Objective:

Evaluate lidocaine ONB for APSH

Background:

Headache is a common complication of stroke, yet there are no established treatment guidelines for acute post-stroke headache (APSH) as defined by ICHD-3 (6.1.1–6.2.3). Most  migraine therapies are contraindicated in acute stroke, leaving few safe treatment options.  Interventional procedures have the potential to provide meaningful relief for APSH. Occipital nerve block (ONB) with lidocaine is an established abortive therapy for migraine, and we hypothesize that it may represent a feasible approach for APSH.  

Design/Methods:

We are conducting an observational, prospective, open-label study in the acute stroke and neuro-ICU units at a tertiary center. Adults with APSH received bilateral greater and lesser ONB using 1 mL of 2% lidocaine per site. Pain (0–10 NRS) and associated symptoms were assessed pre-injection, at 2 hours, and 24 hours post-injection using standardized questionnaires. Rescue medication used during this time period was recorded. The primary outcome was change in NRS; secondary outcomes included pain freedom, improvement in associated symptoms, and rescue medication frequency. Wilcoxon signed-rank tests compared pre- and post-injection scores.  

Results:

Presently, eight patients (7 ischemic, 1 hemorrhagic) have been enrolled. Preliminary analysis shows median pain decreasing from 9.5 [7–10] at baseline to 4 [0–9] at 2 hours (p = 0.0089) and 4 [2–8] at 24 hours (p = 0.0078). At 2 hours, 37.5% were pain-free and 37.5% had ≤3/10 pain; at 24 hours, 28.6% (2/7) had ≤3/10 pain. Associated symptoms improved in most patients across both time points. Rescue medications post-ONB were limited to non-opioid analgesics and antiemetics. No serious adverse events were reported.  

Conclusions:

ONB with lidocaine was associated with statistically significant reductions in APSH pain, improvement in associated symptoms, and decreased need for rescue medication. These findings support ONB as a feasible, well-tolerated intervention for APSH in the inpatient setting and underscore this study’s potential to establish its effectiveness.