Nerve Blocks (Follow the Pain Pattern) for New Daily Persistent Headache

A 25-year-old female with depression (on duloxetine 60 mg) presented to the headache clinic with a 1-year history of new onset continuous and unremitting headache.Her headache was localized to the bilateral frontotemporal and occipital regions.She described it as throbbing and pressure-like, associated with photophobia, phonophobia and nausea.It was not associated with positional change or Valsalva maneuvers.The onset of her headaches developed suddenly on a specific date and time.She denied a preceding history of headache, trauma, infection, surgery, travel or sick contacts.Over-the-counter analgesics (ibuprofen and acetaminophen) and rizatriptan provided no relief.She denied other neurological and systemic symptoms.She was diagnosed with migraine by her general neurologist.Her neurological examination was unremarkable.Magnetic resonance imaging of her head with gadolinium did not reveal any structural lesions to explain her headache.She was diagnosed with suspected new daily persistent headache (NDPH) based on her clinical history and normal imaging.She was prescribed amitriptyline, titrated from 10 mg up to 30 mg and was on it for 3.5 years.Topiramate, titrated up to 100 mg, was added for 1 year.Both medications were discontinued due to intolerance and ineffectiveness.Later, divalproex acid, titrated up to 500 mg twice daily was prescribed and tried for 6 months, but it was discontinued due to brain fog and lack of efficacy.She did not have drug insurance coverage for onabotulinum toxin A or calcitonin gene related peptide monoclonal antibodies or receptor antagonists.Occipital nerve blocks (NB) with local anesthetics were suggested based on failure to oral medications and lack of insurance coverage for advanced headache treatments such as onabotulinum toxin A or calcitonin gene related peptide-based treatment.Bupivacaine 0.5% (5 mg/ml) was injected to the greater (3 ml each side, 6 ml in total), lesser (2 ml each side, 4 ml in total).She had no relief after three sessions (1 month apart).On further head and neck examination, she had tenderness on palpation in multiple nerve distributions including bilateral greater and lesser occipital, auriculotemporal, supraorbital and supratrochlear nerves.Extensive (Follow the pain pattern) NB were suggested as the next step of treatment based on her pain pattern and examination findings.Bupivacaine 0.5% (5 mg/ml) was injected to the greater (3 ml each side, 6 ml in total), lesser