Greater Occipital Nerve Blockade in Veterans With Post-concussion Headache: Sub-study 2

Military Servicemembers are at elevated risk for traumatic brain injury (TBI) and its consequences, including post-traumatic headache (PTH). The most common phenotype of PTH is migraine, for which there are numerous potential treatments, though these have limitations, including poor efficacy, drug-drug interactions, and intolerable side effects. Therefore, the consideration of other methods to manage PTH in Servicemembers and Veterans is warranted.

Anesthetic greater occipital nerve (GON) blockade is a simple, inexpensive, and safe procedure that has demonstrable headache pain suppressing effects in a variety of headache disorders. This intervention is frequently done to provide immediate relief, followed by a period of reduced headache burden.

In this second portion of this study, Veterans with chronic post-traumatic headache will be randomized to receive 0.0%, 0.05%, or 0.5% bupivacaine in bilateral GON blocks. They will maintain a headache diary to measure the change in headache frequency over the two months after injection. This design uses information gathered from sub-study 1 of this project (NCT#06069791). In that initial intervention, different concentrations of bupivacaine were examined to consider the intensity and spread of acute and subacute sensations that occur with GON blockade. This allowed us to select a low dose (0.05%) that approximates the sensations of the full dose of 0.5%.

Inclusion criteria

• United States Military Veterans within VA Connecticut Healthcare System1.
• Head injury with headaches that have continued to occur for at least three months after the head injury
• At least two headache days per week
• Review of the medical record does not reveal another source for headache

Exclusion criteria

• Skull defect
• Other contraindication to bupivacaine
• Allergy or adverse reaction (e.g., rash, cardiac effects) to amide anesthetics, such as lidocaine
• Instruction from clinician to avoid amide anesthetics, such as lidocaine
• Pregnant or lack of adequate birth control
• Clinical review of the patient's case reveals red flag signs or symptoms (e.g., side-locked pain, unilateral numbness/weakness during headache, rapid ascension to peak pain, syncope during attacks) that warrant further work-up (e.g., MRI, arterial imaging).
• Absence of imaging warranted by the standard of clinical care for the head injury with headaches.