S2:Ep13 – Nerve Blocks: An Underutilized Treatment?
TRANSCRIPT
Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease. This episode is brought to you in part by our generous sponsor, Lilly.
You may have heard of nerve blocks, but how much do you know about them? Dr. Dan Henry and nurse practitioner Ruth Kennedy explain what types of nerve blocks are available, how they are given and what patients they are a good option for, including pregnant women and children.
For more than 25 years, Lilly has been committed to helping people affected by headache, investigating more than a dozen different compounds for the treatment of migraine and cluster headache.
Molly O’Brien: Hello and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. In this episode, you’re going to learn about nerve blocks for migraine and headache. We have two guests joining us today, Dr. Dan Henry and Ruth Kennedy. Dr. Henry’s been practicing medicine for over 40 years, and he switched the focus of his practice to migraine and headache disease after his daughter lost her battle with migraine. Like many of you out there listening, Ruth Kennedy is also a migraine patient. She’s a nurse practitioner, and she specializes in migraine.
Dr. Henry and Ruth, thank you so much for joining us today.
Ruth Kennedy: Thank you so much for having us.
Dr. Henry: Thank you for having us.
Ruth: Delighted to be here.
Molly: So, excited to jump into this conversation. Dr. Henry, it’s my understanding you perform several different types of nerve blocks. Can you tell us a little bit about how those work in relation to migraine?
Dr. Henry: Yes, absolutely. So the main nerve blocks that we give are greater occipital nerve blocks, auriculotemporal trigeminal nerve blocks, and supraorbital and supratrochlear nerve blocks. We also do a lot of trigger point injections because a lot of migraineurs have a lot of upper back trapezius muscle pain, so we can do trigger points at the same time.
And it’s a really nice tool because you can use it both for acute rescue, meaning somebody who’s been — they had a real cluster of their migraines, where they’ve been taking the rescue meds one, two, three days in row or more, and they just keep in this cycle of the next day having another migraine. And we can use it in that scenario, which I call rescue. And we’ll work people in. If they call in the morning or before three o’clock in the afternoon, we’ll work them in that day and actually be able to work them in and block them.
And typically, by doing these nerve blocks, we’re able to — about 90 percent of patients, within 1 to 15 minutes, will have a dramatic reduction in not only their pain, but their light sensitivity, their nausea, all their migraine-related symptoms, within 1 to 15 minutes. And the block, they’ll get numbness in the area where they’re injected for about two to three hours, and then it’s kind of like hitting a reset button, is the way I like to kind of simplify it to the patient. It’s like hitting the reset, and hopefully their trigeminal nucleus and their trigeminal nerve settle back down to the way they are when they’re in good balance.
And the only thing really unpredictable is how long will it last. And some patients will get anywhere from two to five or six, seven days. Others will get two, three, four weeks. And a few really lucky ones will get three to four months of marked reduction, if not total resolution. And we even have some patients who that is their — they’re using it not just for rescue; they use it actually as their preventative because they get such a long response.
Molly: Wow, that’s fascinating to hear how people can use these nerve blocks differently and the vast variety of that impact, a minute to 15 minutes, being able to feel the relief, which is incredible.
So you told us a little bit about how people are impacted by the nerve blocks, what you can use them for. But can you tell us a little bit more about how they actually work? What kind of medication is in these blocks? How do they affect the patient? How does it work?
Ruth: Yes. So when we do a nerve block, we’re injecting it with a needle, so there is a little pain with the needle. The needle itself, not a big deal. The medication we’re injecting is a combination of lidocaine and bupivacaine, and those are just numbing medications. So there’s no steroid; there’s no narcotic; there’s no other active ingredient. And so when you do get injected, those medications, they sting a little bit going in. If you’ve ever been to the dentist or had a molar removed, it’s a good little sting. So about 5 or 10 seconds of discomfort.
And essentially, I mean, we’re numbing — we’re targeting the nerve branches that he described, the greater occipital and then the three spots in the auriculotemporal. And so we’re essentially kind of turning the power off to that nerve for just a few hours, and then hopefully — it’s almost like your nerves have forgotten how to calm down. They’re so irritated and going and going and going when you’re having a migraine, that by calming them down, by numbing them, most of the time it can kind of end that cycle.
So it’s a weird feeling. You feel numb to the touch. If you wash your hair later that day or when you go to lean against the seat in your car, you’re like, “Oh, yeah, my head’s numb.” So it’s a weird feeling, but in my opinion — and I’ve had many, many nerve blocks — it’s not a bad feeling. It’s a nice feeling, not having the headache.
Molly: And, Ruth, it’s nice to be able to hear your perspective from the patient side but also from the practitioner’s side as well. Can you tell us, is there anyone that could find this treatment more helpful, or is there a “good candidate” for a nerve block?
Dr. Henry: There’s —
Ruth: What do you think?
Dr. Henry: Yeah, as far as a good subject, is just about — I love to do the first nerve block on somebody when they’re really in the midst of a bad migraine, and the reason is because you can see right off the bat if they get a dramatic response. I mean, their color will come back. I mean, their eyes open up, and all of a sudden, the light in the room doesn’t bother them. And it’s kind of like — some patients will tell you, “That’s magic.” They can’t believe that they can get that kind of a response. And that’s a very consistent response. It’s not one that happens in a rare patient. The vast majority of patients get a response out of this.
And as far as the discomfort, most of them — I give nerve blocks — I think my youngest patient who gets fairly frequent nerve blocks is eight or nine. So I have a number or children, lots of adolescents, as well as adults who get these, and for a lot of them, it’s their favorite thing. They will tell their parent, “I need to go in and get a block,” because they know what they’re going to get, and they know exactly, once they’ve had it, how much of relief they get and that they can get back into their life.
And you don’t have to go home and lay down in a dark room with ice for the rest of the day or anything. We’re near a number of hospitals. We have a lot of nurses and doctors who we take care of here who will come here on their way to work, but they’re in the midst of a bad migraine. They’ve got a 12-hour shift to go. They know they’re not going to be able to — and they’ve already taken their rescue meds orally or injectably, and they’re not getting there. And they can walk out of here and drive to work and work the whole shift and be great.
Ruth: Yeah. I’ve been really surprised too because some of our best responders, there’s really no way of predicting. You’ll get someone who’s not had a headache-free day in 20 years or more, and some of them have done beautifully with nerve blocks.
So I feel like with migraines, the placebo effect has to be really low, because we’ve all tried so many things. Nothing ever works. And so you get a patient like that who’s tried tons of stuff, and you’re like, “Well, you haven’t tried a nerve block. Let’s try that.” But I’ve been very pleasantly surprised. Just because you’ve had headaches for a long time or you’ve tried a lot of things, it does not dictate how you will respond to a nerve block.
Dr. Henry: And probably two-thirds of the patients referred to us are already chronic migraineurs, and a lot of them can’t tell you their last day that was totally headache free from the time they woke up till the time they went to bed. And so while we’re laying out a plan — and as you know, we may be changing their oral preventatives or whatever preventatives they’re on, but all of those take time. They take a good six weeks to three months. And at the same time, you could do a nerve block to buy them that time, to get them relief right now. And for a lot of people, that’s just life changing. All of a sudden, you’ve given them hope again.
Molly: It sure is, and it’s nice to be able to hear, again, both of your perspectives. You talked a little bit about other medications, Dr. Henry. Can you tell us, are there any interactions with migraine medications that people need to be aware of if they’re looking at doing a nerve block?
Dr. Henry: There are none at all. In fact, nerve blocks are the treatment of choice in pregnancy in all three trimesters and nursing mothers. So we’ve blocked a number of patients who either were in early labor on their way to the hospital or with a planned C-section or with a planned induction, and they’ll come here first to get a nerve block, because so often when a patient with migraine delivers their baby, your estrogen levels after the [placenta?] — everything drops like a rock, and a lot of them will have just horrible migraines immediately after delivery. And we can prevent that in a large number of these women.
Molly: That is very exciting for me to hear personally, because moving forward, I think one of my biggest fear is what happens during pregnancy if you have migraine. And a lot of people say, “Oh, they go down. You won’t have as many a month.”
Ruth: [inaudible]
Dr. Henry: Yeah, if somebody — yeah.
Molly: Yeah, yeah, and most treatment options aren’t safe for women who are pregnant. Can you tell us a little bit more about that? And I’m also interested — nerve blocks seem like the — from what you’re saying, the end-all be-all. Why aren’t we all doing this all of the time?
Dr. Henry: It —
Molly: Can you talk a little bit more about that?
Ruth: It’s a great question. Great question.
Dr. Henry: It is a great question, and it’s certainly not an end-all be-all. But on the other hand, it’s one of the most important weapons we have, because, I mean, we do everything from the first appointments in very complicated people all the way above through all the neuromodulators and Botox, the monoclonals, and all of the rescue meds that are out there now with the addition of gepants and ditans.
But nerve blocks are something that Ruth and I do on multiple patients every day. But our practice is a little different in the sense that if a patient calls, my secretary knows that if they say, “Hey, I’m really suffering. I’m struggling, and I’ve taken my rescue meds the last two days, but it just keeps coming back,” we just bring them in. We either do nerve blocks or IVs, and sometimes if they’re really severe, we’ll do both. We can do nerve blocks and IV regimens at the same time, even.
Molly: That’s fascinating to hear. I’m wondering, if someone’s already had a nerve block, and — say a patient comes into your practice. They’ve had a nerve block, but they don’t see any relief. Is it worth trying it again?
Dr. Henry: Absolutely. And a lot of times, we’ll see patients who — they’ve had a nerve block, but maybe they only had a greater occipital nerve block. And in some individuals, they need all of it blocked. They need the greater occipital, the auriculotemporal, the supratrochlear, and supraorbital nerves all blocked, and maybe they need trigger points too. So unless Ruth or I have done the block, and it’s a new patient to us, we commonly will block them even on the very first visit we see them while we’re laying out everything else.
Ruth: And some providers may have a different technique, and sometimes a patient may not always know the difference between a Botox injection or a nerve block injection or a trigger point injection. So a lot of times, what we’ve found is that patients have maybe had a trigger point, or it’s kind of just more superficial and maybe didn’t kind of target the nerve branch. So it’s definitely worth repeating in a new patient or even — I mean, I myself get several different types of headaches, and so there’s some that a nerve block’s the only thing that fixes it. There’s some that a nerve block can help, but probably out of — you just might have one headache that may not respond as well, so.
And then once you’re on preventatives, once you’re on Botox, once you’re on amitriptyline or anything, sometimes that does change how you respond to rescues. So it may be worth trying again if it’s been years or you’re on a different medication.
Dr. Henry: Yeah, the nice thing with Botox is we can do nerve blocks in between rounds of Botox, because when you think about Botox, some patients won’t even respond until the third or even fourth round. That’s a long time. You’re almost out to a year. So we can do nerve blocks in between to carry them along, even though down the road, hopefully, they will need them very rarely or if at all. But again, you can use it as part of the total package, really.
Molly: Definitely sounds like something to add to your migraine toolbox.
Dr. Henry: It is definitely.
Molly: If a new patient is coming in, or, say, an old patient — if someone’s looking for this type of treatment, do they need to know which specific type of nerve block they should ask for or the difference between them?
Dr. Henry: Well, we should be educating them about what we can do and what areas, and it depends on where they get most of their pain and things like that. And we mentioned just superficially about steroids, using things like dexamethasone with the nerve blocks. They did studies where they did patients with steroids with the numbing medications — with the xylocaine and Marcaine — and without steroids, and the difference was nonexsitent really, negligible. Yet there’s a lot more side effects with the steroids as far as can get hair loss or subcutaneous fat wasting and things like that.
There’s one place, though, where steroids — and some people do them always with steroids, which I don’t agree with by any means. But one place you do use steroids is in patients with cluster headache. And greater occipital nerve blocks with steroids is one of the treatments of choice for cluster headache, so we do that a lot too.
Molly: Again, it’s exciting to hear this, that there are options out there, and you’re continuing to give people hope.
So you talked to us a little bit about how they work, what the procedure is like. I’m wondering if we can kind of revisit that. I’ve looked up videos on YouTube of some of these nerve blocks performed, and I have to be honest. It’s a little intimidating, someone sticking a needle in the back of your head, by your nerves, no less. So I’m wondering if these are dangerous, and just if you can kind of reassure people what’s going on.
Dr. Henry: Yeah, the side effects of nerve blocks are really negligible when you read them, and yes, it’s scary to think about, “He’s going to put a needle —
Ruth: Put a needle in my head.
Dr. Henry: — in the back of my head or over my eyes or in my temples or wherever.” Once they receive it, though, and realize, yes, it hurts for a second, but compared to their migraines, the discomfort they’re getting — and it’s just for a few seconds. And like I said, response rates, you don’t have to wait a day or two or a week or a month to see the response. For most people by the time they sit up, they already notice their headache intensity is dropping, so —
Ruth: I feel like I can open my eyes afterwards. I’m like, ahh.
We are very careful. When we’re giving a nerve block, we’re finding the landmarks, and the only time it gets a little tricky is if someone’s had a brain surgery or has a metal plate back there or something like that. But when we’re doing the injections, we’re aspirating. We’re making sure we’re exactly where we want to be.
And lidocaine, bupivacaine, those are very safe medications. I mean, we use them to numb anything, like sometimes surgical sites. Lidocaine, they use IV for cardiac dysrhythmias. So it’s a very well-studied, well-used medication. So unless you specifically have an allergy to lidocaine or bupivacaine, there’s relatively no contraindications to this medication.
Dr. Henry: A rare person may get a little vasovagal, especially with the very first one, because they may be very anxious, and they’re maybe having a headache of a 9 out of a 10 or something like that.
Ruth: Or be dehydrated, haven’t been eating.
Dr. Henry: Yeah, and so you may do it, and they may get a little lightheaded. So some people, we’ll have them just rest for a few minutes afterwards, lay down, stay laying down and everything. But it’s minimal.
Molly: Can you guys tell us a little bit about cost? Is it prohibitive? Is there any help from insurance?
Dr. Henry: Yeah, and the answer is yes and no — both sometimes. The cost, if you were paying in cash, and you paid full price for what the code books tell us to charge and things like that, it could be. Most insurances, however, pay for some if not all of the blocks. There are a few small insurances we have in our region — and every region’s different — we have a couple small insurances that don’t pay it all.
And if the patients can afford to have a nerve block, we have them pay a little bit. If they can’t afford it, we do them. I mean, we’re here to take care of patients, and so that’s not the issue. But yes, most of the time, insurances do cover a fair amount of this.
Molly: That’s so great to hear. And I want to ask you a question from one of our listeners out there. This person asks, “Have you ever seen onset of migraine or headache after getting a nerve block?”
Dr. Henry: Interestingly enough, there are a few patients — it’s kind of interesting. There are a few patients who will get immediate relief and then go home and either later that night or the next morning have a migraine, treat it the way they normally treat, and then their headaches go away for days or weeks. So that occasionally happens. It’s not the majority. It’s maybe 5 percent, but we have seen it.
Ruth: With my nerve blocks, I get pretty good tenderness at the injection sites, and that’s fairly common. And it’s different than a headache. It’s just kind of like — feels bruised or something, and again, it’s a sensitive area. It’s where your nerves are, and we know our migraine nerves are just more sensitive. So that one I hear commonly. The headache the next day is much less common, I think.
Dr. Henry: And one last point about pregnancy, because so many — and I’m not trying to pick on OBs — but so many OBs will tell them — patients who have bad migraine — they’ll say, “Well, it’s only going to be nine months,” and, “Just suck it up,” and they don’t get it. And the thing is, about two-thirds of migraineurs in the first trimester actually do worse with their migraines, have more frequent or more severe. And you could do nerve blocks literally two days in a row. You could do nerve blocks every week or every two weeks. There’s huge flexibility.
I have a patient who just recently — she’s now in her late second trimester — but in the first trimester, we blocked her about — we’d block her. She’d be 7 to 10 days headache-free, which for her was huge, and we’d block her again. And now that she’s into mid- to late second trimester, I think we blocked her the last time maybe a month ago or something like that. So anyway.
Molly: And the way that you’re describing this, it makes me think, “Why aren’t more doctors or headache specialists using this?” And do you think we’ll see nerve blocks used more in the future?
Dr. Henry: I do.
Dr. Henry: More and more, there’s more interest in the headache community, and more people are getting comfortable. I mean, as you know, my background was family practice, so I was used to using a lot of needles and scalpels and things like that, so it just seems like a natural progress. But not all people come from that background, so maybe they haven’t been doing this. But now they’re getting very interested.
Molly: And, Dr. Henry, you mentioned that you do a lot of training in this area and other areas as well. So not every doctor or headache specialist does nerve blocks. If a migraine patient is out there, what should they look for in a healthcare provider?
Ruth: Ooh, good question.
Dr. Henry: Yeah, that’s a very good question. And I have a lot of patients who are out of the region and out of state, even, and when they are someplace else, I always tell them one of the first sites is to go to the American Headache Society website and look up for — you can put in your zip code, and you can find a headache specialist, and that’s a good place to start is to look at that website. And all you do is plug in your zip code, and hopefully a number of people will pop up.
And then when you call, ask them if they do nerve blocks, because at the national meetings that I go to — and these are basically all headache specialists at the headache meetings — there’s a huge number that don’t use needles, that don’t do IV therapy in their office, and don’t do nerve blocks. And more and more are, and thank goodness, because the training program sessions at these meetings are always overbooked. And so I know people are interested in it. We just need to train a lot more people, so.
Molly: Ruth, your background is in ER medicine. Are nerve blocks used there, or do you think we’ll start to see more?
Ruth: It depends on the physician who’s on at the time. There’s a couple ERs in town who I know do nerve blocks, and patients have gone there and have gotten great care, and it works. They have the ingredients. They have the needles. They could very easily do that. But it kind of just depends on the comfort of the practitioner. If they haven’t done it before, they may not be likely to try it. But it’s all medications they’re familiar with, anatomy they’re familiar with, so I think it would be a great tool to use in the ER.
And that’s one of the reasons I was excited to come work here, is because I have a background in this acute medicine. I love doing IVs. I love figuring out the problem, getting to the bottom of it, and providing really good care for people. So, yeah, it’s been a good combination for me.
Dr. Henry: And we’ve been training a lot of residents in the region, and a number of them have gone into ER medicine and have already —
Ruth: That’s true.
Dr. Henry: — incorporated it into their practices in the ER. So it’s always nice to hear.
Molly: That’s so great to hear. It’s been a great discussion, talking about nerve blocks for migraine, and it sounds like this is just another tool to add to the migraine toolbox. I’d like to thank both of our guests, Dr. Dan Henry and Ruth Kennedy, for joining us today. It’s been a great discussion.
Dr. Henry: You’re very welcome. Thanks again for having us. Thank you.
Molly: And that wraps up this episode of Spotlight on Migraine. Thank you again to our guests, and thank you so much for listening. Until next time, I’m Molly O’Brien.
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