Bupivacaine for Benign Headache in the ED

• Symptomatic relief of headache [ Time Frame: 20 minutes post injection ] [ Designated as safety issue: No ]

  Symptomatic relief of headache will be measured by:

  1. Change from pre-intervention pain using a validated pain scale rating

     1. Headache relief
     2. Partial headache relief
     3. No headache relief
     4. Headache worsened
  2. Requirement for further treatment of headache in the emergency department prior to discharge (anti-emetics, NSAIDS, steroids, narcotics).
  
  
• Incidence of immediate and post-discharge complications. [ Time Frame: 72 hours ] [ Designated as safety issue: Yes ]
  Subjects will be monitored for both immediate and post discharge complications up to 72 hours after enrollment that include: persistent local pain, bleeding, infection, and inadvertent intravascular injection resulting in seizure or possible cardiovascular collapse.
  
  

• Headache recurrence [ Time Frame: 72 hours ] [ Designated as safety issue: No ]
  Headache recurrence, measured by re-presentation within 72 hours of enrollment to healthcare provider upon chart review.
  
  
• Length of stay [ Time Frame: Participants will be followed for the duration of the Emergency Department visit, typically several hours ] [ Designated as safety issue: No ]
  Length of stay, measured by time from doctor encounter to disposition decision
  
  

Headache is a common chief complaint of patients presenting to the emergency department (ED), accounting for approximately 3 million ED visits per year. Headache treatment is often a source of frustration for both patients and providers. By the time patients with benign headaches arrive in the emergency department, they have often failed non-invasive therapeutic attempts and providers are often left with few therapeutic options. Treatment of benign headache varies between providers, often including systemic medications with a multitude of possible side effects. Additionally, most headache cocktails require prolonged duration of treatment, occupying valuable bed space in increasingly busy emergency departments.

In recent years, there has been preliminary investigation into anesthetic injections for the undifferentiated headache patient presenting to the emergency department. It has been proposed that these patients presenting with benign headache might benefit from this novel treatment. Since 2003, paraspinal muscle injections of bupivacaine have been used in emergency department patients with encouraging results. The mechanism of action is not clearly understood; however, it has been proposed that these injections affect the trigeminocervical complex hypothesized to play an integral role in headache physiology, similar to the same mechanism behind greater occipital nerve blocks used by neurologists.

To the best of the investigators knowledge, there has never been a prospective double-blinded randomized control trial addressing this novel approach to headache management. Even so, the topic of using bupivacaine to inject the paraspinal musculature of the cervical spine has gained wider recognition over the past year. The topic has been discussed heavily on emergency medicine blogs and podcasts. Additionally, online videos have been posted to educate emergency medicine providers on the injection technique. According to retrospective literature, clinical efficacy was observed with a significant proportion of the patients receiving therapeutic effect. These studies, along with anecdotal experience with the procedure at the investigators institution, have led to great excitement concerning the possibility of a new approach to emergency department headache management. However, the topic still needs investigation with a well-designed prospective clinical trial to determine true clinical utility.