Medical Policy

This document addresses occipital nerve blocks (or blockade) and sphenopalatine ganglion nerve blocks as a treatment of headache syndromes. Occipital nerve block therapy involves injection of a local anesthetic with or without steroid around the greater and lesser occipital nerves located in the back of the head just above the neck. These occipital nerve block procedures have been studied for the treatment of various headache syndromes and occipital neuralgia. Sphenopalatine ganglion nerve blocks involve intranasal insertion of topical anesthetic to block the sphenopalatine ganglion.

Note: Occipital nerve blockade as a diagnostic method for the evaluation of headaches and occipital neuralgia is not included within the scope of this document.

Note: Please see the following related documents for additional information:

• SURG.00112 Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)
• SURG.00096 Surgical and Ablative Treatments for Chronic Headaches

Investigational and Not Medically Necessary:

Occipital nerve block therapy is considered investigational and not medically necessary for the treatment of occipital neuralgia and headache syndromes including, but not limited to, chronic migraine, chronic daily headache, cervicogenic and cluster headache.

Sphenopalatine ganglion nerve block therapy is considered investigational and not medically necessary for all indications including, but not limited to, the treatment of migraine headaches and non -migraine headaches.

Summary

The evidence for occipital nerve blocks (ONB) and sphenopalatine ganglion blocks (SPG blocks) for various headache types is inconsistent and derived from studies with significant methodological limitations. For chronic migraine, several small randomized controlled trials (RCTs) have produced conflicting results, with some showing a modest, short-term benefit over placebo while others show no significant difference. Because headaches, especially migraine headaches, are highly susceptible to expectation effects and invasive procedures magnify those effects, nerve block trials that do not include a convincing sham injection or do not rigorously test blinding integrity risk overestimating treatment benefit. Meta-analyses and recent RCTs highlight the low quality of the existing evidence, citing small sample sizes, short follow-up, and high risk of bias, and note that the addition of corticosteroids to local anesthetics does not appear to improve outcomes. Evidence for other conditions, such as cluster headache, cervicogenic headache, and occipital neuralgia, is similarly limited to small trials, observational studies, or consensus statements. Future studies must incorporate adequate placebo controls, assess blinding success, and extend follow-up to ensure that any observed benefits surpass the well-documented, often substantial placebo response in headache disorders. For these reasons, ONB and SPG blocks are considered investigational and not medically necessary for the treatment of headache syndromes.

Discussion

Occipital nerve blocks

Chronic Migraine Headache:

Several placebo-controlled RCTs have evaluated the use of greater occipital nerve blockade (GONB) for treatment of chronic migraine.

Ashkenazi (2008) reported results for an RCT that evaluated whether adding triamcinolone to local anesthetics increased the efficacy of GONB and trigger-point injections (TPIs) for chronic daily headache (also known as transformed migraine [TM]). The study included 37 participants who met criteria for TM and were randomized to receive GONB and TPIs using lidocaine 2% and bupivacaine 0.5% with either saline (group A) or triamcinolone 40 mg (group B). The severity of headache and associated symptoms were assessed before and 20 minutes after injection. Participants documented headache and severity of associated symptoms for 4 weeks after injections. Changes in symptom severity were then compared between the two groups. Twenty minutes after injection, the mean headache severity had decreased by 3.2 points in group A (p<0.01) and by 3.1 points in group B (p<0.01) with a mean neck pain severity decrease by 1.5 points in group A (p<0.01) and 1.7 points in group B (p<0.01). The mean duration of headache-freedom was reported as 2.7 ± 3.8 days in group A and 1.0 ± 1.1 days in group B (p=0.67). None of the outcome measures differed significantly between the two groups. The authors concluded that the addition of triamcinolone to local anesthetics when performing GONB and TPIs was not associated with improved outcome. The lack of a sham control group prevents conclusions from being drawn about how much this study’s observed effects were affected by placebo effects.

Dilli and colleagues (2015) conducted a randomized, placebo-controlled study of 69 individuals with chronic migraine. In the active treatment group, 34 participants received 2.5 ml of 0.5% bupivacaine plus 0.5 ml (20 mg) methylprednisolone over the ipsilateral (unilateral headache) or bilateral (bilateral headache) occipital nerve (ON). In the placebo group, 35 participants received sham injections with 2.75 ml normal saline plus 0.25 ml of 1% lidocaine without epinephrine. All study participants completed a 1-month headache diary prior to and after the double-blind injection. One month after their injections, 33 participants (97%) in the active group and 30 participants (86%) in the placebo group were available for follow up. In the active and placebo groups respectively, the mean frequency of at least moderate (mean 9.8 versus 9.5) and severe (3.6 vs. 4.3) migraine days and acute medication days (7.9 vs. 10.0) were not substantially different at baseline. The primary outcome measure was defined as a 50% or greater reduction in the frequency of days with moderate or severe migraine headache in the 4-week post-injection study period, compared to the 4-week pre-injection baseline period. At 28 days post-injection, the percentage of participants with at least a 50% reduction in the frequency of moderate or severe headache days was 30% for both groups (10/33 vs. 9/30; 0.00, 95% confidence interval [CI], -0.22 to 0.23). The authors concluded that GONB did not reduce the frequency of moderate to severe migraine days in individuals with episodic or chronic migraine compared to placebo. However, this study did not evaluate the onset or duration of benefit of the GONB; it also did not evaluate the acute response to the injection. Not all trial participants were experiencing headache pain at the time of injection.

Also in 2015, results of a randomized, multicenter, double-blind, placebo-controlled study were published by Inan and colleagues. This study randomly divided individuals with chronic migraine into two groups of 42. GONB was administered once weekly for 4 weeks. Group A received placebo saline injections and group B received bupivacaine injections. After 4 weeks of treatment, the blinding was removed in group A and GONB using bupivacaine was delivered to this placebo group, while group B continued to receive bupivacaine once per month. The primary endpoint was the difference in number of headache days, duration of headache, and pain scores. The following results were observed after 1 month of treatment:

* Difference‑in‑difference = (Group B change) - (Group A change); positive values indicate greater improvement with bupivacaine.

The authors concluded that GONB with bupivacaine was superior to placebo and was effective and safe for the treatment of chronic migraine. However, unequal attrition in the study’s two groups raises concern for attrition bias. While 72 (86%) of the 84 participants completed the study, 9 (21%) of the 42 Group A participants did not complete while Group B lost only 3 (7%) of its participants. Although treatment with bupivacaine reduced the number of headache days per month, it did not reduce the duration of headaches compared with placebo. It should be noted that Group A’s participants experienced fewer headache days, fewer headache hours, and lower VAS scores 1 month after treatment, thus indicating the presence of a placebo effect. This study’s duration of follow-up was limited to only 1 month of actual blinding. This is an insufficient length of time to evaluate possible longer-term placebo effects that may have been present 1 month after treatment.

A randomized, double-blind, placebo-controlled trial published by Malekian and colleagues in 2021 evaluated the efficacy of greater occipital nerve block in 55 participants with episodic migraine without aura. Participants were randomized to receive bilateral injections of triamcinolone alone, lidocaine alone, lidocaine plus triamcinolone, or saline placebo. At 4-week follow-up, all four groups, including the saline placebo group, experienced significant reductions in headache severity and duration (p<0.001 and p=0.001, respectively), with no statistically significant differences between any of the active treatment groups and placebo. Only the groups receiving lidocaine showed a significant reduction in headache frequency compared to baseline. The study was terminated early due to adverse events including cutaneous atrophy and alopecia in participants receiving triamcinolone. The authors concluded that the observed benefits in all groups, including placebo, raised questions about whether improvements were due to the medications themselves or to placebo effects and mechanical compression from the injection volume.

A 2022 RCT by Chowdhury and colleagues evaluated the efficacy and tolerability of chronic migraine treatment with GONB combined with topiramate compared to monotherapy with topiramate. Participants were assigned to one of three treatment arms:

• Group A received topiramate monotherapy once per day
• Group B received topiramate plus GONB with 40 mg lidocaine (2%) and 80 mg (2 ml) methylprednisolone as a first injection followed by 2 monthly injections of lidocaine
• Group C participants received topiramate plus monthly GONB with 40 mg lidocaine (2%) injections for 3 months

There were 125 randomized participants; 41 in group A, 44 in group B, and 40 in group C. All participants met ICHD-3 criteria for chronic migraine. The primary efficacy endpoint was the mean change in monthly migraine days. A secondary endpoint was the number of participants who achieved more than 50% reduction in monthly headache days from baseline to 3 months. Efficacy assessments were done for 121 participants. The following results were reported:

According to these results, participants who received combination therapy and GONB in groups B and C showed greater reductions in monthly migraine days at month 3 compared to those in group A who received topiramate alone. None of the 41 participants in the topiramate-only group were lost to follow-up, whereas 5 of 44 (11%) participants in Group B and 3 of 40 (7.5%) participants in Group C left the study without stating a reason. The authors reported some mild treatment-emergent adverse events including limb paresthesias, local site swelling, bleeding, and dizziness. No serious adverse events were reported. In this study, lack of blinding and the lack of a placebo arm (sham injections) created risks for bias. The authors explained their choice not to include a placebo arm by saying they did this “because we were interested to know the effect of combination treatment versus monotherapy and not the efficacy of GONB in CM per se.”

A meta-analysis of studies evaluating GONB for chronic migraine was published by Velásquez-Rimachi and colleagues in 2022. Review eligibility criteria included control studies evaluating GONB with local anesthetics alone or combined with corticosteroids compared to placebo in adults with chronic migraine. The meta-analysis identified seven eligible RCTs, four of which were included in a quantitative synthesis. In a pooled analysis of three studies (total n=139) reporting headache intensity using a 10-point VAS scale, in the first month, GONB had a statistically significant benefit compared with placebo (mean difference [MD], -1.29; 95% CI, -1.95 to -0.64; p<0.05). The clinical significance of a 1.29 point difference on a 10-point VAS scale is unclear. The authors concluded that “GONB with local anaesthetics might reduce headache frequency and intensity compared with placebo, whereas GONB with local anaesthetics plus corticosteroids did not show any additional benefit”. They stated that they had very low confidence in this conclusion because the available evidence consisted of only seven RCTs of small size that were judged to have significant risks of bias. There were not enough identified studies to conduct meaningful pooled analysis of longer-term follow-up or a separate analysis of studies evaluating local anesthetics alone in the absence of corticosteroids.

Another placebo-controlled RCT was published by Chowdury and colleagues in 2023. Participants met diagnostic criteria for chronic migraine (migraine at least 8 days per month during a 4-week baseline period)(CM). A total of 44 individuals were included in the trial, 22 per group. Enrolled participants all met ICHD-3 criteria for CM. None had received migraine preventive therapy in the 3 months prior to enrollment. Participants received either a GONB injection with 2 ml of 2% lidocaine or a placebo injection of normal saline. Three injections were given, at weeks 1, 4 and 8. A total of 42 individuals completed the double-blind phase of the trial, analysis was done at 12 weeks (4 weeks after the final injection). The primary endpoint was the change in the mean number of headache days from weeks 0-4 to weeks 9-12. This change was -7.2 days (95% CI, -10.9 to -5.8) in the active treatment group compared with -3 days (95% CI, -6.7 to -2.4) in the placebo group. The difference between groups was -4.2 days which was statistically significant, p=0.018. Secondary outcomes also favored the active treatment group. For example, a significantly greater proportion of participants in the active treatment group (40.9%) than the placebo group (9.1%) had at least a 50% reduction in headache days at 9-12 weeks (p=0.024). No serious adverse events were reported. A total of 16 individuals in the active treatment group and 15 in the placebo group reported adverse events that were mostly mild and transient. The blinded comparison period in this study was 12 weeks; however, outcomes were assessed only in the 4 weeks since the last injection. This study's findings may not apply broadly to all chronic migraine (CM) patients because it excluded individuals who had used preventive migraine treatments in the 3 months prior to enrollment. As a result, the participants likely had less treatment-resistant disease.

A 2024 RCT by Unal and colleagues compared GONB to SPGB  randomized 41 adults with episodic migraine (21 to GONB, 20 to SPGB); 37 completed follow-up and were analyzed, and the trial reported greater reductions in headache days  (median 5.0 vs. 2.0, p<0.001), intensity (3.0 vs. 0.0, p<0.001), duration (20.0 vs. 14.0, p=0.022), and disability (MIDAS: 13.0 vs. 6.0, p<0.001) with GONB at 3 months. However, the absence of a placebo control, limited sample size (n=37), baseline imbalances in headache severity, and focus on episodic rather than chronic migraine limit its applicability to the conditions addressed in this document, reinforcing the investigational status of GONB.

A 2024 double-blind RCT by Tanyel Saraçoğlu and colleagues evaluated GONB alone compared to. GONB combined with pulsed radiofrequency (PRF) in 32 participants with chronic migraine, finding greater reductions in VAS scores (3.56 ± 1.15 vs. 5.69 ± 1.58, p=0.002), migraine attacks (~80% reduction, p<0.001), headache days (~85% reduction, p<0.001), and analgesic use (~80% reduction, p<0.001) with GONB+PRF at 6 months. Despite a sham PRF procedure, the lack of a true placebo control, limited sample size (n=32), and absence of a defined primary endpoint restrict conclusions about overall efficacy, supporting the investigational status of GONB.

A 2025 RCT by Taha and colleagues compared ultrasound-guided GONB and SPG block to sham SPG block in 53 participants with chronic resistant migraine. Participants received their GONB, SPG block, or sham SPG block injections only once during the study. Participants receiving SPG block or sham SPG block were blinded to their treatment assignment but their treating physicians were not. Observed results showed significant reductions in headache days, intensity, duration, and functional impact (HIT-6, MIDAS) for both active groups compared to sham at 1 and 3 months (p<0.001), with no difference between GONB and SPG block (p>0.05). The limited sample size (n=53), single-center design, short (3-month) duration, lack of assessor blinding, heterogeneity in steroid selection, unbalanced sham control (SPG block only), and absence of a pre-specified minimal clinically important difference for the primary outcome all limit this study’s internal and external validity.

These findings of limited and conflicting evidence are reflected at the guideline level. The International Headache Society (IHS) places GONB in its 'Optimal' category (as opposed to their ‘Essential’ category) for migraine prevention but qualifies this by stating the blocks have 'limited evidence of efficacy' (Puledda, IHS, 2024). The 2024 IHS guideline does not address blocking occipital nerve branches other than the greater occipital nerve, such as the lesser or third occipital nerves, nor does it address the use of sphenopalatine ganglion (SPG) block for treating headache syndromes. Reflecting trial data on corticosteroids as discussed above, the American Society of Regional Anesthesia and Pain Medicine (ASRA) explicitly recommends that clinicians 'should avoid the use of corticosteroids in greater occipital nerve blocks for migraine and medication-overuse headache' (ASRA, 2025). Together, the guidelines support the conclusion that the evidence basis for GONB as a migraine treatment is weak, and the addition of steroids for migraine is not recommended.

Cluster Headache:

The evidence of benefit of GONB in the management of cluster headache is limited to case series showing only temporary symptomatic relief. Results of these case series varied in terms of frequency, intensity and duration of headache relief. Further study is needed to confirm the results of these observational studies (Gantenbein, 2012; Peres, 2002).

In 2023, the European Academy of Neurology (EAN) published guidelines on the treatment of cluster headache. The guideline states that “Pharmacological nerve block of the GON is recommended and can be repeated if efficacious.” This was, however, a consensus statement, issued because the group determined that the published evidence was insufficient to issue an evidence-based guideline. This guideline does not discuss the use of SPG block as a treatment for cluster headache.

This conditional support for cluster headache is shared by several other major societies, making it the one indication with broad consensus. The American Headache Society (AHS) Special Interest Section identifies GONB for cluster headache as the sole exception to the general 'paucity of evidence' for nerve blocks (AHS, 2013). The British Association for the Study of Headache (BASH) recommends GONB as a 'transitional preventive', and the American Society of Regional Anesthesia and Pain Medicine (ASRA) states that adding a corticosteroid is 'preferred' for this specific indication (ASRA, 2025; BASH, 2019).

A 2024 double-blind RCT by Chowdhury and colleagues evaluated GONB with 2 mL methylprednisolone (80 mg) and 2 mL 2% lignocaine compared to placebo (4 mL saline) in 40 participants with episodic cluster headache, reporting a greater reduction in weekly attack frequency from baseline to Week 4 (−11.1 vs. −7.7; mean difference −3.4; 95% CI, −5.2 to −1.7; p<0.001) and higher remission rates at Weeks 1 (52.6% vs. 20%, p=0.039) and 2 (73.7% vs. 30%, p=0.009). Although this study used a  placebo-controlled design, the limited sample size (n=40), single-center design, and potential confounding from verapamil use in some participants restrict its generalizability. These factors support the continued classification of GONB as investigational for treatment of cluster headache.

Cervicogenic Headache:

A randomized, double-blind, sham-controlled trial evaluated the efficacy of nerve stimulator-guided occipital nerve block (ONB) therapy in the treatment of 50 adults with cervicogenic headache. Reduction in analgesic consumption was the primary outcome measure. Participants were randomly divided into two equal groups of 25 each. All trial participants in both groups received greater and lesser ONB, whereas only 16 participants in each group received facial nerve blockade in association with the occipital blocks. The control group received injections of an equivalent volume of preservative-free normal saline. Pain was assessed using the VAS and the Total Pain Index. Three participants were lost to follow-up. For the remaining 47 participants, anesthetic ONB was effective in reducing the VAS and the Total Pain Index by approximately 50% from baseline values (p=0.0001). Analgesic consumption; duration and frequency of headache; nausea; vomiting; photophobia; phonophobia; decreased appetite; and limitations in functional activities were significantly less in the treated group compared to the control group (p<0.05). It was noted that the nerve stimulator technique for nerve localization enabled the operator to determine the exact location of the nerve, thereby increasing the chance for success. However, while use of the nerve stimulator technique improved the accuracy of ONB, it required the individual’s co-operation for optimal detection of the nerve. For this reason, effectiveness might not always be initially achieved, making repeated blocks necessary to increase the likelihood of success. Limitations of this study included the short duration of outcomes data with follow-up of only 2 weeks and difficulty in blinding due to numbness which was experienced by the treated study group who received the anesthetic blockade (Naja, 2006).

Despite preliminary results from limited trials demonstrating some efficacy for use of GONB in chronic headache syndromes, a review of its use for cervicogenic headaches noted, “Because of the risks associated with these procedures (GONB) and the lack of well-controlled outcomes studies, more conservative interventions are typically prescribed” (Page, 2011).

Occipital Neuralgia:

According to the American Association of Neurological Surgeons (AANS), occipital neuralgia is a distinct headache syndrome classified as primary or secondary in etiology. Secondary headaches are usually associated with an underlying disease that may include tumor, trauma, infection, systemic disease or hemorrhage. Structural and neurologic abnormalities, as well as chronic neck tension and nerve pinching from overly tight neck muscles and nerve compression due to osteoarthritis or lesion, are all known causes of occipital neuralgia. In some cases, no cause can be isolated. Accurate diagnosis and treatment of the underlying condition often eliminates the headache. Magnetic resonance imaging (MRI) and computed tomography (CT) imaging are often used to diagnose occipital neuralgia following abnormal findings on a neurological examination. A positive response (that is, relief of pain) to an anesthetic nerve block can confirm the diagnosis.

The AANS has stated:

Treatment of occipital neuralgia aims to alleviate the pain; however, it is not a cure. Interventions can be surgical or non-surgical…Percutaneous nerve blocks: these injections can be used both to diagnose and treat occipital neuralgia (AANS, 2024).

Regarding the efficacy of GONB therapy for the treatment of occipital neuralgia, efficacy has only been demonstrated in observational and cohort studies and series of small numbers with only short-term outcomes data. There are no high-quality RCTs or long-term data demonstrating a sustained therapeutic benefit. Given that there is no conclusive evidence of the durable therapeutic effect of GONB in occipital neuralgia, further study is needed to confirm its benefits and risks before widespread use can be recommended (Bogduk, 2009; Hammond, 1978; Vanelderen, 2010).

Juškys and colleagues (2018) conducted a prospective study of 44 participants with occipital neuralgia who received occipital nerve blocks with local anesthetic and corticosteroids. At 6-month follow-up, 42 participants (95.45%) demonstrated satisfactory results with mean VAS scores decreasing from 7.23 ± 0.93 pre-treatment to 2.21 ± 1.73 at 6 months, representing a reduction from severe pain to mild pain levels. Additionally, analgesic medication use decreased from 100% to 16.67% of participants, with most participants (83.33%) no longer requiring pain medication at 6 months. However, this uncontrolled, single-center study lacked blinding and a placebo control group, limiting the ability to distinguish treatment effects from placebo response. The authors acknowledged these limitations and recommended RCTs for definitive efficacy assessment.

Sphenopalatine Ganglion Blocks

Chronic Migraine

SPG blocks have also been proposed for treatment of headaches. In a double-blind, parallel-arm, placebo-controlled randomized study, Cady and colleagues (2015a) reported the results of repetitive SPG block as a treatment for chronic migraine compared to saline. There were 41 participants initially randomized 2:1 to receive either an anesthetic agent (n=27) or saline (n=14). In the saline group, 1 participant withdrew from the study citing lack of efficacy. Efficacy was measured using the numeric rating scale (NRS) and, at two of the visits, by using a Headache Impact Test (HIT-6) questionnaire. There were 2 participants in the saline group and 1 participant in the SPG block group removed from data analysis due to protocol violations. Participants received 12 SPG blocks or sham treatments at a frequency of twice per week for 6 weeks. Participants were-re-evaluated at 1 and 6 months after their final treatment. The authors reported the following outcomes:

Adverse events were reported as mild to moderate and included lacrimation, unpleasant taste and mouth numbness. These adverse events may suggest that blinding was not maintained for all participants. The primary end point was not statistically different when comparison was made between those who experienced adverse events and those who did not. There were no controls for use of abortive therapies prior to the study intervention. The authors characterized the study as “exploratory” in nature and noted that “Further research on the efficacy, optimal frequency, and numbers of repetitive SPG blockade is warranted.”

Using the same population as the Cady, 2015a study above, Cady and colleagues (2015b) reported on sustained post-treatment outcomes (6-month) for secondary end points. Participants were assessed for change in the number of headache days from baseline to 1 month post treatment. Comparisons were also made for average pain, general activity, mood, normal work interference, and HIT-6 scores at 6 months post treatment. While some improvements were reported, there were no statistically significant differences in secondary end points between the treatment group and the sham group. The authors note “a more complete study of this novel treatment modality is warranted, as well as more studies to determine the role of the SPG in the physiology in migraine and its treatment.”

A 2022 systematic review and practice guideline for percutaneous interventional strategies for migraine prevention published by the American Academy of Pain Medicine (AAPM)gave a weak recommendation for SPG blocks use as chronic migraine prevention due to a very low certainty of evidence (Barad, 2022).

As referenced earlier, a 2024 single-center, single-operator RCT reported by Unal and colleagues compared SPG block to GONB as a treatment for episodic migraine. The study’s 37 participants were randomized into 2 l groups with 19 receiving GONB,  and 18 SPG blocks . Blocks were provided once weekly for 4 weeks then once monthly for 2 months (total of 6 blocks for each participant). Participants completed headache diaries for 1 month before through 1 month after their injection. A neurologist who was blinded to the treatment type evaluated all participants in 3 monthly visits after treatment. By chance, the participants in the GON block group initially presented with longer headache durations, a higher number of headache days, and increased use of acute medical treatments compared to those who received SPG blocks.  The authors reported the following median changes among the 37 completers:

Although all outcomes except for headache intensity in the SPG block group improved during this study, GONB block was consistently associated with greater improvement over the 3 study months. The single-center, single-operator design, absence of a placebo control, limited sample size (n=37), baseline imbalances in headache severity, and lack of control for use of migraine medications reduce the applicability of this study’s findings. The authors acknowledged that multicenter studies with larger sample sizes will be needed to confirm their results.

A 2025 RCT by Taha and colleagues compared ultrasound-guided infra-zygomatic SPG and GONB to sham SPG block in 53 participants with chronic resistant migraine, showing significant reductions in headache days, intensity, duration, and functional impact (HIT-6, MIDAS) for both active groups vs. sham at 1 and 3 months (p<0.001), with no difference between SPG and GONB (p>0.05). The limited sample size (n=53), lack of physician blinding, absence of a defined primary endpoint, and use of steroids in the injectate limit generalizability, reinforcing the investigational status of SPG block.

Post-Dural Puncture Headache

In 2020, Jespersen and colleagues reported on a study of the use of SPG treatment for post-dural puncture headache (PDPH). In this blinded, randomized clinical trial, 40 participants with post-dural puncture headache received either SPG block with local anesthetic (n=20) or saline (n=20). The primary outcome was pain intensity in upright position as assessed 30 min after the SPG block using a 100 mm VAS. Secondary outcomes included: a) intensity of pain in the upright position at 1 hour and 7 days after SPG block; b) intensity of pain in the supine position at 30 minutes, 60 minutes and 7 days after SPG block; c) frequency of participants with a pain intensity less than 30 mm in the upright position at 30 min after SPG block; and d) the frequency of participants who received rescue SPG block or epidural blood patch. Pain intensity in the upright position 30 min after the block was 26 mm in the local anesthetic group compared to 37 mm in the saline group. There were no significant differences in pain intensity at 60 min and 1 week after the block. The frequency of participants with pain intensity less than 30 mm at 30 min after SPG block was 12/20 (60%) in the local anesthetic group and 9/20 (45%) in the placebo group. In the local anesthetic group, during the time frame from 1 hour to 7 days after the block, 13/20 participants (65%) received a rescue block, and 10/20 (50%) received an epidural blood patch. In the placebo group, during the time frame from 1 hour to 7 days after the block, 13/20 (65%) received a rescue block and 9/20 (45%) received an epidural blood patch. Adverse events were reported for 10 participants. These included severe nasal discomfort and nausea during treatment, light pain or discomfort during treatment, throat discomfort, ear pain, and tingling in the cheek. There were no statistically significant differences in pain intensity between the two groups. Noting a more than 40 mm VAS reduction of pain in both the active therapy and placebo groups, the authors proposed that the treatment effect may not have been related to the local anesthesia injection.

In 2021, the ASA published their statement on Post-Dural Puncture Headache stating “There is currently insufficient evidence to recommend the use of acupuncture, greater occipital nerve blocks, sphenopalatine ganglion blocks, epidural morphine, and prophylactic intrathecal morphine via an intrathecal catheter after UDP in the treatment of obstetric PDPH.”

According to the ATLAS of Headache Disorders and Resources data, headaches, including migraine and tension-type headache, are among the most prevalent disorders in the world’s general population. Worldwide prevalence studies have estimated that one-half to three-quarters of adults aged 18 to 65 years have experienced at least one headache in the previous year. This data reports that over 10% of affected individuals have migraine, and 1.7-4% of the adult population is affected by headache on 15 or more days every month (World Health Organization [WHO], 2011).

The International Classification of Headache Disorders (ICHD) lists migraine as a primary headache. A primary headache is one that is not associated with any demonstrable organic disease, or structural or neurologic abnormality. Migraines may be unilateral or bilateral. They may occur with or without a preceding aura, such as dizziness, tinnitus, photophobia, or visual scintillations (for example, bright zigzag lines). Migraines manifest as a recurring attack usually lasting for 4-72 hours and involving pain of moderate to severe intensity, often with nausea, sometimes vomiting, sensitivity to light and/or sound and other sensory stimuli. Migraines are present in about 28 million people in the United States.

GONB or nerve block therapy has been proposed as a treatment of medically intractable chronic headache types, including migraine, cluster, cervicogenic and occipital neuralgia, using locally injected anesthetics with or without the addition of corticosteroid preparations.

Afferent: A nerve that carries impulses toward the central nervous system (CNS). The opposite of an afferent nerve is an efferent nerve that carries impulses away from the CNS.

Aura: Symptoms, such as disturbances in vision, smell or perception, that occur prior to a migraine headache and that often indicate the impending occurrence of a migraine headache.

Cervicogenic Headache: Pain referred to the head from the upper cervical vertebrae and muscles, which manifests as chronic hemicranial pain usually beginning in the suboccipital region and spreading anteriorly to the ipsilateral orbital, frontal, and temporal areas. This headache, of almost daily occurrence, is typically dominant on one side, but may occasionally be bilateral.

Cluster Headache: Sudden, intensely painful headaches that occur repeatedly in groups or clusters.

Ganglion: A group of neuron cell bodies in the peripheral nervous system. Ganglia provide relay points and intermediary connections between different neurological structures in the body, such as the peripheral and central nervous systems.

Intractable: Having no relief, such as a symptom or a disease that is not relieved by therapeutic measures.

Migraine: A vascular headache believed to be caused by blood flow changes and certain chemical changes in the brain leading to a cascade of events that include constriction of the arteries supplying blood to the brain with resultant severe headache, stomach upset, and visual disturbances, (referred to as aura). Sensitivity to light is also commonly associated with these headaches.  

Nociceptive: The ability of specific portions of the nervous system to sense and transmit painful stimuli.

Nummular Headache: A rare headache disorder characterized by focal and well-circumscribed pain fixed within a rounded or oval/elliptical-shaped area of the head, typically 2 to 6 cm in diameter, which most commonly affects the parietal region and is almost always unilateral and side-locked. The pain is typically characterized as pressure-like, sharp, or stabbing and is usually mild to moderate in intensity. This disorder may be episodic or chronic with distortions of sensation including hyperesthesia, hypoesthesia, allodynia, and paresthesias frequently reported in the affected area.

Occipital Nerves: Spinal nerves; the greater occipital nerve arises from between the first and second cervical vertebrae, along with the lesser occipital nerve.

Occipital Neuralgia: This distinct type of headache is caused by irritation or injury to the greater or lesser occipital nerves. Occipital neuralgia is characterized by piercing, throbbing, or electric shock-like chronic pain in the upper neck, back of the head, and behind the ears, usually on one side of the head. Some individuals also experience pain in the scalp, forehead, and behind the eyes.

Sphenopalatine ganglion: a small structure of nerve cells located behind the bony structures of the nose. This bundle of nerves is associated with the trigeminal nerve which is involved in headache disorders.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:
When the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Peer Reviewed Publications:

1. Afridi SK, Shields KG, Bhola R, Goadsby PJ. Greater occipital nerve injection in primary headache syndromes--prolonged effects from a single injection. Pain. 2006; 122(1-2):126-129.
2. Allen SM, Mookadam F, Cha SS, et al. Greater occipital nerve block for acute treatment of migraine headache: a large retrospective cohort study. J Am Board Fam Med. 2018; 31(2):211-218.
3. Ambrosini A, Schoenen J. Invasive pericranial nerve interventions. Cephalalgia. 2016; 36(12):1156-1169.
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Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Neurological Surgeons (AANS). Occipital Neuralgia. 2024. Available at: https://www.aans.org/patients/conditions-treatments/occipital-neuralgia/. Accessed on June 17, 2025.
2. Ailani J, Burch RC, Robbins MS. American Headache Society (AHS). The American Headache Society position statement on integrating new migraine treatments into clinical practice. Headache. 2021; 61(7):1021-1039.
3. American Society of Anesthesiologists. Statement on post-dural puncture headache management. October 2021. For additional information visit the ASA website: https://www.asahq.org/standards-and-practice-parameters/statement-on-post-dural-puncture-headache-management. Accessed on June 17, 2025.
4. Barad M, Ailani J, Hakim S, et al. Percutaneous interventional strategies for migraine prevention: a systematic review and practice guideline. Pain medicine (Malden, Mass.). 2022; 23(1):164-188.
5. Benzon HT, Elmofty D, Shankar H, et al. Use of corticosteroids for adult chronic pain interventions: sympathetic and peripheral nerve blocks, trigger point injections - guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, and the International Pain and Spine Intervention Society. Reg Anesth Pain Med. 2025 Mar 12; [Epub ahead of print]. .
6. Blumenfeld A, Ashkenazi A, Evans RW. Occipital and trigeminal nerve blocks for migraine. Headache. 2015; 682-689.
7. Blumenfeld A, Ashkenazi A, Grosberg B, et al. Patterns of use of peripheral nerve blocks and trigger point injections among headache practitioners in the USA: results of the American Headache Society Interventional Procedure Survey (AHS-IPS). Headache. 2010; 50(6):937-942.
8. Blumenfeld A, Ashkenazi A, Napchan U, et al. American Headache Society Special Interest Section. Expert consensus recommendations for the performance of peripheral nerve blocks for headaches--a narrative review. Headache. 2013; 53(3):437-446.
9. British Association for the Study of Headache (BASH). National headache management system for adults. 2019. Available at: https://bash.org.uk/wp-content/uploads/2023/02/01_BASHNationalHeadache_Management_SystemforAdults_2019_guideline_versi-1.pdf. Accessed on June 17, 2025.
10. International Headache Society; Headache Classification Subcommittee. The international classification of headache disorders. Third edition. Cephalalgia. 2018; 38(1):1-211.
11. May A, Evers S, Goadsby PJ, et al. European Academy of Neurology Task Force. European Academy of Neurology guidelines on the treatment of cluster headache. Eur J Neurol. 2023 Oct; 30(10):2955-2979.
12. National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH). Occipital neuralgia. Last reviewed November 22, 2024. Available at: https://www.ninds.nih.gov/health-information/disorders/headache. Accessed on June 17, 2025.
13. Puledda F, Sacco S, Diener H-C, et al. International Headache Society global practice recommendations for preventive pharmacological treatment of migraine. Cephalalgia. 2024; 44(9):1-31.
14. World Health Organization (WHO). Atlas of headache disorders and resources in the world. Last reviewed January 11, 2011. Available at: https://www.who.int/publications/i/item/9789241564212. Accessed on August 13, 2025.

Headache
Migraine
Occipital Nerve Block, Blockade (greater, lesser)
Occipital Neuralgia
Sphenopalatine Ganglion Block, Blockade

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