New research recommends use of nerve blocks in the emergency room to treat migraine pain

Anyone with acute migraine pain who seeks relief in the emergency room is now eligible for a nerve block in the occipital nerve.

“If you’re coming to the emergency department with migraine you’ve generally had things at home; most people have tried Advil and whatever treatment they have prescribed if they’ve been seeing a doctor for migraines, so at that point this should be offered to everyone,” said Dr. Serena Orr, a neurologist and associate professor at the Cumming School of Medicine.

“The occipital nerves at the base of the skull bring in pain signals to the same area of the brain where pain signals from all over the head are coming in. By anesthetizing these nerves, patients get relief in two ways,” said Orr.

“First, the back of the head goes numb for several hours,” she said. “Second, we see that pain signals more broadly from all over the head can be dampened down in the brain, given this shared area where pain signals come in for both occipital nerves and other nerves’ branches from the head.”

Orr said this treatment can have fewer side effects. She said how long this treatment lasts depends on the person; it can be as short as two hours or as long as eight.

The last guidelines for treating migraines was released in 2016. Orr did help author that study and said it’s exciting to see this option to treat acute migraine pain.

“There was no mention of nerve blocks (in 2016), and the treatment you received in an emergency room varied from place to place.” she said.

“This update marks a major change in emergency department migraine care, with stronger evidence supporting effective non-opioid treatments. Implementing these approaches can improve patient outcomes and reduce reliance on opioids,” said study co-lead Dr. Jennifer Robblee, a neurologist and migraine and headache disorders specialist at Barrow Neurological Institute which is part of Dignity Health St. Joseph’s Hospital and Medical Center in Phoenix.

The authors noted that opioid use remains common in headache-related ED care, despite decreasing from 54.1 per cent in 2007-10 to 28.3 per cent in 2015-18. The collaboration involved researchers at the University of Calgary’s Hotchkiss Brain Institute, the Barrow Neurological Institute, New York and Ottawa.

Researchers say the next steps will involve sharing and implementing the findings which may include training as nerve block use requires trained personnel and supplies.

The review also included new medications since the 2016 guidelines were published.

The report published in Headache: The Journal of Head and Face Pain update the 2016 American Headache Society guideline (which was also adopted in Canada) for the management of migraine attacks in the ED. The systematic review and meta-analysis used the same methodology as the 2016 study.