Occipital HA

[101N]

What's your algorithm for treating these folks. I'm talking younger folks - typically women - with atraumatic neck pain precipitating a non-migrainous HA. Usually this means pain radiating from the sub-occipital region to the vertex and sometimes to the retro-orbital area. (Note, these arn't LOL's with C1/2 arthropathy.)

In the past I've pretty much done it all - MBB, discography, RFA, ONS - and ended up settling on ONB followed by a ONS trial because it seemed to work best. But lately I've gotten a lot of push back from insurers that ONS is 'experimental'.

As an aside, we should assemble a reference set on ONS. Leaving out the junk journal.

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[lovebailey2001]

I have treated few patients with b/l gr & lesser occipital nerve blocks with LA & steroid (Triamcinolone 80 mg total in 3-5 ml. bupi. .25%) and they got relieved for 4-6 mths., then pain comes back. But repeat injections have worked well till now.

Lately, thinking of doing suboccipital compratment decompression as described by P. Raj, but havn't done it yet.

 

[Ligament]

These young women are almost always TON neurotomies. I have a very bimodal distribution of TON neurotomies. Young women, and old people. Thats it for the most part.

I've never had a young woman with real GON or LON issues. Always TON. I have no idea why.

 

[Ligament]

Here is Racz' lecture on suboccipital nerve decompression using his "stealth" needle from Epimed. I've never done it. I've seen him do it in a DVD from epimed, a paragraph on the procedure in the ASIPP atlas, and this online PPT slide show. Is anything published on this, does anybody here have experience with it?

http://www.ttuhsc.edu/som/cme/Flyers/PainSymp2005/G_Racz_Transforaminal-suboccipital_blocks.pdf

 

[bedrock]

These young women are almost always TON neurotomies. I have a very bimodal distribution of TON neurotomies. Young women, and old people. Thats it for the most part.

I've never had a young woman with real GON or LON issues. Always TON. I have no idea why.

Agree mostly.

I see a trimodal distribution. Young women and old people, + high velocity MVA.

I have seen young women with both TON & GON issues. Maybe due to the convergence between those nerves at the level of the spinal cord.

Quite a few times I've seen patients with both TON/GON symptoms. I start with GON as it's less invasive. GON helps temporarily, but still have TON sympoms. I RF the TON and C3 and they tell me their upper neck pain & temporal headaches are gone, but they still have suboccipital pain, which is again temporarily relieved by GON block.

Anyone still do RF for GON? Or do you just do GON blocks and stim those with inadequate or very brief relief from GON blocks.

 

[spinal]

Here is Racz' lecture on suboccipital nerve decompression using his "stealth" needle from Epimed. I've never done it. I've seen him do it in a DVD from epimed, a paragraph on the procedure in the ASIPP atlas, and this online PPT slide show. Is anything published on this, does anybody here have experience with it?

http://www.ttuhsc.edu/som/cme/Flyers/PainSymp2005/G_Racz_Transforaminal-suboccipital_blocks.pdf

It works. I collected the data on that procedure when I was at TTUHSC.

 

[ALFI]

Seeming as they are mostly young women have you checked there eyes or had an optjmology consult to rule out idiopathic intracranial hypertension?? Classical presentation is negative CT, headaches and migraines worse in the morning, papillaedema of the optic nerves and optic disks eventually leading to double and blurred vision then permanent blindness.

I have IIH and it's crippling but my med school is really good and understands actually just got over a 5 day migraine and am getting my strength back. I was told 'drop 30kg and you'll be fine' not that easy when you take 15 tablets in the morning and 10 at night!!

 

[PMR 4 MSK]

I won't touch HA pts without a full w/u from neuro. Luckily, the neuros here like to do HA, so I don't do much.

No opioids for HA, ever.

But I'll do the nerve blocks for them, or the botox.

 

[olafa]

Agree mostly.

I see a trimodal distribution. Young women and old people, + high velocity MVA.

I have seen young women with both TON & GON issues. Maybe due to the convergence between those nerves at the level of the spinal cord.

Quite a few times I've seen patients with both TON/GON symptoms. I start with GON as it's less invasive. GON helps temporarily, but still have TON sympoms. I RF the TON and C3 and they tell me their upper neck pain & temporal headaches are gone, but they still have suboccipital pain, which is again temporarily relieved by GON block.

Anyone still do RF for GON? Or do you just do GON blocks and stim those with inadequate or very brief relief from GON blocks.

Any one have any additional updates on techniques and efficacy for GON RF (pulsed or heat) - after TON has been taken care of but patient like above, still has posterior occipital pain relieved by GON blocks.

 

[pmrmd]

Sometimes the O-A joint is culprit.

 

[epidural man]

What's your algorithm for treating these folks. I'm talking younger folks - typically women - with atraumatic neck pain precipitating a non-migrainous HA. Usually this means pain radiating from the sub-occipital region to the vertex and sometimes to the retro-orbital area. (Note, these arn't LOL's with C1/2 arthropathy.)

In the past I've pretty much done it all - MBB, discography, RFA, ONS - and ended up settling on ONB followed by a ONS trial because it seemed to work best. But lately I've gotten a lot of push back from insurers that ONS is 'experimental'.

As an aside, we should assemble a reference set on ONS. Leaving out the junk journal.

That is unfortunate about insurance not wanting to pay for stim - it seems to work very well and truthfully would SAVE the insurance company money.

We recently completed a study of GON block steroid/local vs pulsed RF. I don't know the outcome. I don't think I am an author but I did half the blocks - thanks colleagues.

 

[ziggyziggy]

Re-igniting the old thread. Considering no one is paying for ONS and pulsed RFA, treatment algorithm must have changed. At times, I have difficulty in getting covered for C2/3 or TON RFA.

What algorithm are you following? What temp/time are you running for thermal RF and if you have seen any complications from it?

Epidural man - has that study been published and what was the outcome?

 

[willabeast]

interventional Rx for occipital HA (this is after a complete work up, right?) in my hands (when i was working in order of safety. NO EVIDENCE for this except 20+ years of experience.
1. muscle relaxation exercises. takes about 3 months to work, lasts a lifetime. by far the best result/outcome/patient satisfaction. least $$?
2. botox suboccipital block. make sure you avoid dural puncture if using local anesthetic. 50-100 units allergan botox. lasts 3-4 months.
3. cervical ESI if foraminal stenosis
4. MBB TON and C3 with steroid (or no steroid - depends on the patient)
5. RFN if + #4 using bogduk criteria.
always keep in the back of your mind (pun intended) that stress gives a lot of people occipital headaches. when the stress goes away so will the headache. so don't think you are necessarily a genius when you "cure" your patient with an injection. they probably changed jobs or their kid finally got married.
back to my internet surfing

 

[lonelobo]

Interesting to read the 1st post of this thread