Occipital nerve block: follow the artery, then find the nerve

Question 1Which structure guides you to the greater occipital nerve at the superior nuchal line?

1. aThe internal jugular vein
2. bThe occipital artery
3. cThe vertebral artery
4. dThe mastoid process

Question 2A patient with a sudden, severe occipital headache which peaked in seconds asks for a nerve block. What do you do?

1. aDischarge with analgesia
2. bPerform the block, as it will confirm migraine
3. cPerform the block and review in a week
4. dInvestigate for subarachnoid haemorrhage before any block

Question 3What did a small emergency department trial of bilateral greater occipital nerve blocks for migraine show?

1. aThe block was more effective than every intravenous drug
2. bNo patient improved after the block
3. cMore patients were headache-free at 30 minutes after the block than after a sham injection
4. dThe block caused frequent serious complications

Question 4How do you reduce the risk of injecting into the occipital artery?

1. aUse the largest available needle
2. bInject quickly in a single bolus
3. cIdentify it with colour Doppler, aspirate and watch the spread
4. dInject without ultrasound

Question 5How does the nerve look next to the artery on ultrasound?

1. aA bright line with an acoustic shadow
2. bA large pulsatile circle with colour flow
3. cA comet-tail artefact
4. dA small dark oval with a bright rim and no flow on colour Doppler