1. 2025;28;137-145Efficacy of Nerve Blocks for Managing Refractory Posttraumatic Headaches
   Retrospective Study
   Christopher File, BSA, Xiang Fang, MD, PhD, Rowaid Ahmad, MBBS, Ahmed Harazeen, MD, John Jung, BS, Fauwad Ahmed, MD, Naveed Ahmad, BS, Sean Pappolla, ., Remi Nader, MD, and Miguel A. Pappolla, MD, PhD.

BACKGROUND: Nerve blocks (greater occipital, lesser occipital, others) are commonly used, singly or in combination, to treat various forms of refractory headaches, including migraine and cervicogenic headaches. Their efficacy in treating posttraumatic headaches, however, particularly those unresponsive to medications or severely disabling, is not well documented.

OBJECTIVES: To characterize the efficacy of nerve blocks in the treatment of posttraumatic headaches.

STUDY DESIGN: Retrospective chart review.

SETTING: A single-specialty outpatient neurology clinic.

METHODS: Patients from January 2022 through July 2023 who fulfilled International Headache Society criteria for posttraumatic headache (i.e., new onset headache developing within the first week following head trauma) were included. A rigorous, comprehensive, and unbiased selection process was followed via Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Headaches were refractory to various treatments, including analgesic agents or headache prophylactic medications. The treatments the study patients received were a combination of nerve blocks, including greater, lesser, and third occipital nerve blocks, and supraorbital and supratrochlear nerve blocks. We used the percentage of pain improvement in order to assess the response to the blocks: minimal improvement (< 50%), moderate improvement (50–75%), and significant improvement (> 75%) pain relief.

RESULTS: Thirty-four patients met the inclusion criteria; 15 were women (44%). The mean (SD) age was 43.11 ± 14 years. Of these 34, 28 stated a significant improvement in headache pain immediately following their injection. Twenty-one patients (75%) rated their response to nerve blocks as a >= 90% improvement in headaches. Six patients reported complete resolution of their headache pain. Expressed as percentage headache pain improvement, average pain improvement was 88%. Six patients reported moderate improvement of their headaches.

Thirty-one patients reported an average headache improvement of 73% on Postprocedure Day One. Nineteen of these 31 patients had significant pain improvement from baseline, with 12 of them reaching a >= 90% pain improvement. Eight patients reported moderate improvement, while 4 had minimal headache pain improvement.

Twenty-seven patients were available for a 3-month follow-up; they reported an average headache improvement of 73%. Thirteen of these patients reported significant improvement in their headache pain, with 12 of them having a >= 90% improvement in their headaches. Twelve patients reported moderate pain improvement, and 2 had minimal or no pain improvement.

Nineteen patients returned for a 6-month follow-up; they reported an average pain improvement of 78%. Twelve patients reported significant pain improvement, with 11 having an improvement of >= 90%. Four patients reported moderate pain improvement, and 3 reported minimal or no pain improvement. Some patients experienced a biphasic response with partial headache recurrence at 3 months, followed by complete headache resolution at 6 months.

LIMITATIONS: Several patients who received multiple nerve blocks were concurrently prescribed prophylactic medications for headache management. Later score improvements cannot be determined to be solely caused by the nerve blocks.

CONCLUSION: This retrospective review offers preliminary but compelling evidence that nerve blocks are a highly effective option for patients with posttraumatic headaches who have not benefited from medication or who suffer from severe, incapacitating symptoms.

KEY WORDS: Headache, nerve block, posttraumatic headache, concussion, postconcussive syndrome, greater occipital nerve block, lesser occipital nerve block, third occipital nerve block, supraorbital nerve block, supratrochlear nerve block