{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T13:07:53Z","timestamp":1789391273360,"version":"build-2803163510"},"reference-count":33,"publisher":"MDPI AG","issue":"18","license":[{"start":{"date-parts":[[2026,9,12]],"date-time":"2026-09-12T00:00:00Z","timestamp":1789171200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Background: Epidural blood patch (EBP) remains the standard procedural treatment for post-dural puncture headache (PDPH) persisting after conservative care; whereas, the evidence for greater occipital nerve block (GONB) is limited. This study describes pain trajectories during GONB-based management and factors associated with repeated GONB. Methods: Single-centre retrospective observational cohort of all consecutive patients treated for PDPH between January 2016 and January 2018. Eligible patients met the current ICHD-3 criteria after spinal anaesthesia, had a Numerical Rating Scale (NRS) score \u2265 4 and had persistent symptoms after \u226524 h of conservative management. Bilateral landmark-guided GONB (2.5 mL bupivacaine HCl 5 mg\/mL per side) was repeated when the NRS remained \u22654 at a 24 h assessment, so group membership reflected the response to treatment. Results: Sixty-two patients were analysed (mean age 33.9 \u00b1 15.1 years; 64.5% women). NRS decreased over seven days (Friedman \u03c72 = 262.6, p &lt; 0.001; Kendall\u2019s W = 0.847); on day 7, 57 patients (91.9%; 95% CI 82.5\u201396.5%) had absent-to-mild pain. Thirty-eight patients (61.3%; 95% CI 48.8\u201372.4%) received one block. In an exploratory Firth penalised model, baseline NRS (OR 2.41, 95% CI 1.55\u20134.15) and orthopaedic surgery (OR 5.02, 95% CI 1.36\u201321.56) were associated with repeated GONB. No GONB-related complications and no EBP were documented. Conclusions: NRS scores decreased during a strategy comprising one or more GONB sessions with concomitant conservative care, but these uncontrolled observations cannot separate any effect of GONB from spontaneous recovery, regression to the mean or concomitant treatment. They are hypothesis-generating and require prospective randomised confirmation.<\/jats:p>","DOI":"10.3390\/jcm15187079","type":"journal-article","created":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T12:09:51Z","timestamp":1789387791000},"page":"7079","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Pain Trajectories and Factors Associated with Repeated Greater Occipital Nerve Block in Post-Dural Puncture Headache: A Retrospective Observational Cohort Study"],"prefix":"10.3390","volume":"15","author":[{"given":"Sinan","family":"Pekta\u015f","sequence":"first","affiliation":[{"name":"Division of Algology (Pain Medicine), Department of Anesthesiology and Reanimation, Faculty of Medicine, Mu\u011fla S\u0131tk\u0131 Ko\u00e7man University, 48000 Mu\u011fla, T\u00fcrkiye"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2527-3510","authenticated-orcid":false,"given":"\u00c7a\u011fatay","family":"K\u00fc\u00e7\u00fckbing\u00f6z","sequence":"additional","affiliation":[{"name":"Division of Pain Medicine, Department of Anesthesiology and Reanimation, Adana City Training and Research Hospital, 01370 Adana, T\u00fcrkiye"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,12]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Headache Classification Committee of the International Headache Society (IHS) (2018). The International Classification of Headache Disorders, 3rd edition. Cephalalgia, 38, 1\u2013211.","DOI":"10.1177\/0333102417738202"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"471","DOI":"10.1136\/rapm-2023-104817","article-title":"Evidence-based clinical practice guidelines on postdural puncture headache: A consensus report from a multisociety international working group","volume":"49","author":"Uppal","year":"2024","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"451","DOI":"10.1016\/S1521-6896(03)00033-8","article-title":"Post-dural puncture headache: Pathophysiology, prevention and treatment","volume":"17","author":"Candido","year":"2003","journal-title":"Best Pract. Res. Clin. Anaesthesiol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"440","DOI":"10.1136\/jnnp.54.5.440","article-title":"Changes in intracranial CSF volume after lumbar puncture and their relationship to post-LP headache","volume":"54","author":"Grant","year":"1991","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1197","DOI":"10.1016\/S0140-6736(17)32451-0","article-title":"Atraumatic versus conventional lumbar puncture needles: A systematic review and meta-analysis","volume":"391","author":"Nath","year":"2018","journal-title":"Lancet"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"264","DOI":"10.4274\/TJAR.2023.221128","article-title":"Awareness of postdural puncture headache among specialists who perform lumbar punctures and\/or monitor patients following the procedure","volume":"51","author":"Rumeli","year":"2023","journal-title":"Turk. J. Anaesthesiol. Reanim."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"586","DOI":"10.1001\/jama.1956.02970070018005","article-title":"Long-term follow-up of patients who received 10,098 spinal anesthetics; syndrome of decreased intracranial pressure (headache and ocular and auditory difficulties)","volume":"161","author":"Vandam","year":"1956","journal-title":"J. Am. Med. Assoc."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"553","DOI":"10.1136\/jnnp.2007.122879","article-title":"Epidural blood patch in post dural puncture headache: A randomised, observer-blind, controlled clinical trial","volume":"79","author":"Oedit","year":"2008","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1111\/head.14447","article-title":"Management and outcomes of persistent headache after accidental dural puncture in the obstetric population: A 9-year prospective audit","volume":"63","author":"Niraj","year":"2023","journal-title":"Headache"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"121","DOI":"10.2217\/cer-2021-0258","article-title":"Early mobilization in enhanced recovery after surgery pathways: Current evidence and recent advancements","volume":"11","author":"Tazreean","year":"2022","journal-title":"J. Comp. Eff. Res."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"844","DOI":"10.1177\/0269215514558641","article-title":"Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: A systematic review","volume":"29","author":"Guerra","year":"2015","journal-title":"Clin. Rehabil."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"S228","DOI":"10.4103\/0028-3886.315993","article-title":"Role of greater occipital nerve block in headache disorders: A narrative review","volume":"69","author":"Chowdhury","year":"2021","journal-title":"Neurol. India"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"943","DOI":"10.4103\/aian.aian_677_23","article-title":"Ultrasound-guided combined greater occipital nerve block at the C2 level with trapezius trigger point injection and supraorbital-supratrochlear nerve block: More effective on allodynia and disability in chronic migraine","volume":"26","author":"Turan","year":"2023","journal-title":"Ann. Indian Acad. Neurol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1310","DOI":"10.4103\/neurol-india.Neurol-India-D-24-00654","article-title":"A case series in a tertiary care headache center: Ultrasound-guided proximal greater occipital nerve pulsed radiofrequency is effective in migraine with aura for six months","volume":"72","author":"Turan","year":"2024","journal-title":"Neurol. India"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1016\/0361-9230(85)90181-9","article-title":"Innervation of the posterior fossa dura of the cat","volume":"14","author":"Keller","year":"1985","journal-title":"Brain Res. Bull."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"843","DOI":"10.5603\/FM.a2021.0114","article-title":"The posterior cranial fossa\u2019s dura mater innervation and its clinical implication in headache: A comprehensive review","volume":"81","author":"Hage","year":"2022","journal-title":"Folia Morphol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"765","DOI":"10.1016\/j.neurol.2021.07.012","article-title":"Intracranial nociception","volume":"177","author":"Terrier","year":"2021","journal-title":"Rev. Neurol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1016\/j.neulet.2006.04.049","article-title":"Occipital afferent activation of second order neurons in the trigeminocervical complex in rat","volume":"403","author":"Akerman","year":"2006","journal-title":"Neurosci. Lett."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1186\/s10194-020-01161-y","article-title":"Modulation of mechanosensory vibrissal responses in the trigeminocervical complex by stimulation of the greater occipital nerve in a rat model of trigeminal neuropathic pain","volume":"21","author":"Negredo","year":"2020","journal-title":"J. Headache Pain"},{"key":"ref_20","first-page":"87","article-title":"Primary cough headache responded to ultrasound-guided greater occipital nerve block: A case report","volume":"62","year":"2025","journal-title":"Noro Psikiyatr. Ars."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1111\/j.1533-2500.2008.00238.x","article-title":"Nerve stimulator-guided occipital nerve blockade for postdural puncture headache","volume":"9","author":"Naja","year":"2009","journal-title":"Pain Pract."},{"key":"ref_22","first-page":"445","article-title":"Bilateral greater occipital nerve block for treatment of post-dural puncture headache after caesarean operations","volume":"66","year":"2016","journal-title":"Braz. J. Anesthesiol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"80","DOI":"10.3344\/kjp.2018.31.2.80","article-title":"Efficacy of bilateral greater occipital nerve block in postdural puncture headache: A narrative review","volume":"31","author":"Nair","year":"2018","journal-title":"Korean J. Pain"},{"key":"ref_24","first-page":"E443","article-title":"Sphenopalatine ganglion versus greater occipital nerve blocks in treating post-dural puncture headache after spinal anesthesia for cesarean section","volume":"24","author":"Youssef","year":"2021","journal-title":"Pain Physician"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"E137","DOI":"10.36076\/ppj.2025.28.E137","article-title":"Greater occipital nerve block at two levels spares the need for an epidural blood patch for managing postdural puncture headache: A randomized comparative trial","volume":"28","author":"Mahdy","year":"2025","journal-title":"Pain Physician"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"3019","DOI":"10.21873\/invivo.12597","article-title":"Peripheral nerve blocks for postdural puncture headache: A new solution for an old problem?","volume":"35","author":"Giaccari","year":"2021","journal-title":"In Vivo"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"539","DOI":"10.1016\/j.jclinane.2014.03.006","article-title":"Greater occipital nerve block for postdural puncture headache (PDPH): A prospective audit of a modified guideline for the management of PDPH and review of the literature","volume":"26","author":"Niraj","year":"2014","journal-title":"J. Clin. Anesth."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"573","DOI":"10.7326\/0003-4819-147-8-200710160-00010","article-title":"The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies","volume":"147","author":"Altman","year":"2007","journal-title":"Ann. Intern. Med."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"726","DOI":"10.1016\/j.apmr.2026.01.006","article-title":"Getting to know pain effect sizes: Guidelines for effect size and sample size in global pain research","volume":"107","year":"2026","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"23f14933","DOI":"10.4088\/JCP.23f14933","article-title":"How to understand the 95% confidence interval around the relative risk, odds ratio, and hazard ratio: As simple as it gets","volume":"84","author":"Andrade","year":"2023","journal-title":"J. Clin. Psychiatry"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1373","DOI":"10.1016\/S0895-4356(96)00236-3","article-title":"A simulation study of the number of events per variable in logistic regression analysis","volume":"49","author":"Peduzzi","year":"1996","journal-title":"J. Clin. Epidemiol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1093\/biomet\/80.1.27","article-title":"Bias reduction of maximum likelihood estimates","volume":"80","author":"Firth","year":"1993","journal-title":"Biometrika"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"2409","DOI":"10.1002\/sim.1047","article-title":"A solution to the problem of separation in logistic regression","volume":"21","author":"Heinze","year":"2002","journal-title":"Stat. Med."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/18\/7079\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T12:47:37Z","timestamp":1789390057000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/18\/7079"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,12]]},"references-count":33,"journal-issue":{"issue":"18","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["jcm15187079"],"URL":"https:\/\/doi.org\/10.3390\/jcm15187079","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,12]]}}}