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Scalp Block for Migraines and Facial Pain
Daewoong Lee, MD
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Post Procedure

          TERMINOLOGY

          • Abbreviations

            • Electromyography (EMG)
            • Temporomandibular joint (TMJ)
            • Botulinum neurotoxin (BoNT)
          • Definitions

            • PREEMPT study: Phase III research evaluating migraine prophylaxis therapy
              • Combination of 2 largest placebo-controlled clinical trials of chronic migraine population that evaluated efficacy and safety of onabotulinumtoxinA
            • Scalp block targets following 6 nerves
              • Supraorbital and supratrochlear nerves originate from ophthalmic division (V1) of trigeminal nerve and innervate forehead and upper eyelids
              • Auriculotemporal nerve is trigeminal branch of mandibular division (V3) and innervates anterior and superior areas of ears
              • Zygomaticotemporal nerve originates from maxillary division (V2) of trigeminal nerve and innervates lateral to outer cantus of eyes
              • Greater occipital nerves originate from dorsal ramus of C2 and innervate posterior scalp medial to occipital artery
              • Lesser occipital nerves originate from ventral rami of C2 and C3 and innervate scalp behind ear
            • Botulinum toxin type A (BoNT-A): Commercial forms are marketed under following brand names
              • Botox (onabotulinumtoxinA)
                • Original BoNT-A product approved by FDA
              • Dysport (abobotulinumtoxinA)
                • Botox and Dysport differ in purification procedure; Dysport is reported to exhibit greater spread, and dose ratios between Dysport and Botox is commonly estimated to be 3:1
              • Xeomin (incobotulinumtoxinA)
                • Xeomin:Botox ratio is reported to be near 1:1, without any significant differences in safety and efficacy; by stripping BoNT-A of complexing proteins, Xeomin is hypothesized to carry reduced risk of sensitization or antibody formation, which have yet to be validated in literature
            • Botulinum toxin type B (BoNT-B)
              • Myobloc (rimabotulinumtoxinB)
                • This is only BoNT-B commercially available in USA, indicated only for treatment of cervical dystonia in adults
                • Compared to BoNT-A, it shows more rapid onset and greater diffusion but shorter duration of actions and more painful injections
                • Conversion from Botox to Myobloc is reported to be in range of 1:50-100
            • Note: There is no established conversion method for equivalent dosing among different BoNT products
              • Each unit injection from one product is not interchangeable with other preparations
              • They offer different safety and efficacy characteristics, and, thus, interventionalist must be familiar with selected product prior to their use

          PREPROCEDURE

          • Indications

            • Contraindications

              • Getting Started

                PROCEDURE

                • Procedure Steps

                  POST PROCEDURE

                  • Expected Outcome

                    OUTCOMES

                    • Complications

                      Selected References

                      1. FDA website. Botox prescribing information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/125274s112lbl.pdf. Published 2018. Reviewed July 2019. Accessed July 2019.
                      2. Vikelis M et al: Sustained onabotulinumtoxinA therapeutic benefits in patients with chronic migraine over 3 years of treatment. J Headache Pain. 19(1):87, 2018
                      3. Awan KH: The therapeutic usage of botulinum toxin (Botox) in non-cosmetic head and neck conditions - an evidence based review. Saudi Pharm J. 25(1):18-24, 2017
                      4. Janis JE et al: Targeted peripheral nerve-directed onabotulinumtoxin A injection for effective long-term therapy for migraine headache. Plast Reconstr Surg Glob Open. 5(3):e1270, 2017
                      5. Pihut M et al: The efficiency of botulinum toxin type A for the treatment of masseter muscle pain in patients with temporomandibular joint dysfunction and tension-type headache. J Headache Pain. 17:29, 2016
                      6. Scaglione F: Conversion ratio between Botox®, Dysport®, and Xeomin® in clinical practice. Toxins (Basel). 8(3), 2016
                      7. Mor N et al: Temporomandibular myofacial pain treated with botulinum toxin injection. Toxins (Basel). 7(8):2791-800, 2015
                      8. Bebawy JF et al: A modified technique for auriculotemporal nerve blockade when performing selective scalp nerve block for craniotomy. J Neurosurg Anesthesiol. 26(3):271-2, 2014
                      9. McNicholas E et al: Transient facial nerve palsy after auriculotemporal nerve block in awake craniotomy patients. A A Case Rep. 2(4):40-3, 2014
                      10. Guilfoyle MR et al: Regional scalp block for postcraniotomy analgesia: a systematic review and meta-analysis. Anesth Analg. 116(5):1093-102, 2013
                      11. Aurora SK et al: OnabotulinumtoxinA for treatment of chronic migraine: pooled analyses of the 56-week PREEMPT clinical program. Headache. 51(9):1358-73, 2011
                      12. Amsterdam, James et al: Regional Anesthesia of the Head and Neck. Roberts, Hedges. Clinical Procedures in Emergency Medicine. 5th ed. Philadelphia: Saunders Elsevier. 510-2, 2010
                      13. Aurora SK et al: OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 1 trial. Cephalalgia. 30(7):793-803, 2010
                      14. Diener HC et al: OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 2 trial. Cephalalgia. 30(7):804-14, 2010
                      15. Osborn I et al: "Scalp block" during craniotomy: a classic technique revisited. J Neurosurg Anesthesiol. 22(3):187-94, 2010
                      16. Loukas M et al: Identification of greater occipital nerve landmarks for the treatment of occipital neuralgia. Folia Morphol (Warsz). 65(4):337-42, 2006
                      17. Chikhani L et al: [Bruxism, temporo-mandibular dysfunction and botulinum toxin.] Ann Readapt Med Phys. 46(6):333-7, 2003
                      18. Gain P et al: [Facial anesthetic blocks in the treatment of acute pain during ophthalmic zoster.] J Fr Ophtalmol. 26(1):7-14, 2003
                      19. Dimitriou V et al: Blockade of branches of the ophthalmic nerve in the management of acute attack of migraine. Middle East J Anaesthesiol. 16(5):499-504, 2002
                      Related Anatomy
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                      Related Differential Diagnoses
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                      References
                      Tables

                      Tables

                      KEY FACTS

                      • Terminology

                        • Preprocedure

                          • Procedure

                            • Post Procedure

                              TERMINOLOGY

                              • Abbreviations

                                • Electromyography (EMG)
                                • Temporomandibular joint (TMJ)
                                • Botulinum neurotoxin (BoNT)
                              • Definitions

                                • PREEMPT study: Phase III research evaluating migraine prophylaxis therapy
                                  • Combination of 2 largest placebo-controlled clinical trials of chronic migraine population that evaluated efficacy and safety of onabotulinumtoxinA
                                • Scalp block targets following 6 nerves
                                  • Supraorbital and supratrochlear nerves originate from ophthalmic division (V1) of trigeminal nerve and innervate forehead and upper eyelids
                                  • Auriculotemporal nerve is trigeminal branch of mandibular division (V3) and innervates anterior and superior areas of ears
                                  • Zygomaticotemporal nerve originates from maxillary division (V2) of trigeminal nerve and innervates lateral to outer cantus of eyes
                                  • Greater occipital nerves originate from dorsal ramus of C2 and innervate posterior scalp medial to occipital artery
                                  • Lesser occipital nerves originate from ventral rami of C2 and C3 and innervate scalp behind ear
                                • Botulinum toxin type A (BoNT-A): Commercial forms are marketed under following brand names
                                  • Botox (onabotulinumtoxinA)
                                    • Original BoNT-A product approved by FDA
                                  • Dysport (abobotulinumtoxinA)
                                    • Botox and Dysport differ in purification procedure; Dysport is reported to exhibit greater spread, and dose ratios between Dysport and Botox is commonly estimated to be 3:1
                                  • Xeomin (incobotulinumtoxinA)
                                    • Xeomin:Botox ratio is reported to be near 1:1, without any significant differences in safety and efficacy; by stripping BoNT-A of complexing proteins, Xeomin is hypothesized to carry reduced risk of sensitization or antibody formation, which have yet to be validated in literature
                                • Botulinum toxin type B (BoNT-B)
                                  • Myobloc (rimabotulinumtoxinB)
                                    • This is only BoNT-B commercially available in USA, indicated only for treatment of cervical dystonia in adults
                                    • Compared to BoNT-A, it shows more rapid onset and greater diffusion but shorter duration of actions and more painful injections
                                    • Conversion from Botox to Myobloc is reported to be in range of 1:50-100
                                • Note: There is no established conversion method for equivalent dosing among different BoNT products
                                  • Each unit injection from one product is not interchangeable with other preparations
                                  • They offer different safety and efficacy characteristics, and, thus, interventionalist must be familiar with selected product prior to their use

                              PREPROCEDURE

                              • Indications

                                • Contraindications

                                  • Getting Started

                                    PROCEDURE

                                    • Procedure Steps

                                      POST PROCEDURE

                                      • Expected Outcome

                                        OUTCOMES

                                        • Complications

                                          Selected References

                                          1. FDA website. Botox prescribing information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/125274s112lbl.pdf. Published 2018. Reviewed July 2019. Accessed July 2019.
                                          2. Vikelis M et al: Sustained onabotulinumtoxinA therapeutic benefits in patients with chronic migraine over 3 years of treatment. J Headache Pain. 19(1):87, 2018
                                          3. Awan KH: The therapeutic usage of botulinum toxin (Botox) in non-cosmetic head and neck conditions - an evidence based review. Saudi Pharm J. 25(1):18-24, 2017
                                          4. Janis JE et al: Targeted peripheral nerve-directed onabotulinumtoxin A injection for effective long-term therapy for migraine headache. Plast Reconstr Surg Glob Open. 5(3):e1270, 2017
                                          5. Pihut M et al: The efficiency of botulinum toxin type A for the treatment of masseter muscle pain in patients with temporomandibular joint dysfunction and tension-type headache. J Headache Pain. 17:29, 2016
                                          6. Scaglione F: Conversion ratio between Botox®, Dysport®, and Xeomin® in clinical practice. Toxins (Basel). 8(3), 2016
                                          7. Mor N et al: Temporomandibular myofacial pain treated with botulinum toxin injection. Toxins (Basel). 7(8):2791-800, 2015
                                          8. Bebawy JF et al: A modified technique for auriculotemporal nerve blockade when performing selective scalp nerve block for craniotomy. J Neurosurg Anesthesiol. 26(3):271-2, 2014
                                          9. McNicholas E et al: Transient facial nerve palsy after auriculotemporal nerve block in awake craniotomy patients. A A Case Rep. 2(4):40-3, 2014
                                          10. Guilfoyle MR et al: Regional scalp block for postcraniotomy analgesia: a systematic review and meta-analysis. Anesth Analg. 116(5):1093-102, 2013
                                          11. Aurora SK et al: OnabotulinumtoxinA for treatment of chronic migraine: pooled analyses of the 56-week PREEMPT clinical program. Headache. 51(9):1358-73, 2011
                                          12. Amsterdam, James et al: Regional Anesthesia of the Head and Neck. Roberts, Hedges. Clinical Procedures in Emergency Medicine. 5th ed. Philadelphia: Saunders Elsevier. 510-2, 2010
                                          13. Aurora SK et al: OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 1 trial. Cephalalgia. 30(7):793-803, 2010
                                          14. Diener HC et al: OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 2 trial. Cephalalgia. 30(7):804-14, 2010
                                          15. Osborn I et al: "Scalp block" during craniotomy: a classic technique revisited. J Neurosurg Anesthesiol. 22(3):187-94, 2010
                                          16. Loukas M et al: Identification of greater occipital nerve landmarks for the treatment of occipital neuralgia. Folia Morphol (Warsz). 65(4):337-42, 2006
                                          17. Chikhani L et al: [Bruxism, temporo-mandibular dysfunction and botulinum toxin.] Ann Readapt Med Phys. 46(6):333-7, 2003
                                          18. Gain P et al: [Facial anesthetic blocks in the treatment of acute pain during ophthalmic zoster.] J Fr Ophtalmol. 26(1):7-14, 2003
                                          19. Dimitriou V et al: Blockade of branches of the ophthalmic nerve in the management of acute attack of migraine. Middle East J Anaesthesiol. 16(5):499-504, 2002