Droperidol

Written by: Adam Payne, MD (NUEM ‘24) Edited by: Julian Richardson, MD (NUEM ‘21) Expert Commentary by: Matt O' Connor, MD

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Expert Commentary

Thanks to Dr. Payne & Dr. Richardson for putting this together!  I think this was well done, they’ve presented a concise overview of the safety and efficacy of droperidol. 

There’s a lot of utility in droperidol.  It’s great for nausea, migraines, and even as an adjunct for chronic pain.  It’s also a very good choice for agitation.  I use it most often for nausea.  It’s been shown to be as effective as odansetron, and more effective than metoclopramide.  Anecdotally, I find it works particularly well for gastroparesis and cannabinoid hyperemesis (with some low-concentration topical capsaicin cream), with less sedation than haloperidol.  For migraines, it has been shown to be as effective as prochlorperazine.  It works well for sedation in agitated patients as well; IV & IM it has a much faster onset than haloperidol, and so benzodiazepines typically do not have to be co-administered, reducing the level and duration of sedation and need for monitoring.     

The black box warning significantly limited droperidol’s availability, such that many of our newer graduates have not had any first-hand clinical experience with the medication.  If you’re not familiar with its use, don’t let the black box warning completely dissuade you.  Subsequent studies looking at emergency department droperidol use have shown it to be safe, and that complications related to QT prolongation are rare in typical doses.   As a rule of thumb, the dose of droperidol is about half of the dose of haloperidol for a given indication.  For nausea, migraine, or other pain, I usually start with 0.625-2.5mg IV, twice that IM, and can repeat dosing if needed (my most common starting dose is 1.25mg IV).  For agitation, usually 2.5-5mg IM, though up to 10mg IM has been shown likely to be safe.  Although it is prudent to be cautious, I think the literature supports droperidol’s use at appropriate doses in otherwise healthy patients.

Matt O’Connor, MD

Emergency Medicine Physician

BerbeeWalsh Department of Emergency Medicine

University of Wisconsin Hospitals and Clinics

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Payne, A. Richardson, J. (2021, Aug 30). Droperidol. [NUEM Blog. Expert Commentary by O’Connor, M]. Retrieved from http://www.nuemblog.com/blog/droperidol

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Occipital Nerve Block

Written by: Andrew Rogers, MD (PGY-2) Edited by: Aaron Quarles, MD (NUEM ‘19) Expert commentary by: Ben Friedman, MD

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Nerve Blocks of the Head & Neck Part II:

The Occipital Nerve Block

About this series…

This article is part of a series of articles on the nerve blocks of the head and neck.  For more information on other types of useful nerve blocks, please refer to the links below:

Nerve Blocks of the Head & Neck Part I: Facial Nerve Blocks

Nerve Blocks of the Head & Neck Part III: Oral Nerve Blocks

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Introduction/Overview

An occipital nerve block is a peripheral nerve block performed on the greater and lesser occipital nerves to help treat headache.  Occipital nerve block (ONB) has been used in the treatment of cervicogenic headache, cluster headache, and occipital neuralgia, with demonstrated efficacy in improving pain and reducing headache frequency (1-3).  By definition, occipital neuralgia will respond to ONB, and failure of symptoms to resolve should raise into question of the original diagnosis (2, 3).  

Occipital nerve block may also be efficacious in the treatment of migraine.  In a retrospective cohort study of 562 patients who received at least one greater occipital nerve block (GONB) for the treatment of migraine, 82% had >30% reduction in numeric pain scale from baseline with 58% having a >50% improvement (4).  Recently, a small, randomized, sham-controlled trial of GONB performed in the Emergency Department for migraine refractory to metoclopramide therapy demonstrated greater short-term headache relief (5). GONB may be particularly useful in migraine patients with evidence of occipital nerve irritation or tenderness. 

Indications

• Occipital neuralgia

• Cluster headache

• Cervicogenic headache

• Migraine, particularly with occipital nerve irritation or tenderness

Contraindications

• Medication allergy

• Infection overlying site of injection

• Skull defect

Anatomy

Key anatomy points of review:

• The occipital nerve originates from C2-C3 nerve roots

• The GON perforates the fascia just underneath the superior nuchal ridge

• The GON lies just medial to the occipital artery

Figure 1: Greater Occipital Nerve Anatomy (6)

What to Inject

Typically, a local anesthetic such as lidocaine (1-2%) or bupivacaine (0.5%) (or a combination of the two) is injected..  Lidocaine has a quicker onset, while bupivacaine has a longer lasting effect. Total volume injected is 2-4cc per nerve block. 

A steroid such as such as betamethasone (2-4mg) or triamcinolone (10-20mg) may be added to the local anesthetic (3).  For the Emergency Physician, one should consider how the addition of a steroid may complicate or impact a patient’s follow up with their primary neurologist or primary care physician.  Additionally, one study failed to show a significant difference in headache relief for transformed migraines treated with or without triamcinolone in addition to local anesthetic (7).  

The Procedure:

1. Identify the location of the GONB via one of 3 methods:

   1. Palpate the occipital artery pulse about 2cm lateral to the occipital protuberance.  The greater occipital nerve is just medial to the occipital artery

Alternatively

1. Palpate the occipital protuberance and the mastoid process (on side of interest). Measure 1/3 the distance between the two points starting from the occipital protuberance. Stay just superior to the superior nuchal line to remain over the cranium. (Figure 2) 

Alternatively

1. Identify the point of maximal tenderness in the general region as defined above that may elicit paresthesia in the occipital nerve distribution when palpated

1. Clean the site of injection with an alcohol swab or similar cleaning solution.

2. Using a 23-25G needle, insert the needle at a 90-degree angle toward the occiput until a bony endpoint is obtained.  Aspirate to avoid intravascular injection and to prevent injection into CSF. Inject 1cc at the GON, 1cc medial to the nerve, and 1cc lateral to the nerve.  

3. The procedure can be performed bilaterally. 

Figure 2: Representative schematic to aid in locating the greater occipital nerve, using method 1(b) as described above.

Key Points:

• The greater occipital nerve block can used in the treatment of refractory migraine, cluster headache, occipital neuralgia, or cervicogenic headache

• If palpation of the GON reproduces headache pain or irritation, it may be a good target for GONB

• A GONB can be performed bilaterally if needed

• Use local anesthetics such as lidocaine and/or bupivacaine

• Aspirate while inserting the needle to avoid intravascular injection and to avoid being in CSF

• Inject in a fanning technique just medial to the occipital artery pulse, one third of the distance from the occipital protuberance to the mastoid process, or at the site of maximal tenderness in the region

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Expert Commentary

This well-written and informative review of the greater occipital nerve block (GONB) will help clinicians choose appropriate patients for this procedure and perform it with a high likelihood of success. In my experience, the GONB is easy to learn and easy to utilize clinically because it is a “forgiving” nerve block—patients often seen to respond even if the local anesthetic is not delivered precisely. As Dr. Rogers notes, using a “fan” technique maximizes the chances of success. While corticosteroids are efficacious for migraine, the most common type of headache seen in the ED, I prefer to deliver the corticosteroids separately from the GONB as either an intravenous or intramuscular injection. That way, I am not limited by volume and can administer more local anesthetic. And while a 23 or 25 gauge needle can certainly get the job done, my patients seem to appreciate it more when I use a 27 gauge needle. Finally, while not evidence-based, I think about using the GONB for any type of headache that is refractory to first or second line treatment—I’ve had success using it in a wide variety of atypical headaches (just don’t forget to rule out badness!)

Benjamin W. Friedman, M.D.

Professor

Department of Emergency Medicine

Montefiore Medical Center

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How to Cite this Post

[Peer-Reviewed, Web Publication] Rogers A, Quarles A. (2020, Jan 13). Occipital Nerve Block. [NUEM Blog. Expert Commentary by Friedman, B]. Retrieved from http://www.nuemblog.com/blog/occipitalnerveblocl

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References:

Sources

1. “Occipital Nerve Blocks: When and What to Inject?” Tobin, Joshua; Flitman, Stephen. Headache. 2009. Nov-Dec, 49 (10):1521-33

2. “Occipital Neuralgia.” Garza, Ivan. UpToDate. 25 August, 2017. Accessed 28 January 2019. 

3. “Greater Occipital Nerve Block.” Ward, John.  Seminars in Neurology. 2003; 23(1): 059-062.  Accessed 28 January 2019.

4. “Greater Occipital Nerve Block for Acute Treatment of Migraine Headache: A Large Retrospective Cohort Study.” Allen et al. Journal of the American Board of Family Medicine.  Vol 31, Issue 2. March/April 2018. P 211-218.  

5. “A Randomized, Sham‐Controlled Trial of Bilateral Greater Occipital Nerve Blocks With Bupivacaine for Acute Migraine Patients Refractory to Standard Emergency Department Treatment With Metoclopramide.” Friedman, Benjamin, et. Al. Headache. October 2018.  Vol58, Issue 9. Pp1427-1434. 

6. “Greater Occipital Nerve.” Volker, Joseph.  Earthslab.com. 8 August, 2018. 

7. “Greater Occipital Nerve Block Using Local Anaesthetics Alone or with Triamcinolone for Transformed migraine: a radomised comparative study.” Ashkenazi A, et al. Journal of Neurology, Neurosurgery, and Psychiatry. 2008 April; 79(4):415-7

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