A very significant study (abstract below) showed effectiveness of unilateral occipital nerve blocks in treating a range of different types of disabling headaches in pediatric and adolescent patients. Early and effective treatment is especially important in children. The population consisted of 159 patients 79% had chronic migraine, 14% new daily persistent headache, 4% a trigeminal autonomic cephalalgia, 3% secondary headache and one patient had chronic tension-type headache. The study concludes that “…confirms that unilateral injection of the greater occipital nerve is a safe, rapid-onset and effective treatment strategy in disabling headache disorders in children…”
The occipital nerve blocks utilized 1% lidocaine and 40 mg of methylprednisolone. There are always concerns when using steroids in children but its use is definitively better than having patients in constant pain. Relief ranged form 9 weeks +/- 4 weeks which is significant.
If we were to consider the pediatric patient this seems like an excellent treatment for the majority of patients but I would like to go a little further before recommending this as a lone treatment. Sphenopalatine Ganglion Blocks (SPG Blocks) are also extremely effective and can be done less invasively and without steroids. They also have a higher efficacy in adults but I am not sure of pediatric studies. The primary delivery method is via nasal cannula and does not require injections of steroid use. There is a great deal of research showing both safety and efficacy. SPG Blocks are utilized for intractable headaches in adults. https://www.sphenopalatineganglionblocks.com/intractable-headaches-migraines-sphenopalatine-ganglion-spg-blocks-may-fastest-safest-treatment/
The side effects of SPG Blocks are generally positive as they turn off sympathetic overload and the “Fight or Flight” reflex and give patients a sense of well being, decreased anxiety and elicitation of parasympathetic “feed and breed” reflex. The use plain lidocaine and do not require steroids. There is no contraindication to using them with other medications or with greater occipital nerve blocks.
There is one reference to use of SPG Blocks in pediatric patients in patients from 7 to 18 years of age. The study was presented at the Society of Interventional Radiology’s 2017 Annual Scientific Meeting. The minimally invasive SPG Block treatment takes only minutes to provide relief for migraine headaches, the study showed. It did not require injections, a significant advantage and it is safe to repeat as needed to control the pain.
This is a video from 2015 of a 12 year old patient who presented with an extremely severe migraine in 2015.
She was seen on an emergency basis for an extremely severe migraine of two years duration. She has suffered migraines for over 5 years. Trigger point injections and SPG Blocks were utilized to relieve her acute pain. Sarah also reported it was the best she felt in 6 months and that the “fog was lifted” She was taught how to self administer SPG Blocks and is confident she can do them at home. The only medication utilized was 2% lidocaine (no epinephrine or preservatives) both for SPG Block and for Trigger Point Injections.
Self Administration is incredibly important in pediatric and adolescent headaches and migraines. Migraines are extreme disruptive to any patient but especially to pediatric and adolescent patients. The beauty of all three of these techniques is FAST Relief of pain. More important still is that patients can learn to easily self-administer sphenopalatine ganglion blocks. This give the child (or adult) control over their headache pain and their lives. They can avoid lost days to pain and the inconvenience of visits to the ER department or to physician offices. I have given multiple to lectures to members of ICCMO on SPG Blocks and taught physicians and other health care providers.
All headaches and migraines are controlled by the trigeminal nerve. This is almost 100% universal. Headaches that are relieved by occipital nerve blocks are often due to nerve compression in posterior cervical and occipital areas. The underlying cause of this nerve compression is usually impaired nasalpharyngeal breathing and associated forward head posture with rotation at the Atlas Axis (first two cervical vertebrae). The airway restriction has become rampant in the last 400 years. This is too fast to be from genetic changes, it is expected these changes are negative Epigenetic changes. The text “How Anthropology Informs the Orthodontic Diagnosis of Malocclusion’s Causes” (Mellen Studies in Anthropology by Dr. Robert S. Corruccini who received his Ph.D. in Physical Anthropology from the University of California, Berkeley. He is Full Professor of Anthropology at Southern Illinois University, Carbondale. The following link give a partial list of his publications. https://academictree.org/anthropology/publications.php?pid=273524
As a clinician I value his work immensely. He describes the reasons for the decreased airway and forward head position along with the works of Enid Harvold, Dr Jim Garry, Dr Brian Palmer, Dr Tallgren a prosthodontist and more. Dr David Singh produced the DNA Appliance designed to address these Epigenetic negative changes. The DNA Appliance utilizes Epigenetic Orthopedics/ orthodontics to grow the airway significantly. This will reduce forward head position as well as many headaches and migraines. It can actually reverse the negative changes that cause ADD, ADHD, Snoring, Sleep Apnea, Anxiety, Excessive tiredness and many other problems. The next two videos are patients treated with Epigenetic Orthodontics/ orthopedics with the DNA Appliance. The adult patient utilizeed the mRNA version of the DNA Appliance to treat her sleep apnea while doing expansion.
These problems are part of a developmental pathway starting at birth (or even in the womb) that can be reversed. If it is not interupted we develop adults with headaches, migraines, sleep apnea and TMJ disorders. An interesting report that should be read by every headache patient, and every parent of children with headaches, earaches, ADD, ADHD, poor performance, ODD, TMJ disorders is from the NHLBI. https://www.nhlbi.nih.gov/files/docs/workshops/tmj_wksp.pdf
There is a wide range of developmental problems caused by disturbed development. Even though treatment can reverse these problems they are typically denied coverage by insurance companies as unproven, untested techniques. This is actually not true in the slightest and the science is overwhelming but all science that is not randomized, double blinded studies is excluded from consideration. Unfortunately it is not ethically possible to do studies in a clinical practice that meets those guidelines. Drug treatments can be easily double blinded but actual treatment of TMJ disorders, Breathing and /or orthopedics are impossible to design to meet those requirement.
I have lectured both nationally and internationally on these developmental pathways and on the trigeminal nervous system and the Sphenopalatine Ganglion.
Instead, we have a system flooded with medical treatments that can be done in randomized double blind studies. We also have a country where the third leading cause of death is medical mistakes, that has more people dying from opiods yearly than were killed in the Vietnam War.
It is vitally important that we protect and nurture our children and protect their precious airways.
This is another article looking at headaches and migraines coming from Myofascial Trigger Points in the Trapezius muscle. (abstract below)
Children with migraine: Provocation of headache via pressure to myofascial trigger points in the trapezius muscle? – A prospective controlled observational study. It concluded that “In children with migraine headache can often be induced by pressure to myofascial trigger points, but not by pressure to non-trigger points in the trapezius muscle. This supports the hypothesis of a trigemino-cervical-complex in the pathophysiology of migraine” Trapezius is also very involved in headaches and mif=graines
THIS ARTICLE Neurology. 1998 Jun;50(6):1729-36.
Childhood headache at school entry: a controlled clinical study. Looks at childhood headache when beginning school. The conclusions support everything discussed in the atricle. “CONCLUSIONS: Headache classification in children may be improved by palpation of occipital muscle insertions and temporomandibular joint areas, and by discerning a history of triggering events and concurrent symptoms.” The results showed bruxism as a contributing issue but also showed increased fear and anxiety in the children studied. “Children with headache had significantly more bruxism (odds ratio [OR], 1.9; 95% CI, 1.0 to 3.4), tenderness in the occipital muscle insertion areas (OR, 4.8; 95% CI, 1.8 to 12.7), and tenderness in the temporomandibular joint areas (OR, 2.8; 95% CI, 1.3 to 6.0). They also had more travel sickness (OR, 3.4; 95% CI, 1.7 to 6.7) than control children. Eating ice cream (OR, 5.3; 95% CI, 1.4 to 20.3), fear (OR, 3.7; 95% CI, 1.2 to 11.2), and anxiety (OR, 3.2; 95% CI, 1.0 to 10.8) triggered headache more often in migraineurs than in children with tension-type headache. Children with migraine also reported more frequently abdominal (OR, 5.6; 95% CI, 1.7 to 18.1) and other (OR, 3.5; 95% CI, 1.2 to 9.8) pain concurrently with headache, and they used medication for pain relief more often (OR, 3.1; 95% CI, 1.0 to 9.5).”
Treatment of Neuromuscular disorders related to orofacial paon, TMJ, Sleep Disorders and airway.
MUST SEE….TMJ TESTIMONIAL VIDEOS:
Ira L Shapira DDS, D,ABDSM, D,AAPM, FICCMO
Past Chair, Alliance of TMD Organizations
Diplomat, Academy of Integrative Pain Management
Diplomate, American Board of Dental Sleep Medicine
Regent & Fellow, International College of CranioMandibular Orthopedics
Board Eligible, American Academy of CranioFacial Pain
Dental Section Editor, Sleep & Health Journal
Member Cranio Editorial Board, Journal of Craniomandibular and Sleep Practice
Member, American Equilibration Society
Member, Academy of Applied Myofunctional Sciences
Member, Academy of Cosmetic Dentistry
Life Member, American Dental Association
J Headache Pain. 2018 Jan 16;19(1):5. doi: 10.1186/s10194-018-0835-5.
Treatment of disabling headache with greater occipital nerve injections in a large population of childhood and adolescent patients: a service evaluation.
Puledda F1, Goadsby PJ2, Prabhakar P3.
Pediatric headache disorders can be extremely disabling, with marked reduction in the quality of life of children and their carers. Evidenced-based options for the treatment of primary headache disorders with preventive medication is limited and clinical outcomes are often unsatisfactory. Greater occipital nerve injections represent a rapid and well-tolerated therapeutic option, which is widely used in clinical practice in adults, and has previously shown a good outcome in a pediatric population.
This service evaluation reviewed greater occipital nerve injections performed unilaterally with 30 mg 1% lidocaine and 40 mg methylprednisolone, to treat disabling headache disorders in children and adolescents.
We analyzed a total of 159 patients who received 380 injections. Of the population, 79% had chronic migraine, 14% new daily persistent headache, 4% a trigeminal autonomic cephalalgia, 3% secondary headache and one patient had chronic tension-type headache. An improvement after injection was seen in 66% (n = 105) of subjects, lasting on average 9 ± 4 weeks. Improvement was seen in 68% of patients with chronic migraine, 67% with a trigeminal autonomic cephalalgia and 59% with new daily persistent headache. Side effects were reported in 8% and were mild and transient. Older age, female gender, chronic migraine, increased number of past preventive use, medication overuse and developing side effects were all associated with an increased likelihood of positive treatment outcome.
This large single centre service evaluation confirms that unilateral injection of the greater occipital nerve is a safe, rapid-onset and effective treatment strategy in disabling headache disorders in children, with a range of diagnoses and severity of the condition, and with minimal side effects.
Chronic migraine; Cluster headache; Greater occipital nerve injection; New daily persistent headache; Pediatric headache; Trigeminal autonomic cephalalgia
PMID: 29340791 PMCID: PMC5770345 DOI: 10.1186/s10194-018-0835-5
Neurology. 1998 Jun;50(6):1729-36.
Childhood headache at school entry: a controlled clinical study.
Aromaa M1, Sillanpää ML, Rautava P, Helenius H.
Our objective was to study the prevalence of different headache types, characterizations, and triggers of headache in Finnish children starting school.
Questionnaires were sent to 1,132 families with 6-year-old children. Children with headache disturbing their daily activities (n=96) and an asymptomatic control group of children (n=96) participated in a clinical interview and examination.
Children with headache had significantly more bruxism (odds ratio [OR], 1.9; 95% CI, 1.0 to 3.4), tenderness in the occipital muscle insertion areas (OR, 4.8; 95% CI, 1.8 to 12.7), and tenderness in the temporomandibular joint areas (OR, 2.8; 95% CI, 1.3 to 6.0). They also had more travel sickness (OR, 3.4; 95% CI, 1.7 to 6.7) than control children. Eating ice cream (OR, 5.3; 95% CI, 1.4 to 20.3), fear (OR, 3.7; 95% CI, 1.2 to 11.2), and anxiety (OR, 3.2; 95% CI, 1.0 to 10.8) triggered headache more often in migraineurs than in children with tension-type headache. Children with migraine also reported more frequently abdominal (OR, 5.6; 95% CI, 1.7 to 18.1) and other (OR, 3.5; 95% CI, 1.2 to 9.8) pain concurrently with headache, and they used medication for pain relief more often (OR, 3.1; 95% CI, 1.0 to 9.5).
Headache classification in children may be improved by palpation of occipital muscle insertions and temporomandibular joint areas, and by discerning a history of triggering events and concurrent symptoms.
Eur J Pain. 2018 Feb;22(2):385-392. doi: 10.1002/ejp.1127. Epub 2017 Sep 26.
Children with migraine: Provocation of headache via pressure to myofascial trigger points in the trapezius muscle? – A prospective controlled observational study.
Landgraf MN1,2, Biebl JT1,2, Langhagen T1,2, Hannibal I1,2, Eggert T2,3, Vill K1, Gerstl L1, Albers L4, von Kries R4, Straube A2,3, Heinen F1,2.
The objective was to evaluate a supposed clinical interdependency of myofascial trigger points and migraine in children. Such interdependency would support an interaction of spinal and trigeminal afferences in the trigemino-cervical complex as a contributing factor in migraine.
Children ≤18 years with the confirmed diagnosis of migraine were prospectively investigated. Comprehensive data on medical history, clinical neurological and psychological status were gathered. Trigger points in the trapezius muscle were identified by palpation and the threshold of pressure pain at these points was measured. Manual pressure was applied to the trigger points, and the occurrence and duration of induced headache were recorded. At a second consultation (4 weeks after the first), manual pressure with the detected pressure threshold was applied to non-trigger points within the same trapezius muscle (control). Headache and related parameters were again recorded and compared to the results of the first consultation.
A total of 13 girls and 13 boys with migraine and a median age of 14.5 (Range 6.3-17.8) years took part in the study. Manual pressure to trigger points in the trapezius muscle led to lasting headache after termination of the manual pressure in 13 patients while no patient experienced headache when manual pressure was applied to non-trigger points at the control visit (p < 0.001). Headache was induced significantly more often in children ≥12 years and those with internalizing behavioural disorder. CONCLUSION: We found an association between trapezius muscle myofascial trigger points and migraine, which might underline the concept of the trigemino-cervical complex, especially in adolescents. SIGNIFICANCE: In children with migraine headache can often be induced by pressure to myofascial trigger points, but not by pressure to non-trigger points in the trapezius muscle. This supports the hypothesis of a trigemino-cervical-complex in the pathophysiology of migraine, which might have implications for innovative therapies in children with migraine.