• Posted December 11, 2025

Nerve Blocks Now Recommended For ER Migraine Treatment

People hospitalized for a debilitating migraine should receive targeted nerve blocks rather than IV opioids to quell their pain, according to a major update of treatment guidelines.

Doctors should use a nerve block injection to stop pain signals from thrumming through the occipital nerves located near the top of the spine, a report published in Headache: The Journal of Head and Face Pain, said.

“The occipital nerves at the base of the skull bring in pain signals to the same area of the brain where pain signals from all over the head are coming in,” senior researcher Dr. Serena Orr, an associate professor of neurology at the University of Calgary, said in a news release.

Anesthetizing these nerves provides relief in two ways.

“First, the back of the head goes numb for several hours," Orr said. "Second, we see that pain signals more broadly from all over the head can be dampened down in the brain, given this shared area where pain signals come in for both occipital nerves and other nerves’ branches from the head.” 

The guidelines recommend that this occipital nerve block be combined with IV prochlorperazine, a drug that treats nausea and vomiting.

On the other hand, the new guidelines say IV opioids and IV acetaminophen are not recommended pain relievers for treatment of migraines in the ER.

This is the first major update to American Headache Society guidelines for ER migraine treatment since 2016.

“This update marks a major change in emergency department migraine care, with stronger evidence supporting effective non-opioid treatments,” lead researcher Dr. Jennifer Robblee, a headache specialist at Barrow Neurological Institute in Phoenix, said in a news release. “Implementing these approaches can improve patient outcomes and reduce reliance on opioids.”

Migraine accounts for about a quarter of the 3.5 million headache-related cases that U.S. emergency rooms see each year, researchers said in background notes.

Unfortunately, ER doctors still struggle to quell migraine pain, with only 37% of patients leaving the hospital with no headache pain following treatment, researchers said.

Opioids have not been recommended for years but continue to be used in treating migraine cases in the ER, researchers noted. However, their use decreased from 54% of cases in 2007-2010 to 28% in 2015-2018.

To develop the new guidelines, researchers evaluated data from 26 new clinical trials evaluating 20 injectable treatments for migraine. The trials all occurred after a 2016 guideline update.

Researchers found that the combination of an occipital nerve block and IV prochlorperazine had the strongest evidence of effectiveness.

“For the first time, these guidelines formally recommend nerve blocks as an evidence-based treatment for acute migraine attacks in the emergency department. Integrating this option into practice can offer patients faster pain relief and expand the tools available to emergency clinicians,” Robblee said.

However, Orr noted that it make take time for this approach to reach all emergency rooms.

“Because nerve block use requires trained personnel and supplies, dissemination of procedural training and support for implementation will be essential,” she said.

More information

The Cleveland Clinic has more on occipital nerve blocks.

SOURCES: University of Calgary, news release, Dec. 5, 2025; Barrow Neurological Institute, news release, Dec. 5, 2025; Headache: The Journal of Head and Face Pain, December 2025