UUCI Health · Department of Neurology
APP Class II · Procedural Competency Series · 2026
●  Procedure 06·Headache & Outpatient Neurology·Moderate-risk tier
06.

Occipital Nerve

Block.

Greater occipital nerve · optional lesser occipital nerve.
Chadwycke R. Smith, MSN, NP, AGACNP-BC
APP Education · Department of Neurology
Approving authority: Claire Henchcliffe, MD, DPhil · Chair, Department of Neurology
Version 2.0 · 2026-05-11
Source-of-truth: 01_Procedures/06_Occipital_Nerve_Block
Occipital Nerve Block · UCI Neurology APP Class II
01 / 21
UUCI · APP Class II
Procedure 06 · ON Block
02 · Why this matters
AHS 2025 evidence grade · ED migraine
Level A
greater occipital nerve block — 'must offer' parenteral therapy for adult ED migraine per the AHS 2025 systematic review. The strongest evidence-grade endorsement of GONB to date.
  • In-clinic, low-risk procedure with strong evidence for transformed migraine, occipital neuralgia, and cervicogenic headache.
  • Procedural relief routinely outlasts the anesthetic — central modulation of the trigemino-cervical complex drives weeks of benefit.
  • GON block reduced chronic-migraine days vs. placebo in a randomized, placebo-controlled trial (Inan 2017).
  • Owning this skill keeps headache patients out of the ED and shortens time-to-relief.
Robblee J et al. Headache. 2026;66(1):53–76 · PMID 41321235
Tobin J, Flitman S. Headache. 2009;49(10):1521–33 · PMID 19674126
ON Block · Why this matters
02 / 21
UUCI · APP Class II
Procedure 06 · ON Block
03 · Course objectives

What you'll leave with — six competencies.

01 · Cognitive

Anatomy & landmarks.

Describe GON course from C2 dorsal ramus and identify EOP, mastoid, and occipital-artery landmarks on the superior nuchal line.

02 · Cognitive

Indications & contraindications.

Apply accepted indications (occipital neuralgia, cervicogenic, chronic migraine, cluster) and absolute vs. relative contraindications.

03 · Psychomotor

Bony-backstop technique.

Execute perpendicular needle insertion to occipital bone, withdraw 1–2 mm, and inject medial to the occipital artery.

04 · Psychomotor

Mandatory aspiration.

Aspirate in two planes before every injection — the single highest-yield safety step for LAST prevention.

05 · Affective

Consent & time-out.

Lead a TJC UP.01.03.01 time-out confirming patient, procedure, laterality, agent, and dose.

06 · Affective

Complication escalation.

Recognize vasovagal, hematoma, and LAST signs; activate the ASRA LAST protocol with lipid emulsion as indicated.

ON Block · Course objectives
03 / 21
UUCI · APP Class II
Section I of IV
I.
Section one

Anatomy & landmarks.

The greater occipital nerve emerges from the C2 dorsal ramus, pierces semispinalis capitis, and runs the superior nuchal line — medial to the occipital artery. Know the artery, and you know the nerve.
Objectives C-1 · C-2 — slides 5–6
ON Block · Section I
04 / 21
UUCI · APP Class II
Procedure 06 · ON Block
04 · Anatomy I

Greater occipital nerve — course.

Gray's Anatomy Fig 800 — nerves of the scalp showing greater occipital nerve emergence
Gray's Anatomy (1918) · Fig 800 · H.V. Carter Wikimedia · Public domain
Origin · course · target
  • Arises from the C2 dorsal ramus; pierces semispinalis capitis, then trapezius fascia.
  • Emerges subcutaneously over the occipital bone along the superior nuchal line.
  • Textbook landmark: ~1/3 of the EOP-to-mastoid distance from the EOP (≈2.5 cm lateral) for the GON entry (Tobin 2009).
  • The occipital artery sits adjacent and lateral — the most reliable surface landmark when palpable.
  • We aim medial to the artery, perpendicular to the skull, advancing to the bony backstop.
Tobin J, Flitman S. Occipital nerve blocks: when and what to inject? Headache. 2009;49(10):1521–33 · PMID 19674126
ON Block · GON course
05 / 21
UUCI · APP Class II
Procedure 06 · ON Block
05 · Anatomy II

Surface landmarks — EOP, mastoid, artery.

01

External occipital protuberance.

  • Midline bump at the base of the skull
  • Anchors the medial end of the superior nuchal line
  • Confirms patient is in correct neck flexion
02

Mastoid process.

  • Bony prominence posterior to the ear
  • Anchors the lateral end of the nuchal line
  • EOP–mastoid line is the working axis
03

Occipital artery.

  • Palpable pulse, lateral to GON
  • Mark the artery — enter just medial to it
  • LON sits at the ~2/3 mark, posterior border of SCM
Tobin J, Flitman S. Headache. 2009;49(10):1521–33 · PMID 19674126 · Kissoon NR et al. Clin J Pain. 2022;38(4):271–278 · PMID 35132029
ON Block · Surface landmarks
06 / 21
UUCI · APP Class II
Procedure 06 · ON Block
06 · Indications

When to block — five accepted indications.

Accepted indications
  • Occipital neuralgia — sharp, paroxysmal, dermatomal pain in the GON/LON distribution; diagnostic + therapeutic.
  • Cervicogenic headache — unilateral pain referred from upper cervical structures, reproducible by occipital palpation.
  • Chronic migraine / transformed migraine — adjunct to oral or injectable preventives (Blumenfeld consensus; Inan RCT).
  • Cluster headache — acute attack and short-term prophylaxis.
  • Post-craniotomy / post-traumatic occipital pain and post-concussion headache.
Evidence grade — adult ED migraine
Level A

GON block elevated to 'must offer' parenteral therapy for adult ED migraine per the American Headache Society 2025 systematic review — the strongest evidence-grade endorsement of GONB to date.

Robblee J et al. AHS 2025 evidence assessment of parenteral pharmacotherapies for adult ED migraine. Headache. 2026;66(1):53–76 · PMID 41321235
Blumenfeld A et al. Headache. 2013;53(3):437–46 · PMID 23406160
Gul HL et al. Acta Neurol Scand. 2017;136(2):138–144 · PMID 27910088
ON Block · Indications
07 / 21
UUCI · APP Class II
Procedure 06 · ON Block
07 · Contraindications

When not to block.

Absolute
  • Known allergy to the intended local anesthetic or corticosteroid
  • Overlying skin or scalp infection at the planned injection site
  • Patient refusal after informed consent
Tobin J, Flitman S. Headache. 2009;49(10):1521–33 · PMID 19674126
Relative
  • Therapeutic anticoagulation — apply ASRA Pain Medicine 5th-ed principles; superficial scalp block on a compressible surface tolerates lower thresholds than neuraxial procedures.
  • Prior craniectomy with absent occipital bone — loss of the bony backstop dramatically increases the risk of intracranial / vascular injection.
  • Pregnancy — block generally safe; minimize steroid exposure.
  • Bleeding diathesis — risk–benefit balance.
Kopp SL et al. ASRA Pain Medicine consensus practice guidelines on regional anesthesia in patients receiving antithrombotic or thrombolytic therapy (5th ed). Reg Anesth Pain Med. 2025 · PMID 39880411
ON Block · Contraindications
08 / 21
UUCI · APP Class II
Procedure 06 · ON Block
08 · Pre-procedure · time-out

Before you inject — the last gate.

  • 01
    Informed consent. Indication, alternatives, risks — vasovagal, bruising, intravascular injection, alopecia / fat atrophy from steroid, LAST signs, no guarantee of relief, rebound at 6–8 h, option to decline.
  • 02
    Allergy & med review. Local anesthetic, corticosteroid, latex. Review anticoagulation; ASA / NSAID hold not required.
  • 03
    Laterality decided. Unilateral vs. bilateral; mark the side(s) to be blocked.
  • 04
    Time-out called. Per TJC UP.01.03.01 — correct patient, procedure, site / side, injectate & volume, consent confirmed aloud.
  • 05
    Landmark verification. Palpate EOP, mastoid, and the occipital-artery pulse on the symptomatic side before prep.
TJC standard

UP.01.03.01

Pre-procedure verification, site marking, formal time-out — the three-part protocol that exists because someone, somewhere, blocked the wrong side.
The Joint Commission. Universal Protocol UP.01.03.01.
TJC Hospital Accreditation Standards · 2024.
ON Block · Pre-procedure verification
09 / 21
UUCI · APP Class II
Key fact · AHS 2025
Robblee · AHS systematic review · 2025/26
Level A
‘Must offer’ parenteral therapy for adult ED migraine. The strongest evidence-grade recommendation in the AHS 2025 systematic review. Greater occipital nerve block is now guideline-endorsed first-line parenteral therapy.
01
Adult ED
migraine.
02
Level A
'must offer'.
03
Strongest grade
in the review.
04
Endorses GONB
over consensus.
Robblee J et al. Headache. 2026;66(1):53–76 · PMID 41321235
10 / 21
UUCI · APP Class II
Procedure 06 · ON Block
09 · Kit · tray

What's in your hand — before you inject.

Tray checklist
  • 25–27 G, 1.5-inch hypodermic needle
  • 3 mL syringe
  • Non-sterile clean gloves
  • 2% CHG / 70% IPA prep
  • Sterile skin marker
  • 1–2 mL bupivacaine 0.5% (or lidocaine 1–2%) per side
  • Optional: methylprednisolone 40 mg/mL · or triamcinolone 10–40 mg
  • Cotton gauze · adhesive dressing
  • Emesis basin · sharps disposal
Resuscitation backup — at hand
  • Ammonia ampule (vasovagal)
  • Supine recliner / Trendelenburg-capable chair
  • Pulse oximetry, manual BP cuff
  • 20% lipid emulsion per ASRA LAST protocol — bolus 1.5 mL/kg, infusion 0.25 mL/kg/min
  • Code-cart access and a clear path to MD page / emergency response
Neal JM et al. ASRA practice advisory on LAST: 2017 version. Reg Anesth Pain Med. 2018;43(2):113–23 · PMID 29356773
Neal JM et al. ASRA checklist for LAST: 2020 version. Reg Anesth Pain Med. 2021;46(1):81–82 · PMID 33148630
ON Block · Kit & tray
11 / 21
UUCI · APP Class II
Section II of IV
II.
Section two

The block
sequence.

Position. Landmark. Prep. Insertion to bone. Aspirate. Slow injection. Withdraw and dress. Six steps, every one a verification gate. Aspiration is the gate that prevents LAST.
Objectives P-1 · P-2 · P-3 · P-4 · P-5 · P-6 · P-7 — slides 13–15
ON Block · Section II
12 / 21
UUCI · APP Class II
Procedure 06 · ON Block
10 · Steps 1–2

Position, then landmark.

01

Position ·
seated or prone.

  • Seated, leaning forward, forehead on folded arms on a padded bedside table — preferred for cooperative patients
  • Alternative: prone with chin tucked, pillow under chest to flex cervical spine
  • Part hair along the planned needle track; clip if dense — do not shave
  • EOP-to-mastoid line at operator eye level
02

Landmark ·
EOP · mastoid · artery.

  • Palpate EOP and ipsilateral mastoid; draw the imaginary nuchal-line axis
  • GON entry ≈ 1/3 of the EOP-to-mastoid distance from the EOP (≈2–3 cm lateral to midline on the superior nuchal line)
  • Palpate the occipital-artery pulse · mark the artery · plan to enter just medial to it
  • LON, when added, sits at ≈2/3 the EOP–mastoid distance along the posterior border of SCM
Tobin J, Flitman S. Headache. 2009;49(10):1521–33 · PMID 19674126
ON Block · Steps 1–2
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UUCI · APP Class II
Procedure 06 · ON Block
11 · Steps 3–4

Prep, insert to bone, aspirate.

03

Skin prep ·
aseptic no-touch.

  • Hand hygiene · non-sterile clean gloves (sterile not required for superficial peripheral block)
  • 2% CHG / 70% IPA · friction ≥30 s, dry ≥30 s
  • Fenestrated drape; keep syringe, needle, gauze on the field only
  • Do not re-palpate the prepped site with ungloved finger — re-mark with sterile marker if needed
04

Insert to bone ·
aspirate.

  • 25–27 G, 1.5-inch needle · perpendicular to skull at the marked entry
  • Advance slowly until contact with the occipital bone — the bony backstop
  • Withdraw 1–2 mm off periosteum
  • Aspirate in two planes — if blood returns, withdraw and re-site before any injectate
  • Never inject against resistance or into a paresthesia
Tobin J, Flitman S. Headache. 2009;49(10):1521–33 · PMID 19674126 · Blumenfeld A et al. Headache. 2013;53(3):437–46 · PMID 23406160
ON Block · Steps 3–4
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UUCI · APP Class II
Procedure 06 · ON Block · Critical checkpoint
Critical safety checkpoint · mandatory before every injection plane

Aspirate before every
injection plane.

Why · the occipital artery

The occipital artery sits within millimeters of the GON. A 3 mL bolus of bupivacaine into the artery is a LAST event — perioral numbness, metallic taste, tinnitus, then seizure or arrhythmia.

If blood returns

Withdraw. Re-site. Re-aspirate. Inject only when no blood returns in two planes. If a patient reports any LAST prodrome — stop injecting and activate the ASRA LAST checklist.

LAST treatment
20% lipid emulsion · 1.5 mL/kg IV bolus
then 0.25 mL/kg/min infusion.
Intravascular injection is the catastrophe — prevented by mandatory aspiration.
Neal JM et al. Reg Anesth Pain Med. 2018;43(2):113–23 · PMID 29356773
ON Block · Aspirate-before-inject checkpoint
15 / 21
UUCI · APP Class II
Procedure 06 · ON Block
12 · Steps 5–6 · optional LON

Slow injection, withdraw, optional LON.

05

Slow injection.

  • 1.5–3 mL total per nerve site over 20–30 s
  • Aspirate before each new plane
  • Distribute dose — half at GON, half toward LON when treating both
  • Do not inject against resistance
06

Withdraw + dress.

  • Withdraw needle in one smooth motion
  • Firm digital pressure 1–2 min over the site
  • Massage depot along nuchal line to spread anesthetic
  • Adhesive dressing · confirm onset at 5–10 min
07

Optional LON.

  • Add when pain radiates lateral / postauricular
  • Target ≈2/3 of EOP–mastoid line, posterior SCM
  • Subcutaneous (not to bone) · fan 1–2 mL
  • Keep total methylprednisolone ≤ 80 mg/session
Tobin J, Flitman S. Headache. 2009;49(10):1521–33 · PMID 19674126 · Kissoon NR et al. Clin J Pain. 2022;38(4):271–278 · PMID 35132029 · Blumenfeld A et al. Headache. 2013;53(3):437–46 · PMID 23406160
ON Block · Steps 5–6 & LON option
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UUCI · APP Class II
Section III of IV
III.
Section three

Recognize.
Escalate.

Complications happen — the catastrophe is the delay in recognition. Observe ≥15 min. Six events you diagnose on sight, four pitfalls we see in real cases.
Objectives C-7 · A-3 · A-4 — slides 18–19
ON Block · Section III
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UUCI · APP Class II
Procedure 06 · ON Block
13 · Complications · pitfalls

Six events · four pitfalls — recognize on sight.

01 · Common

Vasovagal.

Most common acute event. Lay supine, ammonia ampule, monitor. Observe ≥15 min seated post-injection.

02 · Immediate

Arterial puncture · hematoma.

Blood on aspiration → withdraw, re-site. Firm digital pressure 1–2 min to tamponade.

03 · Catastrophic

LAST.

Perioral numbness, metallic taste, tinnitus, diplopia → seizure / arrhythmia. Stop · ASRA LAST checklist · 20% lipid emulsion.

04 · Rare disaster

Vertebral artery injection.

If needle placed too medial / too deep without bony backstop. Immediate neurosurgery / neurocritical care consult; CT angiography.

05 · Delayed

Alopecia · fat atrophy.

Focal hair loss or dermal/subcutaneous atrophy at steroid site. Dose-dependent; counsel; space sessions ≥12 weeks.

06 · Delayed

Rebound headache.

Expected at 6–8 h as lidocaine wears off before steroid takes effect. Counsel up front.

Four pitfalls · too superficial · too medial/too deep · skipping aspiration · steroid sessions < 12 weeks apart
ON Block · Complications & pitfalls
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UUCI · APP Class II
Procedure 06 · ON Block
14 · UCI FPPE · OPPE

Your competency pathway.

StageTriggerScope
FPPEBoard approval of ON Block privilegeFirst 3 independent blocks · concurrent review within 14 days · aggregate review at 3-case completion · closed within 6 months
OPPEContinuous baseline · TJC MS.08.01.03Every 6 mo · 10% sample (min 2, max 10) · 100% review on complication flag
Reinstatement< 5 blocks over 24 moStream B skills checklist re-run + 1 proctored live case
RenewalBiennial · 22 CCR §70703 (CA)OPPE indicators aggregate · Chair sign-off
Tracked OPPE indicators
  • Vasovagal events requiring rapid-response activation — zero
  • LAST events (prodrome or full) — zero
  • Aspiration-before-injection documented per laterality — 100%
  • Time-out documented including laterality — 100%
  • Documentation completeness (consent, agent, volume, technique, tolerance, observation, counseling) — 100%
Moderate-risk tier Departures require written justification.
ON Block · FPPE / OPPE pathway
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UUCI · APP Class II
Procedure 06 · ON Block
15 · References & acknowledgments

Sources of truth.

  1. 01Tobin J, Flitman S. Occipital nerve blocks: when and what to inject? Headache. 2009;49(10):1521–1533. PMID 19674126.
  2. 02Blumenfeld A, Ashkenazi A, Napchan U, et al. Expert consensus recommendations for the performance of peripheral nerve blocks for headaches — a narrative review. Headache. 2013;53(3):437–446. PMID 23406160.
  3. 03Gul HL, Ozon AO, Karadas O, Koc G, Inan LE. The efficacy of greater occipital nerve blockade in chronic migraine: a placebo-controlled study. Acta Neurol Scand. 2017;136(2):138–144. PMID 27910088.
  4. 04Kissoon NR, Watson JC, Boes CJ, et al. Comparative effectiveness of landmark-guided greater occipital nerve (GON) block at the superior nuchal line versus ultrasound-guided GON block at the level of C2. Clin J Pain. 2022;38(4):271–278. PMID 35132029.
  5. 05Robblee J, Buse DC, Halker Singh RB, et al. AHS 2025 evidence assessment of parenteral pharmacotherapies for adult emergency-department migraine — greater occipital nerve block Level A 'must offer'. Headache. 2026;66(1):53–76. PMID 41321235.
  6. 06Kopp SL, Vandermeulen E, McBane RD, et al. ASRA Pain Medicine consensus practice guidelines on regional anesthesia in patients receiving antithrombotic or thrombolytic therapy: 5th edition. Reg Anesth Pain Med. 2025. PMID 39880411.
  7. 07Neal JM, Barrington MJ, Fettiplace MR, et al. The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity: Executive Summary 2017. Reg Anesth Pain Med. 2018;43(2):113–123. PMID 29356773.
  8. 08Neal JM, Neal EJ, Weinberg GL. American Society of Regional Anesthesia and Pain Medicine local anesthetic systemic toxicity checklist: 2020 version. Reg Anesth Pain Med. 2021;46(1):81–82. PMID 33148630.
  9. 09The Joint Commission. Universal Protocol UP.01.03.01. TJC Hospital Accreditation Standards; 2024.
  10. 09aThe Joint Commission. Universal Protocol UP.01.01.01 — preprocedure verification; use a standardized list (H&P, signed consent, nursing & preanesthesia assessment, labeled imaging, required equipment/devices). National Patient Safety Goals (HAP); effective January 2025.
  11. 09bThe Joint Commission. NPSG.01.01.01 EP 1 — use at least two patient identifiers (room number is not an identifier) before any treatment or procedure. National Patient Safety Goals (HAP); effective January 2025.
  12. 09cThe Joint Commission. NPSG.07.01.01 EP 1 — implement CDC and/or WHO hand-hygiene categories IA, IB, IC. National Patient Safety Goals (HAP); effective January 2025.
  13. 09dThe Joint Commission. Universal Protocol UP.01.02.01 — mark the procedure site; mark by the accountable licensed practitioner (APRN/PA delegation permitted per institutional policy); unambiguous, visible after prep & drape. National Patient Safety Goals (HAP); effective January 2025.
  14. 09eThe Joint Commission. NPSG.03.04.01 — label all medications, medication containers, and solutions on and off the sterile field (name, strength, amount, diluent, expiration). EP 4 requires two-individual verification when preparer ≠ administrator. National Patient Safety Goals (HAP); effective January 2025.
  15. 10The Joint Commission. MS.08.01.01 and MS.08.01.03 — Focused and ongoing professional practice evaluation. TJC Hospital Accreditation Standards; 2024.
  16. 11UCI APP Class 2 Training Plan Process. Department of Neurology, University of California, Irvine. April 2026.
ON Block · References
20 / 21
UUCI · APP Class II
Procedure 06 · ON Block
End of module · Procedure 06

Now —
the post-test.

Stream A
15-item post-test
≥ 12/15
Stream B
20-item skills checklist
on phantom
Stream C
3 proctored cases
Headache Clinic
Live
FPPE on first 3
independent blocks
Routing: IDPC → Department Chair → APP Director per UCI Medical Staff Bylaws.
Approving authority: Claire Henchcliffe, MD, DPhil · Chair, Department of Neurology.
UCI Health · APP Education
Version 2.0 · 2026-05-11
ON Block · End
21 / 21