There are several procedures used to treat NDPH, including nerve blocks, Botox injections, facet blocks, nerve decompression, and nerve stimulator surgery. These may be used alongside or instead of medication. Talk with your headache specialist to determine which procedures would be beneficial for your NDPH.

Botox Injections

Botox injections for headache are usually given as a series of 31 injections (155 units total) in various areas on the head, face, and neck that can be repeated every 12 weeks. Botox blocks the release of acetylcholine at the neuromuscular junction in head and face muscles, temporarily preventing the peripheral and central transmission of pain messages. There is no NDPH-specific Botox protocol, so doctors usually follow the migraine protocol described above. If Botox is effective, it usually will become evident within 7-10 days after the injections. It may take up to 3 treatment cycles to fully assess whether Botox works for you. Occasionally, Botox becomes less effective over time. Evidence for Botox in NDPH is mixed; studies report response rates from 32% to above 90%. However, Botox has relatively few side effects and is definitely worth trying, since everyone responds differently.

Nerve Blocks

Depending on where your NDPH pain is located, doctors can use nerve blocks with lidocaine or bupivacaine to try and numb the nerves causing your pain. The effects last only a few hours, but can be a good diagnostic tool to determine which nerves are causing your pain and if you might be a candidate for nerve decompression surgery. Nerve blocks are also used to treat occipital neuralgia or trigeminal neuralgia, both of which can commonly occur with NDPH.

Click on each of the procedure names below to learn more about the anatomy and procedure for each block.

Occipital nerve blocks

Supraorbital & supratrochlear nerve blocks

Auriculotemporal nerve blocks

Sphenopalatine ganglion (SPG) blocks

Stellate ganglion blocks

Gasserian ganglion/trigeminal nerve blocks

Cervical Facet Blocks/ Medial Branch Blocks

Cervical facet blocks are a more invasive procedure where a pain management doctor or anesthesiologist injects an anesthetic (usually bupivacaine) into the cervical facet joints to temporarily numb the nerves that run from the back of the neck to the head. Since this procedure requires fluoroscopy to determine the precise location of the injections, it is usually done under anesthesia. The C1, C2, and C3 spinal levels most commonly refer pain to the head, but if you have neck pain with your NDPH, the doctor may inject lower levels (C4-C7). If these facet injections successfully relieve your pain, you may be a candidate for radiofrequency ablation, a more permanent procedure where the nerve root is burned to stop the transmission of pain signals. This can give from 6 months to a year of pain relief, but may need to be repeated.


Nerve Decompression Surgery

If your pain responds well to nerve blocks, or if you have exhausted other medications and procedures, nerve decompression surgery may be an option. In this type of surgery, a plastic surgeon cuts into certain locations on the head (occipital, frontal, temporal, or nasal) to carefully untangle nerves from surrounding blood vessels or muscle where they may be compressed.

Nerve Stimulators

As a last resort, nerve stimulators may provide some relief for NDPH patients. These typically involve small wires (leads) that are placed near the occipital nerves, supraorbital nerves, or both. A battery pack is implanted above the collarbone, and leads run up the neck and over the head to deliver electrical stimulation that interrupts the pain signals. A trial with temporary implanted leads is performed first to see if the patient is a good candidate for surgery. The stimulation can be adjusted using a remote to change the pattern of electrical signaling to match the patient’s pain levels.