Greater Occipital Nerve (GON) Blocks to Treat Migraines with Aura with Concomitant Symptomatic Relief of Bipolar II

Case Diagnosis: Greater occipital nerve block significantly ameliorated hypomanic episodes as well as status migrainosus flare-ups.

Case Description or Program Description: The patient displayed weekly hypomanic episodes consisting of grandiosity, mood swings, impulsivity, and disorganized flight of ideas, as well as monthly status migrainosus, both conditions poorly controlled with pharmacological therapy, requiring bi-weekly visits to the emergency department. Significant spasms of the suboccipital triangle and upper cervical paraspinals were noted on physical exam. The greater occipital nerve (GON) traverses the upper cervical and occipital regions. A GON-block was performed bilaterally using a 1:4 ratio of triamcinolone acetonide (40 mg/ml) and lidocaine 2% mixed in a 5 cc syringe with a 25 gauge needle. The location of the GON was identified by palpation as approximately one third of the distance from the occipital protuberance to the mastoid process on each side. Using an inferior-lateral approach aiming towards the GON, the needle was advanced until the skull was reached, then withdrawn 1mm and aspirated, ensuring no impingement with the occipital artery, before administration of the anesthetic in a fan-like fashion.

Setting: Underserved Geriatric Clinic, Virginia USA

Assessment/Results: Post GON block in office, the patient reported no flare-ups to necessitate further emergency room visits in 2 months. Upon close weekly follow-up visits, she had better mood and less impulsivity. Thought process progressed from tangential to linear.

Discussion (relevance): White matter hyperintensities have been remarked on MRI brain imaging taken over 10 years ago, consolidating migraine and bipolar co-occurrence. Both conditions involve similar neurotransmitters including dopamine, serotonin, and glutamate.

Conclusions: Bipolar patients are usually on multiple drugs including mood stabilizers, anti-psychotics, and anti-depressants, which may or may not sufficiently control symptoms and flare-ups. This case demonstrates the bidirectional relationship between bipolar and migraine disorders and sheds light on nerve blocks as a highly effective alternative modality of management.