title: Patterns of Use of Peripheral Nerve Blocks and Trigger Point Injections for Pediatric Headache: Results of a Survey of the American Headache Society Pediatric and Adolescent Section.
abstract: OBJECTIVE
  To describe current patterns of use of nerve blocks and trigger point injections for treatment of pediatric headache.
  
  
  BACKGROUND
  Peripheral nerve blocks are often used to treat headaches in adults and children, but the available studies and practice data from adult headache specialists have shown wide variability in diagnostic indications, sites injected, and medication(s) used. The purpose of this study was to describe current practice patterns in the use of nerve blocks and trigger point injections for pediatric headache disorders.
  
  
  METHODS
  A survey was created in REDCap, and sent via email to the 82 members of the Pediatric and Adolescent Section of the American Headache Society in June 2015. The survey queried about current practice and use of nerve blocks, as well as respondents' opinions regarding gaps in the evidence for use of nerve blocks in this patient population.
  
  
  RESULTS
  Forty-one complete, five incomplete, and three duplicate responses were submitted (response rate complete 50%). About 78% of the respondents identified their primary specialty as Child Neurology, and 51% were certified in headache medicine. Twenty-six (63%) respondents perform nerve blocks themselves, and seven (17%) refer patients to another provider for nerve blocks. Chronic migraine with status migrainosus was the most common indication for nerve blocks (82%), though occipital neuralgia (79%), status migrainosus (73%), chronic migraine without flare (70%), post-traumatic headache (70%), and new daily persistent headache (67%) were also common indications. The most commonly selected clinically meaningful response for status migrainosus was ≥50% reduction in severity, while for chronic migraine this was a ≥50% decrease in frequency at 4 weeks. Respondents inject the following locations: 100% inject the greater occipital nerve, 69% lesser occipital nerve, 50% supraorbital, 46% trigger point injections, 42% auriculotemporal, and 34% supratrochlear. All respondents used local anesthetic, while 12 (46%) also use corticosteroid (8 bupivacaine only, 4 each lidocaine + bupivacaine, lidocaine + corticosteroid, bupivacaine + corticosteroid, lidocaine + bupivacaine + corticosteroid, and 2 lidocaine only).
  
  
  CONCLUSIONS
  Despite limited evidence, nerve blocks are commonly used by pediatric headache specialists. There is considerable variability among clinicians as to injection site(s) and medication selection, indicating a substantial gap in the literature to guide practice, and supporting the need for further research in this area.
authors.affiliation: Department of Neurology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.|Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
authors.forename: Christina L
authors.initials: CL
authors.lastname: Szperka
authors.affiliation: Departments of Neurology and Pediatrics, University of California San Francisco (UCSF), San Francisco, CA, USA.
authors.forename: Amy A
authors.initials: AA
authors.lastname: Gelfand
authors.affiliation: Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA.|Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Hershey
mesh_terms: D000293:Adolescent; D000779:Anesthetics, Local / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006261:Headache / Q000628:therapy*; D006306:Health Surveys; D006801:Humans; D007267:Injections / Q000379:methods*; D008297:Male; D009407:Nerve Block / Q000379:methods*; D010372:Pediatrics; D012955:Societies, Medical / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D013997:Time Factors; D061028:Trigger Points
chemical_list: D000779:Anesthetics, Local
keywords: headache; migraine; pediatric; peripheral nerve block; practice survey