Topics in this EM Quick Hits podcast
Matthew MacArthur on the role of occipital nerve block for the treatment of headache (1:32)
Ian Chernoff on the role of POCUS in patients with pulmonary embolism (10:25)
Hans Rosenberg on identification and management of myelopathy in the ED (29:13)
Shawn Segeren on the importance of the recorder during resuscitations (35:27)
Brit Long on incidental neutropenia (39:20)
Kylie Booth on Emergency Medicine peer programs (49:50)

Podcast production, editing and sound design by Anton Helman
Podcast content, written summary & blog post by Brandon Ng, Brit Long, Mathew MacArthur, edited by Anton Helman, June, 2025
Cite this podcast as: Helman, A. MacArthur, M. Chernoff, I. Rosenberg, H. Segeren, S. Long, B. Booth, K. EM Quick Hits 65 - Occipital Nerve Block, PoCUS in Pulmonary Embolism, Myelopathy, Team Resuscitation, Incidental Neutropenia, Peer Programs. Emergency Medicine Cases. June, 2025. https://emergencymedicinecases.com/em-quick-hits-june-2025/. Accessed June 3, 2025.
Indications, evidence, techniques and tips of occipital nerve block for headache management
Indications for occipital nerve block

* Suspected diagnosis of occipital neuralgia: Recurrent sharp stabbing headache with reproducible tenderness on percussion in the occipital nerve distribution.

* ICHD diagnostic criteria for occipital neuralgia includes symptom relief from nerve block.


* Other occipital headaches, including occipital migraines, cervicogenic headaches, cluster headaches.

* Consider occipital nerve block especially if patient fails first line treatments, and if headaches are predominantly occipital.



Source: Levin M. Nerve blocks in the treatment of headache. Neurotherapeutics. 2010 Apr;7(2):197-203
Occipital nerve block technique

* Medication: ~3cc of 2% lidocaine (± dexamethasone or bupivacaine).
* Landmarks:

* Palpate for the occipital protuberance and the mastoid process.
* Draw a linear line between the two landmarks = superior nuchal line of the occipital bone.
* Greater occipital nerve (GON) ≈ 1/3 from midline to mastoid process.
* Lesser occipital nerve (LON) ≈ 2/3 from midline to mastoid process.
* The GON & LON can also be landmarked using palpation or ultrasound to identify the occipital artery (the GON runs medially to artery), or by percussing along the superior nuchal line and injecting at the point of maximal tenderness.


* Injection:

* Use a small, 25–27G needle,
* Advance needle perpendicularly to periosteum, then withdraw slightly and aspirate.
* Inject ~1cc over nerve, and fan/reposition the needle to inject 1cc medial and 1cc lateral to the nerve.
* Always inject on or just above the superior nuchal line.



A single injection can halt the dysregulated pain signaling and provide sustained headache relief even after the anesthetic wears off.
Evidence for occipital nerve blocks for headache

Based on recent systematic reviews, the current RCT evidence for occipital nerve block shows statistically significant reductions in occipital headache intensity and frequency, both immediately and over the weeks that follow
Also no serious adverse events
However the evidence is limited by small sample sizes, with variations between different nerve block techniques (eg choice of ...