Proximal and Distal Approaches to Ultrasound-guided Greater Occipital Nerve Block for Chronic Migraine: A Systematic Review and Meta-analysis of Efficacy and Safety
Basant Lashin1, Haneen Sabet2, Ahmed Samir3, Abdallah Abbas3, Shrouk Ramadan4, Mohamed El-Moslemani3, Ahmed F Younis5, Obai Yousef6, Rovan Ahmed Rouby7, Fatma Aljalawy8, Alaa Abd-Elsayed9
1Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA., 2Faculty of Medicine, South Valley University, Qena, Egypt., 3Faculty of Medicine, Al-Azhar University, Damietta, Egypt., 4Faculty of Medicine, Ain-Shams University, Cairo, Egypt, 5Faculty of Medicine, Al-Azhar University, Damietta, Egypt, 6Department of Neurosurgery, Tishreen University Hospital, Latakia, Syria., 7Faculty of Medicine, Fayoum University, Fayoum, Egypt., 8Department of Physiology, Ain Shams University Hospital, Cairo, Egypt., 9Department of Anesthesiology and Pain Management, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
Objective:
To evaluate the efficacy and safety of ultrasound-guided greater occipital nerve block (US-GONB) in migraine and compare clinical outcomes between proximal and distal injection approaches.
Background:
Chronic migraine is a highly disabling disorder often refractory to pharmacological therapy. Greater occipital nerve block (GONB) is an established interventional strategy; however, traditional landmark-guided techniques may limit accuracy and safety. Ultrasound guidance allows precise visualization of the nerve at both proximal (C2 level) and distal (occipital) locations, potentially improving outcomes. Current literature presents variability in technique and uncertainty regarding the optimal injection site.
Design/Methods:
A systematic review and meta-analysis following PRISMA guidelines was conducted. PubMed, Scopus, Web of Science, and Cochrane Library databases were searched from inception to July 2025. Clinical trials and observational studies assessing US-GONB in migraine were included. Primary outcomes were pain intensity and headache frequency; secondary outcomes included headache duration, migraine frequency, analgesic use, and adverse events. Random-effects models were used to calculate pooled mean differences, and subgroup analyses compared proximal versus distal approaches.
Results:
Twelve studies comprising 658 patients were included. US-GONB significantly reduced pain intensity (MD: –3.48) and monthly headache frequency (MD: –9.12), with sustained benefits up to three months. Both single- and repeated-frequency protocols demonstrated effectiveness, with repeated injections producing greater improvements. Proximal and distal approaches were similarly effective in reducing pain, but proximal injections achieved greater reductions in monthly headache frequency (–10.83 vs –6.36 days; P = 0.006). US-GONB also reduced headache duration and analgesic use. Adverse events were generally mild; however, proximal blocks were associated with higher rates of sensory changes and vasovagal symptoms.
Conclusions:
US-GONB provides clinically meaningful reductions in pain, headache burden, and medication use, supporting its use as an effective adjunct in migraine management. Proximal injections offer greater benefit, indicating technique selection may optimise outcomes and inform practice integration for improved patient care.
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