Medical Policy: 02.01.52
Original Effective Date: December 2013
Reviewed: August 2018
Revised: August 2018
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services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Injection therapy delivers local anesthetics, steroids or other agents into the region of the affected nerve(s) thereby reducing pain and inflammation. Examples of injections used to treat headaches/migraines or occipital neuralgia include, but may not be limited to, occipital nerve injections, greater occipital nerve injections, sphenopalatine nerve injections or application (with or without the use of the SphenoCath or Allevio devices), stellate ganglion injections, supraorbital nerve injections or supratrochlear nerve injections.
- Chronic Migraine: Migraine is a common disabling primary headache disorder. Chronic migraine headache is defined as greater than or equal to 15 days per month lasting 4 hours a day or longer in an adult patient.
- Chronic tension type headache: Frequent episodic tension type headache, with daily or very frequent episodes of headache, typically bilateral, pressing to tightening in quality and of mild to moderate intensity, lasting hours, to days or unremitting. The pain does not worsen with routine physical activity, but may be associated with mild nausea, photophobia or phonophobia.
- Chronic cluster headache: Chronic cluster headaches is one of the trigeminal autonomic cephalagias (TACs), a group of primary headache disorders characterized by unilateral trigeminal distribution pain that occurs in association with ipsilateral cranial autonomic features. Cluster headache is characterized by attacks of severe unilateral, orbital, supraorbital or temporal pain. In the episodic form, attacks occur daily, usually one to eight times a day for several weeks, followed by a period of remission. The chronic form of cluster headaches occur for more than 1 year without remissions, or with remission periods lasting less than 1 month.
- Cervicogenic headache: The clinical features of cervicogenic headache may mimic those associated with primary headache disorders (e.g. tension-type headache, migraine, or hemicranias continua), making it difficult to distinguish among headache types. Cervicogenic headaches is characterized by continuous, unilateral head pain radiating from the occipital areas to the front area, with associated neck pain and ipsilateral shoulder or arm pain. The headache is moderate in intensity with non-throbbing character. It is described as dull, boring, dragging pain that can fluctuate in intensity. The duration of the headache may range from a few hours to several days, and in some cases several weeks. The pain can be exacerbated by neck movements and is usually caused by neck trauma.
- The anatomic point for cervicogenic headache is the trigeminocervical nucleus in the upper cervical spinal cord, where sensory nerve fibers in the descending tract of the trigeminal nerve are believed to interact with sensory fibers from the upper cervical roots. This functional intersection of upper cervical and trigeminal sensory pathways is through to allow bidirectional transmission of pain signals between the neck and the trigeminal sensory receptor fields of the face and head.
- Cervicogenic headache is typically caused by a disorder of the cervical spine and its component bony, disc and/or soft tissue elements, usually but not invariably accompanied by neck pain.
There has been an increase in use of injection of local anesthetic, either with or without ultrasound guidance, for the diagnosis or treatment of headache, migraine, and headache syndrome into the occipital nerve, greater occipital nerve, sphenopalatine ganglion (with or without the use of the SphenoCath device), stellate ganglion, supraorbital nerve or supratrochlear nerve.
A variety of medications are used to treat acute migraine episodes. They include medications taken at the onset of an attack to abort the attack (triptans, ergotamines) and medications to treat the pain and other symptoms of migraines once they are established (nonsteroidal anti-inflammatory drugs, antiemetics). Prophylactic medication therapy may be appropriate for people with migraines that occur more than 2 days per week. In addition to medication, behavioral treatments (eg, relaxation, cognitive therapy) are used to manage migraine headache.
Severe acute cluster headaches may be treated with abortive therapy including breathing 100% oxygen, and triptan medications. Other medications used to treat cluster headaches include steroids, calcium channel blockers, and nerve pain medications. Due to the severity of pain associated with cluster headaches, patients may seek emergency treatment. Tension-type headaches are generally treated with over the counter pain medication.
Sphenopalatine Ganglion Device
A sphenopalatine ganglion (SPG) block has been introduced as a quick, minimally invasive procedure. A local anesthetic, currently Marcaine but historically Lidocaine, is introduced intranasally for topical administration. Access to this structure can be gained via a small area of mucosa just posterior and superior to the tail of the middle turbinate on the lateral nasal wall. At this aspect, there is no bony boundary to the SPG. Depending on the type of headache disorder being treated, the procedure may be repeated in the other nostril. Recently, better catheters have been developed, including the Sphenocath®, Tx360®, and Allevio™ devices. The duration of pain relief varies from a few weeks to months. The procedure is repeated as required.
SGB blocks are proposed for both short- and long-term treatment of headaches and migraines. When used in the emergency setting in patients with severe acute headaches, the goal of treatment is to abort the current headache while the patient is in the emergency department.
Occipital nerve blocks have been used for the management of occipital neuralgia, cluster headache, cervicogenic headache, and migraine. The literature regarding diagnosis and management of occipital neuralgia is conflicting. The pathophysiology of occipital neuralgia is uncertain. Treatment for the condition is largely conservative, although injection therapy, electrical stimulation, neurostimulation, and surgical intervention (including occipital neurectomy, radiofrequency ablation, and denervation) have been utilized. The effectiveness of these therapies has not been established in peer-reviewed literature; but injection therapy has been widely used.
Injection as Diagnosis
Standards for diagnostic occipital nerve blocks remain to be published. There are no well-designed clinical trials that state injection of the greater occipital nerve can be used as a specific diagnostic test for headaches/migraines.
Guidelines and Position Statements
European Headache Society
Although excellent international guidelines for organization of headache service and management have been introduced there is no single standard of care for patients presenting with primary chronic headache symptoms. For example, treatment choices for acute migraine are based on headache severity, attack frequency, associated symptoms, and co-morbidities. Despite significant improvement in management of migraine, achieving a satisfactory treatment outcome is still a challenge because of inadequate response of medications and difficulty in predicting individual response to a specific agent or dose.
The medical treatment of patients with chronic primary headache syndromes (such as chronic migraine, chronic cluster headache, chronic tension-type headache or hemicrania continua) is particularly challenging as valid studies are few and in many cases even higher doses of preventative medication is ineffective and adverse side effects frequently complicate the course of medical treatment.
The American Society of Anesthesiologists
The American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine’s practice guidelines on “Chronic pain management” (2010) stated that “Peripheral somatic nerve blocks should not be used for long-term treatment of chronic pain”.
Recommendations for Ablative Techniques:
- Chemical denervation: (e.g. alcohol, phenol or high concentration local anesthetic) should not be used in the routine care of patients with chronic non-cancer pain.
American Headache Society
The AHS Special Interest Section for Peripheral Nerve Blocks and Other Interventional Procedures cited the paucity of evidence for treatment of most headache disorders and cranial neuralgias, excluding cluster headaches.
The Institute for Clinical Systems Improvement’s clinical guideline on “Diagnosis and treatment of headache” (2013) did not mention trigeminal nerve block as a therapeutic option.
NICE National Institute For Health and Care Excellence
Headache Diagnosis and Mangagement (2015)
Migraine with or without aura
- Offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol, for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events. For young people aged 12–17 years consider a nasal triptan in preference to an oral triptan. 
- For people in whom oral preparations (or nasal preparations in young people aged 12–17 years) for the acute treatment of migraine are ineffective or not tolerated:
- offer a non-oral preparation of metoclopramide or prochlorperazine and
- consider adding a non-oral NSAID or triptan if these have not been tried. 
- Offer topiramate or propranolol for the prophylactic treatment of migraine according to the person's preference, comorbidities and risk of adverse events. Advise women and girls of childbearing potential that topiramate is associated with a risk of fetal malformations and can impair the effectiveness of hormonal contraceptives. Ensure they are offered suitable contraception if needed. 
- Offer oxygen and/or a subcutaneous or nasal triptan for the acute treatment of cluster headache. 
- 1.3.7 Consider aspirin, paracetamol or an NSAID for the acute treatment of tension-type headache, taking into account the person's preference, comorbidities and risk of adverse events. 
- 1.3.8 Do not offer opioids for the acute treatment of tension-type headache. 
See Related Medical Policies 07.01.66 Ablative Treatments for Occipital Neuralgia, Chronic Headaches and Atypical Facial Pain
Injections of local anesthetic, used as nerve blocks or topical application of local anesthetic to the: sphenopalatine ganglion, stellate ganglion, supraorbital nerve, occipital nerve, or trigeminal nerve for chronic headache, migraine, or tension type headache is considered investigational.
There is only minimal research to show that local applications/injections for headaches/migraines improves health outcomes. In addition, practice guidelines do not recommend sphenopalatine ganglion blocks/application, occipital nerve blocks/application, stellate ganglion blocks/application, supraorbital nerve blocks/application, or trigeminal nerve blocks/application for headaches/migraines. Injection therapy has not shown long term benefit for the treatment of headaches/migraines outside of cluster headaches.
Procedure Codes and Billing Guidelines:
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
- 64400 Injection, anesthetic agent; trigeminal nerve, any division or branch
- 64405 Injection, anesthetic agent; greater occipital nerve
- 64505 Injection, anesthetic agent, sphenopalatine ganglion
- 64510 Injection, anesthetic agent; stellate ganglion (cervical sympathetic)
- 30999 Unlisted procedure, nose
- 64999 Unlisted procedure, nervous system
- American Society of Health System Pharmacists; AHFS Drug Information 2009. Bethesda, MD. (2009), p. 3334
- Levin M. Nerve blocks in the treatment of headache. Neurotherapeutics, 7(2): 197-203 2010.
- Bogduk N. Role of anesthesiologic blockade in headache management. Curr Pain Headache Rep, 8(5): 399-403 2004.
- Tian Medical Inc. Use of the Tx360 Nasal Applicator in the Treatment of Chronic Migraine Clinical Trials. Bethesda (MD): National Library of Medicine (US). 2012
- International Headache Society. The International Classification of Headache Disorders, 2nd edition May, 2005. Web site. Accessed. November 2013.
- Krusz JC. Aggressive interventional treatment of intractable headaches in the clinic setting. Clinics in Family Practice, 7(3)2005.
- Khan, S; Schoenen, J; Ashina, M. "Sphenopalatine ganglion neuromodulation in migraine: What is the rationale?" Cephalalgia 2014;34(5):382–391
- Journal of Headache and Pain 2013, 14:86 doi:10.1186/1129-2377-14-86
- Schoenen, J; Jensen, RH; Lantéri-Minet, M; Láinez, MJ; Gaul, C; Goodman, AM; Caparso, A; May, A. "Stimulation of the sphenopalatine ganglion (SPG) for cluster headache treatment. Pathway CH-1: a randomized, sham-controlled study." Cephalalgia. 2013 Jul;33(10):816-30.
- Khan, S; Schoenen, J; Ashina, M. "Sphenopalatine ganglion neuromodulation in migraine: What is the rationale?" Cephalalgia 2014;34(5:382–391.
- Martelletti, P; Jensen, RH; Antal, A; Arcioni, R; Brighina, F’ de Tommaso, M; Franzini, A; Fontaine, D; Heiland, M; Jürgens, TP; Leone, M; Magis, D; Paemeleire, K; Palmisani, S; Paulus, W; May, A. "Neuromodulation of chronic headaches: position statement from the European Headache Federation." J Headache Pain 2013;14(1):86.
- Piagkou, M; Demesticha, T; Troupis, T; Vlasis, K; Skandalakis, P; Makri, A; Mazarakis, A; Lappas, D; Piagkos, G; Johnson, EO. "The pterygopalatine ganglion and its role in various pain syndromes: from anatomy to clinical practice." Pain Pract. 2012;12(5):399-412.
- Roger Cady, Joel Saper, Kent Dexter and Heather R. Manley A Double-Blind, Placebo-Controlled Study of Repetitive Transnasal Sphenopalatine Ganglion Blockade With Tx360® as Acute Treatment for Chronic Migraine Headache: The Journal of Head and Face Pain 55 Article first published online: 23 OCT 2014 | DOI: 10.1111/head.12458
- Zarembinski C, Graff-Radford S. An Unusual Challenge in Performing Sphenopalatine Ganglion Block with Enlarged Coronoid Process: Jacob's Disease. Pain Med. 2014 Feb;15(2):329-32.
- Practice Guidelines for Chronic Pain Management. An Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 2010; 112:1–1.
- American Migraine Foundation. Sphenopalatine Ganglion Blocks in Headache Disorders. 2016
- American Academy of Neurological Surgeons (AANS). Occipital Neuralgia. November 2006. Updated 2013.
- Blumenfeld 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.
- Cho SJ, Song TJ, Chu MK. Treatment update of chronic migraine. Curr Pain Headache Rep. 2017;21(6):26.
- Ambrosini A, Schoenen J. Invasive pericranial nerve interventions. Cephalalgia. 2016 Mar 22 [Epub ahead of print].
- Mehta, D. , Leary, M. C., Yacoub, H. A., Elâ€Hunjul, M. , Kincaid, H. , Koss, V. , Wachter, K. Malizia, D. , Glassman, B. and Castaldo, J. E. (2018), The Effect of Regional Anesthetic Sphenopalatine Ganglion Block on Selfâ€Reported Pain in Patients With Status Migrainosus. Headache: The Journal of Head and Face Pain. . doi:10.1111/head.13390
- Puledda F, Goadsby PJ, Prabhakar P. Treatment of disabling headache with greater occipital nerve injections in a large population of childhood and adolescent patients: a service evaluation. The Journal of Headache and Pain. 2018;19(1):5. doi:10.1186/s10194-018-0835-5.
- Pringsheim, T., Davenport, W. J., Marmura, M. J., Schwedt, T. J. and Silberstein, S. (2016), How to Apply the AHS Evidence Assessment of the Acute Treatment of Migraine in Adults to your Patient with Migraine. Headache, 56: 1194–1200. doi:10.1111/head.12870
- Tobin J, Flitman S. Occipital nerve blocks: when and what to inject? Headache. 2009 Nov-Dec; 49(10):1521-33.
- August 2018 - Annual Review, Policy Revised
- August 2017 - Annual Review, Policy Revised
- August 2016 - Annual Review, Policy Revised
- September 2015 - Annual Review, Policy Revised
- October 2014 - Annual Review, Policy Renewed
- December 2013 - New Policy
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