To test the efficacy of greater occipital nerve blocks with lidocaine in children/adolescents with acute migraine in a randomized control trial. 

Peripheral nerve blocks (PNBs), injections of local anesthetics over branches of the occipital and/or trigeminal nerves, have been associated with benefit for pediatric headaches in case series.  PNBs are used by 80% of pediatric headache specialists, but have not been tested in a randomized pediatric trial.   

We conducted a randomized, double-blind trial of bilateral occipital nerve blocks with lidocaine versus saline for treatment of acute, severe headache refractory to usual therapies.  Participants were ages 10-21 years with a migraine flare of 24hrs to 3 months duration with insufficient response to other treatments for status migrainosus.  All participants had lidocaine cream applied for 30min as a run-in step and could decline injections if they experienced sufficient benefit from cream alone.  The injection medication was block randomized by episodic versus chronic migraine.  The primary comparison was difference in change in pain score between lidocaine and saline injection groups. 

Sixty-four youth signed consent and assent, and 58 were eligible.  Mean age was 16±1.8 years; reported gender was female for 44, male for 11, and non-binary or transgender for 3.  Topical lidocaine cream lead-in resulted in mean decrease in pain score of 0.2±0.9 points on 0-10 scale, and all participants proceeded to randomized injection.  The lidocaine injection group reported mean decrease of 2.3±1.9 points on 0-10 scale and the saline injection group reported mean decrease of 1.1±1.9 points (t-test, p=0.01).  Of those injected, 22/29 getting lidocaine reported at least partial relief in severity or location of pain compared to 14/29 getting saline (X² p=0.03)

Greater occipital nerve injections with lidocaine resulted in a significantly larger drop in pain score compared to saline injections for youth with status migrainosus.