Chronic migraine prophylaxis: Comparative study between ultrasound-guided greater occipital nerve block and medical treatment.

[BACKGROUND] Migraine is a common disabling primary headache disorder. It might become quite severe and incapacitating for patients and management can be challenging even in experienced clinics. The objective of this work was to assess the efficacy of ultrasound guided greater occipital nerve block either by local anesthetic or by botulinum toxin in comparison to medical therapy in prevention of chronic migraine.

[METHODS] This study was prospective, non-randomized, comparative clinical trial study conducted on 117 patients diagnosed with chronic migraine according to the International Classification of Headache Disorders (3rd edition) criteria (≥15 headache days per month for >3 months, with ≥8 days fulfilling migraine criteria; mean migraine days 9.74 ± 1.81, with all patients having ≥15 total headache days per month). Patients were recruited from the outpatient headache clinic of the Neuropsychiatry Department, Tanta University Hospitals, between May 2022 and May 2024. Participants were allocated into three groups: Group I received ultrasound-guided GONB with either bupivacaine 0.5% or onabotulinumtoxinA. Group II received medical therapy either oral medical treatments or monoclonal antibodies. Group III received standard botulinum toxin A injections according to the PREEMPT protocol. Patients were evaluated at baseline, 1 month and 3 months using headache impact (HIT-6); depressive symptoms (BDI) and quality of life (MSQOL). and at baseline and 3 months using headache-related disability (MIDAS).

[RESULTS] All groups showed significant improvement. The most rapid and pronounced early improvement across all scales was observed with onabotulinumtoxinA (GONB and PREEMPT). At 3 months, mean MIDAS scores in the PREEMPT group (Group III) decreased from 3.74 (SD 0.44) at baseline to 1.30 (SD 0.63) (p < 0.001). MIDAS was not assessed at 1 month due to the instrument's 90-day recall period. Significant reductions in BDI and improvements in MSQOL were also seen across groups.

[CONCLUSION] All studied interventions were effective. OnabotulinumtoxinA (via both GONB and PREEMPT injection) provided the most rapid and substantial benefit, while monoclonal antibodies provided progressive, sustained improvement.