Treatment of Headaches in the ED With Lower Cervical Intramuscular Bupivacaine Injections: A 1-Year Retrospective Review of 417 Patients

• Published in: Headache Vol. 46; no. 9; pp. 1441 - 1449
• Main Authors: Mellick, Larry B., McIlrath, S. Timothy, Mellick, Gary A.
• Format: Journal Article
• Language: English
• Published: Malden, USA Blackwell Publishing Inc 01-10-2006; Blackwell
• Subjects: Adult; allodynia; Biological and medical sciences; bupivacaine; Cardiovascular system; cervical; Cluster Analysis; Color Perception - physiology; Female; headache; Humans; injection; intramuscular; Male; Medical sciences; migraine; Migraine Disorders - etiology; Muscle; Neurology; pain; paraspinous; Pattern Recognition, Visual; Pharmacology. Drug treatments; Photic Stimulation; Principal Component Analysis; trigeminocervical; Vascular diseases and vascular malformations of the nervous system; Vasodilator agents. Cerebral vasodilators; Allodynia; Human; Headache; Nervous system diseases; Migraine; intramuscular; Cardiovascular disease; cervical; Cerebral disorder; Vascular disease; Local anesthetic; Bupivacaine; Pain; Treatment; Follow up study; trigeminocervical; Central nervous system disease; Carboxamide; Organic amide; Neurological disorder; injection; Anilide; Cerebrovascular disease; paraspinous
• ISSN: 0017-8748; 1526-4610
• DOI: 10.1111/j.1526-4610.2006.00586.x

Objective.—The primary objective of this retrospective chart review is to describe 1 year's experience of an academic emergency department (ED) in treating a wide spectrum of headache classifications with intramuscular injections of 0.5% bupivacaine bilateral to the spinous process of the lower cervical vertebrae.
Background.—Headache is a common reason that patients present to an ED. While there are a number of effective therapeutic interventions available for the management of headache pain, there clearly remains a need for other treatment options. The intramuscular injection of 1.5 mL of 0.5% bupivacaine bilateral to the sixth or seventh cervical vertebrae has been used to treat headache pain in our facility since July 2002. The clinical setting for the study was an academic ED with an annual volume of over 75,000 patients.
Methods.—We performed a retrospective review of over 2805 ED patients with the discharge diagnosis of headache and over 771 patients who were coded as having had an anesthetic injection between June 30, 2003 and July 1, 2004. All adult patients who had undergone paraspinous intramuscular injection with bupivacaine for the treatment of their headache were gleaned from these 2 larger databases and were included in this retrospective chart review. A systematic review of the medical records was accomplished for these patients.
Results.—Lower cervical paraspinous intramuscular injections with bupivacaine were performed in 417 patients. Complete headache relief occurred in 271 (65.1%) and partial headache relief in 85 patients (20.4%). No significant relief was reported in 57 patients (13.7%) and headache worsening was described in 4 patients (1%). Overall a therapeutic response was reported in 356 of 417 patients (85.4%). Headache relief was typically rapid with many patients reporting complete headache relief in 5 to 10 minutes. Associated signs and symptoms such as nausea, vomiting, photophobia, phonophobia, and allodynia were also commonly relieved.
Conclusion.—Our observations suggest that the intramuscular injection of small amounts of 0.5% bupivacaine bilateral to the sixth or seventh cervical spinous process appears to be an effective therapeutic intervention for the treatment of headache pain in the outpatient setting.