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Migraine headache disease is a common and disabling phenomenon affecting thousands of people. For that reason, I am presenting a simple and safe ultrasound-guided procedure that has proven itself to be extremely effective for patients suffering from, often times, years of very frequent (and even daily) migraine headaches.

The procedure involves sonographic evaluation and guided injection near the Greater Occipital nerve. Some medical practitioners are comfortable with doing blind/unguided injections of the Greater Occipital nerve near the occiput via palpation, and the injection is performed in the area of the Greater Occipital nerve along the Nuchal line. The pitfall in this unguided procedure is the presence of an associated artery.


Ultrasound Imaging

The Greater Occipital nerve is visualized using a linear transducer on the prone patient. A bolster under the chest helps provide cervical flexion. The transducer is placed in the short axis (perpendicular to the spine) at the level of C2. Slightly translating/sliding the transducer laterally once the bifid C2 spinous process is visualized, the cross-sectional area of the Splenius Capitus muscle is demonstrated. It forms part of the floor of the posterior triangle of the neck, above and behind levator scapulae; it is deep to the rhomboideus and trapezius.

The caliber of the Greater Occipital nerve within the Splenius Capitus is small.  Experience in MSK imaging is needed to develop a good technique to visualize a small nerve such as this. Once the bony landmarks are visualized, quickly translate the transducer proximately and distally to visualize this small nerve in cross-section. By doing this semi-rapid back-and-forth motion, the perineurium and perhaps 2 or 3 hyperechoic nerve fascicles can be demonstrated.

It is also prudent to do comparative imaging and measurements to determine which of the nerves to approach with the biocellular product. Comparative cross-sectional measurements are helpful.


Ultrasound Guided Injection

Under ultrasound guidance, the needle can be advanced in-plane, medial to lateral, into the Splenius Capitus. In this approach, the full-length reflection of the needle can be visualized. There is no significant vasculature in this needle path approach. I suggest, then, that the bio-cellular product be placed just deep/ adjacent to the nerve.

This simple and safe procedure has proven to be very effective with long-term results.