Acute Headache Treatment in Pregnancy: Occipital Nerve Block vs PO Acetaminophen With Caffeine
Acute Headache Treatment in Pregnancy: Occipital Nerve Block vs PO Acetaminophen With Caffeine
This is an open label randomized controlled trial evaluating response to bupivacaine
 occipital nerve block compared to Tylenol/Caffeine cocktail in treatment of pregnant patients
 seeking care of headache.
This is an open label randomized controlled trial. Women who present to the MEU with headache
 will be assessed by trained nurse practitioners and/or OB/GYN residents. If the woman meets
 criteria for the study she will be enrolled by an MEU provider doing the primary assessment.

 See Figure 1 for the flow diagram depicting the patient's course through MEU. If eligible for
 inclusion, women will be randomly assigned to ONB or headache cocktail. Randomization will
 occur at time of enrollment. Prior to headache treatment 10-point visual/verbal rating scale
 (VRS) will be obtained. Treatment time is defined as time the patient takes the medication or
 the time that the needle is inserted into the greater occipital notch. At 60 min after
 treatment VRS will again be obtained by nursing staff or primary provider. If headache pain
 is resolved, defined as a VRS 0, the patient will be discharged to home (at the discretion of
 the managing team providing there are no other indications for further observation or
 admission). If pain continues to be present VRS will again be assessed at 120 min after
 treatment. If pain is not improved to mild range, defined as a VRS ≤ 3, or resolved,
 crossover treatment will be given. VRS will be obtained at 60 min after cross over treatment;
 if pain is resolved patient will be discharge to home. If pain continues to be present VRS
 will be obtained at 120 min after cross over treatment. If pain is not improved to mild pain
 or resolved; second line treatment of Promethazine 25mg/Benadryl 25mg will be given. VRS will
 again be obtained 60 min after second line treatment. If pain is not improved to mild pain
 (VRS ≤3) or resolved neurology consult will be considered. If at any point during treatment
 the patient develops new neurological symptoms study protocol will be stopped and neurology
 will be consulted.

 Patients will be called 7 days after discharge to access short term outcomes (headache
 frequency since MEU visit, injection site complications, and satisfaction with treatment.)
 Patients will again be called at 28 days and a chart abstraction will be done to access for
 long term outcomes (recurrent presentation for headache to the MEU, maternal complications
 including preeclampsia, or fetal complications).
Inclusion criteria:

 1. Women presenting to Maternal Evaluation Unit at UAB hospital

 2. Confirmed live intrauterine pregnancy (previous ultrasound, bedside ultrasound, fetal
 monitoring)

 3. Complaint of headache

 4. Minimal pain level of 4 on VRS

 Exclusion criteria:

 1. Systolic BP >= 140 or diastolic BP>=90 with 1+ protein on urine dip

 2. Systolic BP >=160 or diastolic BP>=105

 3. Focal neurological symptoms

 4. Altered level of consciousness defined as not being oriented to person, place,
 situation, and/or year

 5. Complaint of seizure

 6. Known under lying brain abnormality

 7. Fever

 8. Use of >3 grams of acetaminophen in past 24hrs

 9. ONB in the past 3 months

 10. Reported allergy to study medications (Bupivacaine, acetaminophen, or caffeine)