Efficacy of Ultrasound-Guided Combined Greater Occipital Nerve Block and Greater Auricular Nerve Block Versus Greater Occipital Nerve Block Alone in the Management of Chronic Migraine

Migraine is one of the most prevalent neurological disorders worldwide and remains a leading cause of disability, particularly among individuals of working age. Chronic migraine affects approximately 1-2% of the global population and is associated with substantial impairment in quality of life, reduced work productivity, and increased healthcare utilization . Despite recent advances in migraine management, including calcitonin gene-related peptide (CGRP)-targeted monoclonal antibodies and gepants, many patients continue to experience inadequate symptom control, treatment intolerance, or limited access to these therapies . Consequently, peripheral nerve blocks have emerged as effective non-pharmacological treatment options for patients with refractory migraine and other primary headache disorders .

Among the available interventional techniques, the greater occipital nerve block (GONB) is one of the most widely used procedures for both acute and preventive treatment of migraine. The therapeutic effect of GONB is believed to result from modulation of nociceptive transmission within the trigeminocervical complex, thereby reducing central sensitization and interrupting convergence between cervical and trigeminal afferents. Several randomized clinical trials and systematic reviews have demonstrated that GONB significantly reduces headache intensity, headache frequency, analgesic consumption, and migraine-related disability while maintaining an excellent safety profile .

Migraine pain often involves overlapping sensory territories supplied by interconnected peripheral nerves. The greater auricular nerve (GAN), a superficial sensory branch of the cervical plexus arising from the C2 and C3 spinal nerves, supplies the skin over the parotid region, mastoid process, lower auricle, and angle of the mandible . Because cervical sensory afferents converge with trigeminal nociceptive pathways within the trigeminocervical complex, the GAN may contribute to peripheral nociceptive transmission involved in migraine pathophysiology . Combined blockade of multiple cervical sensory nerves may therefore provide broader interruption of peripheral nociceptive input, potentially enhancing analgesic efficacy and reducing central sensitization . Ultrasound-guided GONB has been shown to produce greater procedural accuracy and consistent clinical outcomes than landmark-guided techniques .

Despite the increasing use of peripheral nerve blocks in headache medicine, evidence regarding the additional benefit of combining a greater auricular nerve block with the standard greater occipital nerve block remains limited. To the best of our knowledge, no prospective randomized double-blind clinical trial has directly compared ultrasound-guided combined GONB and GAN block with GONB alone in patients with chronic migraine.