saline (placebo) applied using the Tx360® device. Patients received a series of 12 treatments, 2 treatments a week for 6 weeks. The primary outcome was change in pain severity, measured by a 0 to 10 numeric rating scale (NRS). Pain severity was assessed 15 minutes, 30 minutes and 24 hours after each treatment. Key secondary outcome measures were the Patient’s Global Impression of Change (PGIC), the Headache Impact Test (HIT-6) questionnaire and patient satisfaction with treatment. In addition, patients kept headache diaries throughout the study.
 
Forty-one patients met eligibility criteria and had CM diagnoses confirmed during the baseline period.
These patients were randomized to receive application of bupivacaine (n=27) or placebo (n=13). One patient in the placebo group withdrew consent, and 3 patients were excluded from analysis due to protocol violations, leaving 38 patients in the final dataset. This included 26 in the bupivacaine group and 12 in the placebo group. Mean baseline scores on the NRS were 4.8 in the bupivacaine group and 4.5 in the placebo group. When pooling findings for all treatments, patients in the bupivacaine group reported a significantly greater reduction in the NRS than the placebo group at 15 minutes, 30 minutes, and 24 hours after treatment. An analysis also found significantly lower PGIC scores in the bupivacaine than saline groups at 30 minutes and 24 hours post treatment. No statistically significant between group differences were found in HIT-6 scores or in average acute mediation use. Only 1 serious adverse event (SAE) was reported and it was not treatment-related.
 
Another 2015 publication by Cady and colleagues on this study reported on 1- and 6- month follow-up results and on supplemental secondary end points (Cady, 2015, Apr). To control for multiple comparisons, the cutoff for statistical significance for the supplemental secondary end points was p less than 0.01. There were not statistically significant differences between groups in the reported supplementary secondary outcomes. These outcomes include the number of headache days per month, the mean pain score and quality of life measures. A post hoc power analysis revealed that the study was underpowered to detect significant differences in secondary outcomes. Some results were suggestive of a possible long-term effect (e.g. the bupivacaine group had a lower, albeit non-significant number of headache days in the month post treatment than the placebo group (17 vs 23). However, a study with a larger sample size would be needed to confirm whether or not 1- or 6-month results are significantly better after bupivacaine versus placebo treatment.
 
Section Summary: Chronic Migraine
One double-blind placebo-controlled RCT has evaluated transnasal SPG blocks for chronic migraine. The study found a significantly greater short-term (up to 24 hours) reduction in pain severity after active treatment versus placebo. However, there were not significant longer-term effects on outcomes (ie, 1 and 6 months after a course of 12 treatments over 6 weeks). The study was underpowered to detect outcomes at 1 and 6 months, and additional adequately powered trials are needed to determine the impact of SPG blocks on health outcomes.
 
SEVERE ACUTE HEADACHE TREATED IN AN EMERGENCY SETTING
The published literature on SGB blocks to treat severe acute headache consists of 1 double-blind placebo-controlled RCT (Schaffer, 2015). The study included patients between the ages of 18 and 65 who presented to the emergency department with a frontal-based crescendo-onset headache and a negative neurological examination. The study focused on frontal-based headaches because these were considered most likely to respond to SPG blocks. Headaches were not classified into specific types but patients with sudden onset headache were excluded. Ninety-three patients met eligibility criteria and were randomized 1:1 to receive treatment with bupivacaine 0.5% (n=45) or a saline placebo (n=48) applied using the Tx360® device. The intervention consisted of 1 treatment session. The primary outcome was a 50% absolute pain reduction on a 100-mm visual analog scale (VAS) 15 minutes post-treatment. Four patients, 2 in each group, withdrew before receiving the intervention and 2 were deemed ineligible after randomization. Thus, 41 patients in the bupivacaine group and 46 in the placebo group were included in the primary analysis.
 
For the primary outcome, 20 (49%) patients in the bupivacaine group and 19 (41%) patients in the placebo group had at least a 50% reduction in the mean VAS score. The difference between groups was not statistically significant (difference, 7.5%; 95% CI, -13% to 27%). Secondary outcomes including at least a 19mm reduction in VAS, percent of patients who were headache-free 15 minutes post-intervention and percent of patients who were nausea-free 15 minutes post-intervention, also did not differ significantly between groups. Seventy-six (88%) patients were available for follow-up after 24 hours. The percent of patients headache free at 24 hours was significantly higher in the bupivacaine group (n=26 [72%]) than the placebo group (n=19 [48%]; difference, 25%; 95% CI, 2.6 to 44%). No SAEs were reported in either group. The authors stated that, in retrospect, outcome assessment at 1 hour after treatment would have been useful since headache relief at 1 hour, but not at 24 hours, is clinically relevant for ED headache patients.
 
Section Summary: Severe Acute Headache
One double-blind placebo-controlled RCT has evaluated a single transnasal SPG block for treating patients with acute headache presenting to an emergency department. The authors did not find a statistically significant benefit of active treatment compared with placebo 15 minutes post-intervention. Significantly more patients were headache-free at 24 hours in the active treatment versus placebo group, but, in the absence of short-term pain relief, SPG blocks would not be a clinically useful treatment in the emergency setting. Future studies conducted in the emergency setting should assess outcomes in an intermediate time period (eg, 1 or 2 hours after treatment).
 
CLUSTER HEADACHE
No RCTs or non-randomized controlled studies were identified that evaluated intranasal SPG blocks for treating cluster headache. Two case series in patients with chronic drug-resistant cluster headache (CH) were published by a research group in Milan, Italy (Felisati, 2006; Pipolo, 2010). Both studies used a needle (20-gauge in 1 study and 18-gauge in the other) under endoscopic control to inject a mixture of local anesthetics and steroid as close as possible to the SPG. The mixture consisted of triamcinolone acetonide (40mg), 1% bupivacaine (4mL) and 2% mepivacaine with 1/100,000 adrenaline (2mLThe earlier study, published in 2006 by Felisati and colleaguesl included 21 patients who received between 2 and 4 total treatment sessions, provided 1 week apart. Including 1 patient in whom the treatment could not be applied, 9 (45%) experienced no efficacy, 3 (15%) experienced a partial benefit and 8 (40%) experienced a complete temporary benefit. In the 8 patients who had complete disappearance of attacks, the benefit lasted between 2-4 weeks in 3 patients, 3-6 months in 3 patients and 12-24 months in 2 patients. Four patients (19%) experienced treatment-related complications which consisted of 1 case of marked nasal epistaxis 3 days after the procedure and 3 cases of temporary diplopia.
 
In 2010, Pipolo reported on 15 patients who received 3 treatments a mean of 3 days apart. Eight of the 15 patients (53%) experienced complete remission of CH symptoms. Three of these (20%) continued to be in remission at last followup (mean: 18 months). One patient (7%) experienced partial benefit and 6 (40%) reported either no benefit or a benefit for less than 2 weeks. Three patients (20%) experienced complications including 2 cases of severe epistaxis and 1 reduced buccal opening that resolved after 5 months.
 
Section Summary: Cluster Headache
The literature includes 2 case series, both of which were published by the same research group in Italy. The approach to treatment was similar in the 2 studies but differed in terms of medication and application technique from the intervention currently available in the United States. It is not clear how the safety or efficacy of the procedure used in the case series differs from an intranasal SPG block applying local anesthetics and using an FDA cleared device. In the series, 40-50% of patients experienced complete symptom relief for a variable length of time and about 20% had treatment-related complications. The studies are limited by small sample sizes and lack of a sham treatment or alternative therapy for treating cluster headache.
 
SUMMARY OF EVIDENCE
For individuals who have chronic migraine who receive sphenopalatine ganglion blocks, the evidence includes 1 RCT and a case report. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The RCT was double-blind and placebo controlled, and provided a course of 12 SPG blocks over 6 weeks. It found significantly greater short-term (up to 24 hours) benefits of active treatment versus placebo. There were not significant longer-term effects (ie, 1 and 6 months after a course of 12 treatments). The study was underpowered to detect longer term efficacy. Additional adequately powered RCTs demonstrating efficacy are needed. The evidence is insufficient to determine the effects of the technology on health outcomes.
 
For individuals who have severe acute headache treated in an emergency setting who receive sphenopalatine ganglion blocks, the evidence includes 1 RCT. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The RCT was double-blind and placebo controlled, and provided a single SPG block. There was not a statistically significant difference between active treatment and placebo in the primary outcome, pain reduction 15 minutes post-intervention. The study did not collect pain data again while patients were in the emergency department (eg, at 1 hour after treatment). At 24 hours after treatment, significantly more patients were headache-free in the active treatment versus placebo group. However, there is insufficient evidence that SPG blocks are an effective treatment in the emergency setting. The evidence is insufficient to determine the effects of the technology on health outcomes.
 
For individuals who have cluster headache who receive sphenopalatine ganglion blocks, the evidence includes case series. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Two small case series were available; the approach to intranasal SPG blocks differed from the intervention currently available in the United States. It is not clear how the safety or efficacy of the procedure used in the case series differs from an intranasal SPG block applying local anesthetics and using an FDA cleared device. In the series, 40-50% of patients experienced complete symptom relief for a variable length of time and about 20% had treatment-related complications. Additional studies, preferably RCTs are needed to evaluate SPG blocks for treating cluster headaches. The evidence is insufficient to determine the effects of the technology on health outcomes.
 
ONGOING AND UNPUBLISHED CLINICAL TRIALS
Some currently unpublished trials that might influence this review are listed below:
 
Ongoing
(NCT02365909) Study Evaluating Sphenopalatine Ganglion Block (SPGB) for Treatment of Postdural Puncture Headache (PDPH); planned enrollment 30; projected completion date December 2017.
 
(NCT02090998) Sphenopalatine Ganglion Nerve Block vs. Elavil for Treatment of Transformed Migraines; planned enrollment 200; projected completion date May 2018.
 
2019 Update
A literature search was conducted through July 2019.  There was no new information identified that would prompt a change in the coverage statement.  
 
2020 Update
Annual policy review completed with a literature search using the MEDLINE database through July 2020. No new literature was identified that would prompt a change in the coverage statement.
 
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through July 2021. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
Jespersen et al conducted a double-blind RCT comparing administration of SPG block with local anesthetic (lidocaine 4% and ropivacaine 0.5%) to placebo (saline) (Jespersen, 2020). Twenty patients were randomized to each group with an upright median visual analog scale (VAS) pain score of 74 and 84 mm, respectively. Eligibility criteria included adult patients 18 yr with PDPH defined as moderate-to-severe VAS pain score (>30 mm) in an upright position that develops within 3 days after an intended or accidental dural puncture. The headache must have persisted for at least 1 day after dural puncture and must be intractable to treatment with fluids, caffeine, and acetaminophen, fulfilling eligibility criteria to receive an EBP. The primary outcome, median pain intensity in the upright position at 30 min after SPG block, was 26 mm in the anesthetic group and 37 mm in the placebo group (estimated median difference, 5 mm; 95% CI, -14 to 21; P = 0.53). Patients were offered a rescue SPG block if persistent pain was experienced, defined as VAS 30 mm, between 1 h and 7 days after initial block. The rescue block was a repeated SPG block with open-label anesthetic. Rescue blocks were required in 65% of patients in each group, received an average of 1.4 h or 1.5 h following the initial block in the anesthetic and placebo groups, respectively. An EBP was offered if the rescue block failed to relieve pain. In the anesthetic group, 50% of patients required an EBP compared with 45% treated with placebo (P = 0.76). Interpretation of EBP use is limited by broad administration of rescue blocks in both groups. The median time to EBP was 11 vs 5.5 h in anesthetic vs placebo groups, respectively.
 
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through July 2022. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
The American Academy of Pain Medicine conducted a systematic review to develop practice recommendations for use of percutaneous interventional strategies for the preventive treatment of migraine (Barad, 2021). Sphenopalatine ganglion blocks received a weak recommendation for chronic migraine prevention based on a very low certainty of evidence. The only therapy evaluated in the guideline that received a strong recommendation for chronic migraine prevention was onabotulinumtoxinA.
 
The American Headache Society guideline on the treatment of cluster headache includes subcutaneous sumatriptan, zolmitriptan nasal spray, and high flow oxygen as Level A (established as effective) acute treatment recommendations (Robbins, 2016). Sphenopalatine ganglion stimulation is rated as a Level B (probably effective) acute treatment recommendation. However, the recommendation for sphenopalatine ganglion stimulation was based on 1 randomized controlled trial that evaluated an implanted, on-demand, acute electrical stimulation device of the SPG, rather than a catheter device used to apply local anesthetic (Schoenen, 2013). There are no Level A recommendations for reducing the frequency of cluster headaches in the guideline.
 
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through July 2023. No new literature was identified that would prompt a change in the coverage statement.
 
2024 Update
A literature search using the MEDLINE database was performed through April 2024. Following is a summary of the key literature to date.
 
Sphenopalatine Ganglion Block
Dwivedi et al (2023) published a systematic review and meta-analysis of 9 RCTs comparing SPG block to other treatments in patients with PDPH. The SPG blocks consisted of various lidocaine concentrations (2% to 10%) with some studies combining lidocaine with ropivacaine, dexamethasone, or epinephrine. Comparators included sham block with saline, intranasal lidocaine block, greater occipital nerve block, or pharmacotherapy. Six studies were considered to have "some concern" for bias while the remaining 3 had a low risk of bias. Efficacy outcomes included pain at various time points from 30 minutes up to 7 days after intervention. Limitations of the of the studies include the variety of anesthetic strengths and combinations used for SPG, the open-label design of the majority of the studies, and the small sample sizes.
 
Occipital Nerve Block
Inan et al (2015), published the results of a randomized, multicenter, double-blind, placebo-controlled trial that measured the effect of greater occipital nerve blockade (GONB) on chronic migraine headaches. Patients with chronic migraine headaches were randomly divided into two groups of 42 participants. GONB was administered 4 times (once per week) with saline placebo in group A and with bupivacaine in group B. After 4 weeks of treatment, the blinding was removed in group A and GONB was delivered to this placebo group by also using bupivacaine, while group B continued to receive bupivacaine only once per month. The primary endpoint was the difference in number of headache days, duration of headache, and pain scores. After 1 month of treatment, the number of headache days had decreased from 16.9 ± 5.7 to 13.2 ± 6.7 in group A (p=0.035) and from 18.1 ± 5.3 to 8.8 ± 4.8 in group B (p<0.001) and p=0.004 between groups. The duration of headache (in hours) had decreased from 24.2 ± 13.7 to 21.2 ± 13.4 in group A (p=0.223) and from 25.9 ± 16.3 to 19.3 ± 11.5 in group B (p<0.001),and p=0.767 between groups. The visual analog scale (VAS) score decreased from 8.1 ± 0.9 to 6.7 ± 1.6 in group A(p=0.002) and from 8.4 ± 1.5 to 5.3 ± 2.1 in group B (p<0.001) and p=0.004 between groups. After blinding was removed (in months 2 and 3), group A exhibited similar results to group B in month 3. The authors concluded that, in this limited trial, GONB with bupivacaine was superior to placebo and was effective and safe for the treatment of chronic migraine. However, limitations were noted within this small study, which compared GONB vs. saline placebo. Only 72 of the 84 subjects actually completed the study (n=33 placebo; n=39 bupivacaine). Although treatment with bupivacaine reduced the number of headache days per month, it did not reduce the duration of headaches, compared with placebo. This preliminary study is the first placebo-controlled study of GONB in chronic migraine with only a short duration of follow-up, which was limited to only 1 month of actual blinding and did not address the potential confounder of a placebo effect.
 
Dilli and colleagues published the results of a randomized, placebo-controlled trial of 63 subjects with chronic migraine where a single treatment of GONB was delivered to 33 individuals in the active treatment arm. Study participants were randomized to receive either 2.5 ml of 0.5% bupivacaine plus 0.5 ml (20 mg) methylprednisolone over the ipsilateral (unilateral headache) or bilateral (bilateral headache) occipital nerve (ON) or 2.75 ml normal saline plus 0.25 ml of 1% lidocaine without epinephrine (placebo arm). In the active and placebo groups respectively, the mean frequency of at least moderate (mean9.8 versus 9.5) and severe (3.6 versus 4.3) migraine days and acute medication days (7.9 versus 10.0) were not substantially different at baseline. All study subjects completed a 1-month headache diary prior to and after the double-blind injection. The primary outcome measure was defined as a 50% or greater reduction in the frequency of days with moderate or severe migraine headache in the 4-week post-injection study period, compared to the 4-week pre-injection baseline period. At 28 days post-injection, the percentage of subjects with at least a 50% reduction in the frequency of moderate or severe headache days was 30% for both groups (10/30 vs. 9/30, 0.00, 95% confidence interval [CI], -0.22 to 0.23). The authors concluded that GONB does not reduce the frequency of moderate to severe migraine days in individuals with episodic or chronic migraine compared to placebo.
 
In 2008, Ashkenazi et al published the results of a randomized comparative trial to determine whether adding triamcinolone to local anesthetics increased the efficacy of GONB and trigger-point injections (TPIs) for chronic daily headache (transformed migraine [TM]). Study subjects with TM were randomized to receive GONB and TPIs using lidocaine 2% and bupivacaine 0.5% with either saline (group A) or triamcinolone 40 mg (group B). The severity of headache and associated symptoms were assessed before and 20 minutes after injection for 37 individuals with TM. The study subjects documented headache and severity of associated symptoms for 4 weeks after injections. Changes in symptom severity were then compared. Twenty minutes after injection, the mean headache severity had decreased by 3.2 points in group A(p<0.01) and by 3.1 points in group B (p<0.01) with a mean neck pain severity decrease by 1.5 points in group A (p<0.01)and 1.7 points in group B (p<0.01). The mean duration of headache-freedom was reported as 2.7 ± 3.8 days in group A and 1.0 ± 1.1 days in group B (p=0.67). None of the outcome measures differed significantly between the two groups. The authors concluded that the addition of triamcinolone to local anesthetics when performing GONB and TPIs was not associated with improved outcome.
 
A 2020 Chowdhury et al published the results of a randomized controlled study on the efficacy and tolerability of combined chronic migraine treatment with GONB with topiramate compared to monotherapy with topiramate. Patients received one of three treatment arms; group A consisted of topiramate monotherapy once per day, group B consisted of topiramate plus GONB with 40 mg lidocaine (2%) and 80 mg (2 ml) methylprednisolone as the first injection followed by 2 monthly injections of lidocaine. Group C participants received topiramate plus monthly GONB with 40 mg lidocaine (2%) injections for 3 months. The primary endpoint was the mean change in monthly migraine days. A secondary endpoint was the number of participants who achieved more than 50% reduction in monthly headache days from baseline to 3 months. There were 125 randomized participants; 41 to group A, 44 to group B, and 40 to group C. Efficacy assessments were done for 121 participants. Patients who received combination therapy and GONB in groups B and C showed greater reductions in monthly migraine days at month 3 compared to those in group A who received monotherapy only. The mean monthly migraine days changed from 14.1 days at baseline to 6.7 days at month 3 in group A compared to12.9 days to 4 days in group B and 15 days to 4.2 days in group C. At the end of month 3, 30/42 participants (71.4%) in group B and 24/38 participants (62.4%) in group C achieved a greater than 50% reduction in monthly headache days. This compared to 16/41 participants (39%) with greater than 50% improvement in group A. There were some mild treatment-related adverse events which included limb paresthesia, local site swelling, bleeding, and dizziness. No serious adverse events were reported. In this study, lack of investigator blinding, and lack of a placebo arm (sham injections) were potential risks of bias.
 
The AANS has stated:
Often, occipital neuralgia symptoms will improve or disappear with heat, rest, physical therapy including massage, anti-inflammatory medications, and muscle relaxants… Percutaneous nerve blocks may not only be helpful in diagnosing occipital neuralgia but can also help alleviate pain. Nerve blocks involve either the occipital nerves or in some patients, the C2 and/or C3 ganglion nerves. It is important to keep in mind that repeat blocks using steroids may cause serious adverse effects (AANS, 2013).
 
Regarding the efficacy of GONB therapy for the treatment of occipital neuralgia, efficacy has only been demonstrated in observational and cohort studies and series of small numbers with only short-term outcomes data. Given that there is no conclusive evidence of the durable therapeutic effect of GONB in occipital neuralgia, further study is needed to confirm its benefits when closely balanced with risk, before widespread use can be recommended (Bogduk, 2009; Hammond, 1978;Vanelderen, 2010).

CPT/HCPCS:
64405Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve
64505Injection, anesthetic agent; sphenopalatine ganglion
64999Unlisted procedure, nervous system

References: American Migraine Foundation.(2016) Sphenopalatine Ganglion Blocks in Headache Disorders. 2016; https://americanmigrainefoundation.org/understanding-migraine/sphenopalatine-ganglion-blocks-inheadache-disorders

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