(732) Occipital nerve block versus acetaminophen/caffeine for headache treatment in pregnancy: a randomized trial

Friday, February 10, 2023

10:30 AM – 12:00 PM

Objective: To evaluate the efficacy of occipital nerve block (ONB) compared to standard care (SC) for treatment of acute headache (HA) in pregnancy.

Study Design: Single-center randomized controlled trial of pregnant patients with HA and pain score >3 on the verbal rating scale (VRS). Patients with secondary HA, preeclampsia, >3g of acetaminophen within 24 hours, ONB within 3 months, and/or allergy to study medications were excluded. Participants were randomized 1:1 in variable block sizes to bilateral ONB with 5cc of 5% bupivacaine or SC (oral 650mg acetaminophen/200mg caffeine). Crossover treatment was given at 2 hrs and 2nd-line treatment (oral 25mg promethazine/diphenhydramine) at 4 hrs to those with worsening VRS or VRS >3. The primary outcome was HA resolution or improvement to VRS ≤3 2 hrs after initial therapy. Secondary outcomes included serial VRS scores, receipt of crossover or 2nd-line therapy, patient satisfaction, and perinatal outcomes. Outcomes were assessed in an intention-to-treat analysis. We estimated a sample of n=62 would afford 80% power to detect a difference from 85% to 50% between groups.

Results: From 2/2020-5/2022, 62 participants were randomized to ONB (n=31) or SC (n=31). Groups were similar except payor status (Table 1). The primary outcome was higher in the ONB group, albeit nonsignificant (64.5 vs 51.6%, p=0.30) (Table 2). However, the ONB group had faster improvement of HA at 1 hr (VRS 2 [IQR 0-5] vs 6 [IQR 2-7], p=0.014) and more ONB patients had VRS score ≤3 at 1 hr. This resulted in 18 patients (58%) leaving triage within 2 hrs of ONB due to HA resolution versus 11 (35%) receiving SC. Among remaining participants, the SC group had significantly lower VRS score at 1 hr following crossover to ONB than the ONB group receiving crossover to SC (p=0.028). There were no significant differences in 2nd-line treatment, refractory HA, satisfaction, or complications. Patients receiving ONB delivered earlier (36.6 vs 37.8 wks), but preterm birth did not differ between groups (Table 2).

Conclusion:

ONB appears to be a promising and quick-acting treatment option for acute HA in pregnancy.

Primary & Presenting Author(s)

Gabriella D. Cozzi, MD (she/her/hers)
Fellow/Instructor
Center for Women's Reproductive Health, University of Alabama at Birmingham
Birmingham, Alabama, United States

Coauthor(s)

CB
Christina T. Blanchard, MS
Statistician
Center for Women’s Reproductive Health, University of Alabama at Birmingham
Birmingham, Alabama, United States
EB
Elisa T. Bushman, MD
Fellow
University of Alabama at Birmingham
Birmingham, Alabama, United States
Allison M. Davis, MD
Resident Physician
Department of Obstetrics and Gynecology, University of Alabama at Birmingham
Birmingham, Alabama, United States
Lorie M. Harper, MD,MSCI (she/her/hers)
Associate Professor
University of Texas Dell Medical School
Austin, Texas, United States
BJ
Benjamin Jones, MD
Department of Neurology, University of Alabama at Birmingham
Birmingham, Alabama, United States
JS
Jeff M. Szychowski, PhD
Associate Professor
Center for Women's Reproductive Health, University of Alabama at Birmingham
Birmingham, Alabama, United States
KD
Kathleen Digre, MD
Department of Neuro-ophthalmology, University of Utah
Salt Lake City, Utah, United States
BC
Brian M. Casey, MD
Center for Women's Reproductive Health, University of Alabama at Birmingham
Birmingham, Alabama, United States
Alan T. Tita, MD, PhD
Professor
University of Alabama at Birmingham
Birmingham, Alabama, United States
Rachel Sinkey, MD (she/her/hers)
Center for Women's Reproductive Health, University of Alabama at Birmingham
Birmingham, Alabama, United States