Occipital nerve blocks can stop a migraine attack when other treatments fail. This is a relatively simple procedure (although not many physicians are trained in it), and it consists of an injection of lidocaine or a similar local anesthetic drug into an area at the back of the head on one or both sides. There are two branches of the nerve - greater and lesser occipital nerves and I usually inject both. The block can help even if the headache is not strictly localized to the back of the head. In some people headache returns after a few hours, once the effect of the local anesthetic wears off. However, a recent study presented at the American Academy of Neurology suggested that up to 60% of patients with an acute migraine may respond without return of the headache. Adding steroid medication to the local anesthetic does not seem to improve outcome. However, occipital nerve block with steroid medication (Depo-Medrol, Celestone, and other) is effective in aborting cluster headaches.
Obviously, occipital nerve block is not practical or necessary treatment for people who respond to oral or self-injected medications, but if these treatments fail such a block is an excellent option. However, even if other treatments fail, we usually start office treatment of severe migraines with intravenous magnesium, which is more effective than any other treatment in those 50% of patients who are magnesium deficient.