Real-Time Ultrasound-Guided Stellate Ganglion Block for Migraine: An Observational Study

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To observe whether ultrasound-guided stellate ganglion block (SGB) can effectively relieve migraine pain and improve the quality of migraine patients’ life. Methods. 81 patients with migraines were enrolled in this trial. The patients received SGB with 6 ml of 0.15% ropivacaine once every week for four times. Migraine was assessed with the Migraine Disability Assessment Scale (MIDAS) at baseline and three-months follow-up (Tm). The numerical rating scale (NRS) score at baseline, one day after treatment (Td) and Tm, the frequency of analgesic use in 3 months and the side effects were also recorded at the same time. Results. The NRS score of migraine subjects decreased significantly from 7.0 (2.0) to 3.0 (1.0) at Td and 2.0 (2.0) at Tm (vs baseline, P<0.01). The MIDAS total scores were 14.0 (10.5) at baseline and 7.0 (4.5) at Tm (P<0.001). During the three months, the frequency of analgesic consumption was decreased from 6.2 ± 2.8 to 1.9±1.8. There were no serious side effects. Conclusions. This study confirmed that ultrasound-guided SGB is an effective method to treat migraines. This technique can reduce pain and disability and then improve the quality of life of patients with migraines. Anesthesiology & Pain Medicine Ultrasound guidance Stellate ganglion block (SGB) Migraine XYZ Figures Figure 1 Figure 2 Figure 3 Introduction Migraine is a nervous system disease characterized by headache, nausea, vomiting and sensitivity to visual, auditory, olfactory and skin irritation. It is usually recurrent with moderate to severe pain and poor drug control. Migraine is the third leading cause of disability globally. It affects hundreds of millions of people and accounts for about 10% of the world’s population [ 1 , 2 ]. In addition, migraine-related disability and malpractice cause substantial financial costs [ 3 ]. Although there are some drugs for acute treatment and prevention of migraine, other treatment options for patients with poor drug response or intolerance to drug treatment should be considered [ 4 ]. Stellate ganglion block (SGB) is a safe procedure that may provide extended relief for breast cancer-related lymphedema (BCRL) and all clusters of Post-Traumatic Stress Disorder (PTSD) symptoms [ 5 , 6 ]. SGB is also an accepted intervention for the treatment of various pain conditions of the head and neck regions as well as the upper limbs [ 7 ]. The stellate ganglion is a sympathetic ganglion, approximately 2.5 cm in length, 1 cm in width and 0.5 cm in thickness. It is located in front of the neck of the first rib and can extend to the seventh cervical spine (C7) [ 8 , 9 ]. Yu et al. reported that ultrasound-guided SGB could effectively relieve cervical headache [ 10 ]. However, the time point of pain assessment was 1 day after SGB, with no long-term follow-up data. One study showed that bilateral SGB was effective to reduce pain and improve the Migraine Disability Assessment Scale (MIDAS) score in two migraine patients [ 4 ]. Evidence regarding the effect of SGB on migraines is scanty. Herein, we investigate whether SGB can reduce acute migraine attacks and whether it can effectively reduce the frequency of migraine attacks within three months. Methods Patients were enrolled between June 15, 2017 and March 20, 2019. The inclusion criteria were participants over 18 years old, diagnosed with migraine [11]. Migraine is defined as follows: Without aura, A. ≥5 attacks in a lifetime fulfilling criteria B-D. B. Headache attacks lasting 4-72 h (untreated or unsuccessfully treated). C. Headache has ≥2 of the following characteristics: unilateral in location, pulsating in quality, moderate or severe pain intensity and aggravated by or causing avoidance of routine physical activity (e.g., walking or climbing stairs). D. During headache at least one of the following symptoms: nausea and/or vomiting, photophobia and phonophobia. E. Not better accounted for by another International Classification of Headache Disorders-3 (ICHD-3) diagnosis. With typical aura, A. ≥2 attacks in a lifetime fulfilling criteria B and C. B. Aura consisting of visual, sensory or speech/language symptoms, each fully reversible, but no motor weakness or brainstem symptoms. C. ≥2 of the following characteristics: ≥1 aura symptom spreads gradually over ≥5 min, and ≥2 symptoms occur in succession; each aura symptom lasts 5-60 min; ≥1 aura symptom is unilateral; aura accompanied or followed within 60 min by headache. D. Not better accounted for by another ICHD-3 diagnosis, and transient ischemic attack has been excluded [11]. The exclusion criteria included patients with a space-occupying lesion, coagulation disorders, systemic or local infection and drug allergies. Psychotic patients and migraine with bilateral attacks were also excluded from this study. All patients were administered with SGB on the affected side and 0.15% ropivacaine was injected. SGB was conducted once a week for 4 times. All patients were followed up for 3 months. Analgesics such as diclofenac sodium were taken orally if the migraine attacks and the pain was serious, but no more than 10 times per month to avoid medication overuse headache. Data Recording The primary outcome was the MIDAS score at 3-months follow-up (Tm). The MIDAS questionnaire is one of the most widely used to measure the decline of quality of life caused by migraine [12]. The MIDAS questionnaire is a short, self-administered questionnaire designed to quantify headache-related disability within 3 months. It includes five questions about work, housework and non-work activity (social, family and leisure activities) to assess the degree of disability caused by headaches. The MIDAS score is closely related to the judgment of the severity of the headache and the need for medical care [13] and has been widely used in China [14-16]. Secondary outcomes include the numerical rating scale (NRS) score at baseline, one day after treatment (Td) and 3 months after treatment (Tm). The NRS allows the subject to rate their pain on an eleven-point numerical scale. The scale is composed of 0 (no pain at all) to 10 (worst imaginable pain) [17]. We defined migraine with an NRS score >7 as severe migraine. The frequency of non-steroidal anti-inflammatory drugs (NSAIDs) consumption in 3 months was also recorded. During the follow-up period, SGB-related side effects such as hoarseness, dysphagia and foreign body sensation in the throat, upper limb weakness and hematoma formation were confirmed and recorded by doctors. Serious complications such as general spinal anesthesia, epidural block and pneumothorax were reported to the ethics committee. Patients were asked to inform doctors of any adverse symptoms they had experienced at any time. Procedures Ultrasound-Guided SGB The patient’s position was similar to that of the traditional blind method. Patients were positioned in a lateral position with their necks slightly hyperextended. Assisted by ultrasound imaging equipment and a 7-14 MHz linear array probe (S-Nerve, SonoSite, USA), the C7 level was confirmed. Because of the tiny or absent anterior tubercle of the C7, sonoanatomy of the C7 transverse process was similar to the traditional Chinese “imperial concubine chair”. The thyroid gland, carotid artery, compressible internal jugular vein, vertebral artery, brachial plexus and the oval-shaped structure of the longus colli muscle were revealed on this short-axis view. The color Doppler mode was used before needling to avoid penetrating blood vessels such as the vertebral artery, internal jugular vein and inferior thyroid vessel (Fig. 1). Ultrasound can provide the perfect technical means to achieve this goal. We used a 25-gauge, 8-cm needle for a puncture, and the puncture point was 1-1.5 cm away from the ultrasound probe. The in-plane puncture technique was used for real-time display of the whole process of puncture. The tip of the needle reached the surface of the longus colli muscle and the 5 o’clock position of the carotid artery (Fig. 2a). Under the guidance of the ultrasound, SGB was performed by injection of 6 ml of 1.5% ropivacaine. The common carotid artery was observed “floating” upward under ultrasound, indicating that the drug diffused in the prevertebral space on the surface of the longus colli muscle (Fig. 2b). All measurements were performed by a senior anesthesiologist using the same ultrasound instrument. Statistical Analysis MIDAS and NRS scores are expressed as median with interquartile range (IQR). A generalized linear mixed model (GLMM) was performed to evaluate changes in pain NRS scores over repeated measurements. If the repeated measures demonstrated a statistically significant time interaction, multiple comparison corrections were performed using Bonferroni correction. Changes in migraine outcomes as assessed by the MIDAS questionnaire were compared using a paired Wilcoxon test or signed rank-sum test. A P-value <0.05 was considered statistically significant. Statistical analyses were conducted using SPSS 18.0 software for Windows (SPSS Inc, Chicago, IL, USA) Results Subject Characteristics We recruit 186 subjects. After preliminary investigation, 107 subjects were assessed for eligibility. However, among 107 subjects, 15 subjects did not meet the inclusion criteria and the informed consent form was not obtained from 5 subjects. Therefore, 86 subjects were finally enrolled in the study. Of 86 patients, 6 patients did not complete all the four SGB and 2 patients lost follow-up, and therefore 81 patients (23 men, 58 women; median age, 33.2 ± 7.9 years; range, 18-62 years) were included in the final analysis (Fig. 3). Within three months, 17 patients had severe migraine attacks 12 times (Table 1). Clinical Assessment MIDAS total scores of subjects were 14.0 (10.5) at baseline and 7.0 (4.5) at Tm (P<0.001) (Table 2). NRS scores at baseline, Td and Tm were 7.0 (2.0), 3.0 (1.0) (vs baseline, P<0.01) and 2.0 (2.0) (vs baseline, P<0.01), respectively. The frequency of analgesic use within 3 months was 6.2 ± 2.8 at baseline and 1.9 ± 1.8 at Tm. Of the 86 patients recruited, two patients developed headaches after receiving a single SGB treatment and gave up follow-up treatment. Among the 81 patients who were included in the final analysis, there were 6 cases of hoarseness, 3 cases of local bruise and 2 cases of transient upper limb numbness. There were no serious complications such as gastrorrhagia, general spinal anesthesia, epidural block and pneumothorax. Discussion Although migraine is not the most frequent primary headache in the world, its incidence is quite high, affecting more than 10% of the world’s population. Migraine is usually unilateral and moderate to severe. It worsens with daily physical activities, such as walking and climbing stairs, seriously affecting patients’ work and quality of life [ 1 ]. In addition to prophylactic (e.g., flunarizine, topiramate and amitriptyline) and acute (e.g., diclofenac sodium and triptans) migraine therapies, treatment of migraine triggers and other lifestyle factors that may aggravate the migraine tendency in patients is critical. Specific behavioral therapies, including biofeedback, teaching relaxation techniques and cognitive behavioral therapy (CBT), are also beneficial [ 18 ]. However, these treatment modalities require patient education and, in some cases, specific behavioral skills. This may cause great confusion for elderly patients or patients who do not receive proper education. Furthermore, the effect of nerve block on migraine has been documented. The cranial nerve block was an effective adjuvant therapy, which could reduce the intensity, duration and frequency of pain, and improve the satisfaction of migraine and central sensitization patients [ 19 ]. A large retrospective cohort study showed that greater occipital nerve block can effectively reduce migraine [ 20 ]. Li et al. reported a case of long-term effective treatment with pulsed radiofrequency of C2 dorsal root ganglion under ultrasound guidance [ 21 ]. The application of trigger point therapy in migraine has also been reported [ 22 ]. Moreover, SGB block has been confirmed to effectively treat migraine [ 4 ]. However, studies evaluating SGB in the treatment of migraine are limited, and even a case report shows that SGB causes migraine attacks [ 23 ]. In the present study, we found that ultrasound-guided SGB, once a week for four weeks, can significantly relieve the pain of migraine patients. Ultrasound is a valuable tool for imaging soft tissue structures and nerves, guiding needle advancement and confirming the spread of the injectate around the target without exposing physicians and patients to the risks of radiation. There is a rapidly growing interest in ultrasound-guided SGB, as evidenced by the surging number of publications in the last few years [ 8 , 24 , 25 ]. It has been reported that 2 ml of 2% mepivacaine can be effective when SGB is performed at the level of the 6th cervical transverse process under ultrasound [ 26 ]. About 6 ml of 0.15% ropivacaine was found to be sufficient for a successful SGB with fewer complications, which coincides with the present study [ 27 ]. The stellate ganglion is extensively connected with the cerebral cortex, hypothalamus, amygdala and hippocampus [ 28 ]. SGB can effectively treat postherpetic neuralgia, hot flushes and night awakenings in survivors of breast cancer, tension headache and PTSD, in part by improving blood supply and inhibiting the connection between the stellate ganglion and the brain through sympathetic action within its innervation; however, the exact mechanism remains unclear [ 5 , 6 , 29 – 32 ]. Low melatonin levels have been reported in migraine patients and SGB has been shown to restore melatonin rhythm. Melatonin can effectively prevent migraines by inhibiting the synthesis of nitric oxide and the release of calcitonin-related peptides and antagonizing excitotoxicity caused by glutamate [ 33 – 35 ]. In addition, stress is the most common migraine trigger. In response to stress, sympathetic activity increases, leading to the release of migraine-associated neurotransmitters, such as dopamine and prostaglandins [ 36 – 38 ]. High dopamine levels can lead to nausea and vomiting, while increased prostaglandins can increase pain sensitivity and inflammation in migraine patients. SGB can regulate sympathetic nerve activity, thereby alleviating most of the symptoms in migraine patients. MIDAS was designed to quantify headache-related disability over 3 months. The reliability and internal consistency of the MIDAS score are comparable to those of a previous questionnaire (Headache Impact Questionnaire). However, the MIDAS score requires fewer questions, is easier to score and provides intuitively meaningful information on lost days of activity in three domains [ 39 , 40 ]. The MIDAS questionnaire was considered highly reliable and effective and was relevant to clinical judgment on medical care needs. In our study, the MIDAS score of patients was significantly decreased at 3-months follow-up. Besides, NRS scores decreased significantly one day and 3 months after SGB. The frequency of analgesic use was also significantly decreased after 3 months. These results suggest that SGB once a week for 4 weeks can reduce the headache and disability among migraine patients and improve their work and quality of life. Two patients who were recruited but not included in the analysis experienced migraine aggravation after a single SGB treatment, suggesting that migraine has more complex mechanisms. Wulf et al. detailed complications after SGB. Most of them were related to the central nervous system (such as convulsions). Other serious complications included high-level subarachnoid block, high-level epidural block, pneumothorax and allergic reaction. All SGBs were performed without fluoroscopy [ 41 ]. In our study, serious complications such as subarachnoid block, epidural block and convulsion were not observed. It is suggested that ultrasound-guided SGB is safer than fluoroscopy because ultrasound can clearly distinguish nerves, blood vessels and muscles, and monitor the puncture needle in real-time, while fluoroscopy has no such functions. Conclusions In summary, the findings of this study suggest that real-time ultrasound-guided SGB may be an effective treatment option for migraine patients without serious complications. However, further studies should be performed to verify this hypothesis. Limitations This study was not a randomized controlled study, and only a few cases were included. Declarations Ethics approval and consent to participate This study was approved by the ethics committee of Shanghai Sixth People’s Hospital (No. 2016-44) and registered in the Chinese Clinical Trial Registry (Identifier: ChiCTR-IOR-17011536). All subjects were from Shanghai Sixth People’s Hospital and Shanghai Eighth People’s Hospital. All procedures involving human studies were following the ethical standards of the national research committee. Written informed consent was obtained from all subjects according to the Helsinki declaration. All medical records were anonymous and no subject information was extracted except for the study purpose. Consent for publication No conflict of interest exits in the submission of this manuscript, and manuscript is approved by all authors for publication. Availability of data and materials We are willing to share individual deidentified participant data, such as the age of the subjects and MAIDS score and NRS score. We will share the data within three months after the accept of the article and keep it for at least three years. The data can be accessible at https://weibo.com/u/2759448832/home . Competing interests The authors declare that they have no conflicts of interest. Funding This work was supported through a grant from Shanghai Municipal Health Commission, No. 201840248 Authors’ contributions Jiawei Hou wrote the main manuscript text. Xingguo Xu was responsible for data statistics. Shaofeng Pu and Zhiqiang Lu were responsible for patient recruitment. Junzheng Wu and Zhiqiang Lu were responsible for puncture operation and figures 1-3. Junzheng Wu was responsible for article check. All authors reviewed the manuscript. Acknowledgments We gratefully acknowledge Xuan Chen for her comments on the manuscript. References Collaborators GBDMM. Global, regional, and national levels of maternal mortality, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1775–812. Silberstein SD. Migraine. Lancet. 2004;363:381–91. Burch RC, Buse DC, Lipton RB. Migraine: Epidemiology, Burden, and Comorbidity. Neurologic clinics. 2019;37:631–49. Moon S, Lee J, Jeon Y. Bilateral stellate ganglion block for migraine: A case report. 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Wulf H, Maier C. [Complications and side effects of stellate ganglion blockade. Results of a questionnaire survey]. Der Anaesthesist. 1992;41:146–51. Tables Table 1. Demographic Characteristics. Frequency (n) Proportion (%) Gender Male 58 71.6 Female 23 28.4 Age 18-28 19 23.5 29-38 46 56.8 39-48 12 14.8 ＞48 4 4.9 Frequency of severe headache pre quarter (NRS＞7) ＜3 17 21.0 3-6 44 54.3 7-12 11 13.6 ＞12 9 11.1 Table 2. Migraine outcomes as assessed by the MIDAS questionnaire MIDAS mean SGB (n=81) Tb Tm Z-Value p-Value Total score 17.52±9.62 7.12±4.28 7.553 <0.001 On how many days in the last 3 months did you miss work or school because of your headaches? 0.96±0.92 0.18±0.39 5.781 <0.001 How many days in the last 3 months was your productivity at work or school reduced by half or more because of your headaches? 4.15±2.67 2.21±1.33 5.955 <0.001 On how many days in the last 3 months did you not do household work because of your headaches? 3.70±2.47 1.22±1.17 7.026 <0.001 How many days in the last 3 months was your productivity in household work reduced by half or more because of your headaches? 6.76±4.09 2.32±1.78 7.656 <0.001 On how many days in the last 3 months did you miss family, social, or leisure activities because of your headaches? 1.85±1.19 0.98±0.96 5.276 <0.001 Tb: Baseline, Tm: Three-months follow-up. MIDAS: Migraine Disability Assessment Scale. SGB: stellate ganglion block. Table 3. NRS of migraine Tb (Baseline) Td (24h after treatment) Tm (3 months follow-up) NRS 6.91±1.71 2.84±1.57 * 2.27±1.52 * Values present the mean±SD; * p<0.01, vs NRS at baseline; NRS, numeric pain scale. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Mar, 2022 Read the published version in BMC Anesthesiology → Version 1 posted Editorial decision: Major revision 28 Feb, 2022 Reviews received at journal 27 Feb, 2022 Reviews received at journal 29 Dec, 2021 Reviewers agreed at journal 20 Dec, 2021 Reviewers invited by journal 19 Dec, 2021 Editor assigned by journal 19 Dec, 2021 Editor invited by journal 16 Dec, 2021 Submission checks completed at journal 16 Dec, 2021 First submitted to journal 28 Nov, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1122553","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":70727042,"identity":"ab8bb08a-25d4-48cc-aee1-a3e8f7bae9e9","order_by":0,"name":"Jiawei Hou","email":"","orcid":"","institution":"The Third People's Hospital of Tongzhou District","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jiawei","middleName":"","lastName":"Hou","suffix":""},{"id":70727043,"identity":"398905ae-73b3-440c-b63b-30f011f731d7","order_by":1,"name":"Shaofeng Pu","email":"","orcid":"","institution":"Shanghai Jiao Tong University Affiliated Sixth People’s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shaofeng","middleName":"","lastName":"Pu","suffix":""},{"id":70727044,"identity":"8e7748d7-dd79-47c5-971d-6eada39a7f7c","order_by":2,"name":"Junzhen Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYHACxgNAgoeBvYHBAMw/QIQeiBaeAwwGB0jRwsAgkQBlEdLCP7v5wcEvFXUy/DOfPyj+2MYgx3cjgfFzAR4tEneOGRyWOXOYR+J2joHBwTYGY8kbCczSM/BZcyPB4LBk2wEehts5DCAtiRtuJLAx8+DRIX8j/cNhyX91PPI3jz8AaaknqMXgRo7BwY8NzDwGNxjADkswIKTF8EZOwWGGY4d5DM8A/XLmnIThzDMPm6XxaZG7kb7x4Y+aOnu548efGVSU2cjzHU8++BmfFhCAOYMNGPsSQJqxgYAGoJIfUK0PCCodBaNgFIyCEQkAq+RT+4RZn3YAAAAASUVORK5CYII=","orcid":"","institution":"Shanghai Jiao Tong University Affiliated Sixth People’s Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Junzhen","middleName":"","lastName":"Wu","suffix":""},{"id":70727045,"identity":"576c57b9-677d-4a5e-abe7-d1aeed9677f8","order_by":3,"name":"Zhiqiang Lu","email":"","orcid":"","institution":"Shanghai Eighth People’s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zhiqiang","middleName":"","lastName":"Lu","suffix":""},{"id":70727046,"identity":"3588bc56-1020-4480-b308-36155ae19606","order_by":4,"name":"Xingguo Xu","email":"","orcid":"","institution":"Affiliated Hospital of Nantong University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xingguo","middleName":"","lastName":"Xu","suffix":""}],"badges":[],"createdAt":"2021-11-29 04:44:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1122553/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1122553/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12871-022-01622-8","type":"published","date":"2022-03-24T23:49:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":16616946,"identity":"f812cf66-3829-45d2-9e3d-1a877306c6af","added_by":"auto","created_at":"2021-12-20 15:56:55","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":138694,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasonic exploration of stellate ganglion. A: Patient's position and placement of ultrasound probe. B: Ultrasound image of the cervical structure during stellate ganglion block.1, thyroid; 2, common carotid artery; 3, internal jugular vein; 4, brachial plexus; 5, vertebral artery; 6, longus colli muscle.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1122553/v1/574b996d4164eba5cce2ca08.jpg"},{"id":16616945,"identity":"6be98c3a-2a45-49eb-8a03-a654af1a275a","added_by":"auto","created_at":"2021-12-20 15:56:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":496691,"visible":true,"origin":"","legend":"\u003cp\u003eStellate ganglion block process. A: The tip of the needle reached the surface of the longus colli muscle and the 5 o'clock position of the carotid artery. B: After administration of ropivacaine, the carotid artery can be seen floating like a balloon in real time under ultrasound, which indicates that the ropivacaine diffuses in the paravertebral space and can effectively block the stellate ganglion. 1, common carotid artery; 2, longus colli muscle; The three arrows indicate the puncture needle, and the two-way arrows indicate that the distance between the common carotid artery and the longus colli muscle is larger than that in Figure A.\u003c/p\u003e","description":"","filename":"3196284fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-1122553/v1/adb7ce40fd00f771db0d876a.png"},{"id":16617546,"identity":"dfc6f4f1-a2f7-4164-ba1f-0f46a25cfc6c","added_by":"auto","created_at":"2021-12-20 15:59:55","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":32066,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart for selecting study population.\u003c/p\u003e","description":"","filename":"3196284fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-1122553/v1/4d6111b8531ca9f25be664af.png"},{"id":19591751,"identity":"f4c90baa-5a58-41d0-8ba7-d4d088a48422","added_by":"auto","created_at":"2022-03-24 23:49:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":773075,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1122553/v1/3bfa64dd-b055-40ff-bc75-9119b18ea9fe.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Real-Time Ultrasound-Guided Stellate Ganglion Block for Migraine: An Observational Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMigraine is a nervous system disease characterized by headache, nausea, vomiting and sensitivity to visual, auditory, olfactory and skin irritation. It is usually recurrent with moderate to severe pain and poor drug control. Migraine is the third leading cause of disability globally. It affects hundreds of millions of people and accounts for about 10% of the world\u0026rsquo;s population [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In addition, migraine-related disability and malpractice cause substantial financial costs [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Although there are some drugs for acute treatment and prevention of migraine, other treatment options for patients with poor drug response or intolerance to drug treatment should be considered [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStellate ganglion block (SGB) is a safe procedure that may provide extended relief for breast cancer-related lymphedema (BCRL) and all clusters of Post-Traumatic Stress Disorder (PTSD) symptoms [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. SGB is also an accepted intervention for the treatment of various pain conditions of the head and neck regions as well as the upper limbs [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The stellate ganglion is a sympathetic ganglion, approximately 2.5 cm in length, 1 cm in width and 0.5 cm in thickness. It is located in front of the neck of the first rib and can extend to the seventh cervical spine (C7) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Yu et al. reported that ultrasound-guided SGB could effectively relieve cervical headache [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, the time point of pain assessment was 1 day after SGB, with no long-term follow-up data. One study showed that bilateral SGB was effective to reduce pain and improve the Migraine Disability Assessment Scale (MIDAS) score in two migraine patients [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Evidence regarding the effect of SGB on migraines is scanty. Herein, we investigate whether SGB can reduce acute migraine attacks and whether it can effectively reduce the frequency of migraine attacks within three months.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003ePatients were enrolled between June 15, 2017 and March 20, 2019. The inclusion criteria were participants over 18 years old, diagnosed with migraine [11]. Migraine is\u0026nbsp;defined as follows: Without aura, A.\u0026nbsp;\u0026ge;5 attacks in a lifetime fulfilling criteria B-D. B. Headache attacks lasting 4-72 h (untreated or unsuccessfully treated). C. Headache has\u0026nbsp;\u0026ge;2 of the following characteristics: unilateral in location, pulsating in quality, moderate or severe pain intensity and aggravated by or causing avoidance of routine physical activity (e.g., walking or climbing stairs). D. During headache at least one of the following symptoms: nausea and/or vomiting, photophobia and phonophobia. E. Not better accounted for by another International Classification of Headache Disorders-3 (ICHD-3) diagnosis. With typical aura, A.\u0026nbsp;\u0026ge;2 attacks in a lifetime fulfilling criteria B and C. B. Aura consisting of visual, sensory or speech/language symptoms, each fully reversible, but no motor weakness or brainstem symptoms. C.\u0026nbsp;\u0026ge;2 of the following characteristics:\u0026nbsp;\u0026ge;1 aura symptom spreads gradually over\u0026nbsp;\u0026ge;5 min, and\u0026nbsp;\u0026ge;2 symptoms occur in succession; each aura symptom lasts 5-60 min;\u0026nbsp;\u0026ge;1 aura symptom is unilateral; aura accompanied or followed within 60 min by headache. D. Not better accounted for by another ICHD-3 diagnosis, and transient ischemic attack has been excluded [11].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe exclusion criteria included patients with a space-occupying lesion, coagulation disorders, systemic or local infection and drug allergies. Psychotic patients and migraine with bilateral attacks were also excluded from this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll patients were administered with SGB on the affected side and 0.15% ropivacaine was injected. SGB was conducted once a week for 4 times. All patients were followed up for 3 months. Analgesics such as diclofenac sodium were taken orally if the migraine attacks and the pain was serious, but no more than 10 times per month to avoid medication overuse headache.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Recording\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome was the MIDAS score at 3-months follow-up (Tm). The MIDAS questionnaire is one of the most widely used to measure the decline of quality of life caused by migraine [12]. The MIDAS questionnaire is a short, self-administered questionnaire designed to quantify headache-related disability within 3 months. It includes five questions about work, housework and non-work activity (social, family and leisure activities) to assess the degree of disability caused by headaches. The MIDAS score is closely related to the judgment of the severity of the headache and the need for medical care [13] and has been widely used in China [14-16].\u003c/p\u003e\n\u003cp\u003eSecondary outcomes include the numerical rating scale (NRS) score at baseline, one day after treatment (Td) and 3 months after treatment (Tm). The NRS allows the subject to rate their pain on an eleven-point numerical scale. The scale is composed of 0 (no pain at all) to 10 (worst imaginable pain) [17]. We defined migraine with an NRS score \u0026gt;7 as severe migraine. The frequency of non-steroidal anti-inflammatory drugs (NSAIDs) consumption in 3 months was also recorded. During the follow-up period, SGB-related side effects such as hoarseness, dysphagia and foreign body sensation in the throat, upper limb weakness and hematoma formation were confirmed and recorded by doctors. Serious complications such as general spinal anesthesia, epidural block and pneumothorax were reported to the ethics committee. Patients were asked to inform doctors of any adverse symptoms they had experienced at any time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUltrasound-Guided SGB\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient\u0026rsquo;s position was similar to that of the traditional blind method. Patients were positioned in a lateral position with their necks slightly hyperextended. Assisted by ultrasound imaging equipment and a 7-14 MHz linear array probe (S-Nerve, SonoSite, USA), the C7 level was confirmed. Because of the tiny or absent anterior tubercle of the C7, sonoanatomy of the C7 transverse process was similar to the traditional Chinese \u0026ldquo;imperial concubine chair\u0026rdquo;. The thyroid gland, carotid artery, compressible internal jugular vein, vertebral artery, brachial plexus and the\u0026nbsp;oval-shaped structure of the longus colli muscle were revealed on this short-axis view. The color Doppler mode was used before needling to avoid penetrating blood vessels such as the vertebral artery, internal jugular vein and inferior thyroid vessel (Fig. 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUltrasound can provide the perfect technical means to achieve this goal. We used a 25-gauge, 8-cm needle for a puncture, and the puncture point was 1-1.5 cm away from the ultrasound probe. The in-plane puncture technique was used for real-time display of the whole process of puncture. The tip of the needle reached the surface of the longus colli muscle and the 5 o\u0026rsquo;clock position of the carotid artery (Fig. 2a). Under the guidance of the ultrasound, SGB was performed by injection of 6 ml of 1.5% ropivacaine. The common carotid artery was observed \u0026ldquo;floating\u0026rdquo; upward under ultrasound, indicating that the drug diffused in the prevertebral space on the surface of the longus colli muscle (Fig. 2b).\u0026nbsp;All measurements were performed by a senior anesthesiologist using the same ultrasound instrument.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMIDAS and NRS scores are expressed as median with interquartile range (IQR). A generalized linear mixed model (GLMM) was performed to evaluate changes in pain NRS scores over repeated measurements. If the repeated measures demonstrated a statistically significant time interaction, multiple comparison corrections were performed using Bonferroni correction. Changes in migraine outcomes as assessed by the MIDAS questionnaire were compared using a paired Wilcoxon test or signed rank-sum test. A P-value \u0026lt;0.05 was considered statistically significant. Statistical analyses were conducted using SPSS 18.0 software for Windows (SPSS Inc, Chicago, IL, USA)\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eSubject Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe recruit 186 subjects. After preliminary investigation, 107 subjects were assessed for eligibility. However, among 107 subjects, 15 subjects did not meet the inclusion criteria and the informed consent form was not obtained from 5 subjects. Therefore, 86 subjects were finally enrolled in the study. Of 86 patients, 6 patients did not complete all the four SGB and 2 patients lost follow-up, and therefore 81 patients (23 men, 58 women; median age, 33.2 \u0026plusmn; 7.9 years; range, 18-62 years) were included in the final analysis (Fig. 3).\u003c/p\u003e\n\u003cp\u003eWithin three months, 17 patients had severe migraine attacks \u0026lt;3 times, 44 patients had severe migraine attacks 3-6 times, 11 patients had severe migraine attacks 7-12 times and 9 patients had severe migraine attacks \u0026gt;12 times (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMIDAS total scores of subjects were 14.0 (10.5) at baseline and 7.0 (4.5) at Tm (P\u0026lt;0.001) (Table 2). NRS scores at baseline, Td and Tm were\u0026nbsp;7.0 (2.0), 3.0 (1.0) (vs baseline, P\u0026lt;0.01) and 2.0 (2.0) (vs baseline, P\u0026lt;0.01), respectively. The frequency of analgesic use within 3 months was 6.2 \u0026plusmn; 2.8 at baseline and 1.9 \u0026plusmn; 1.8 at Tm.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOf the 86 patients recruited, two patients developed headaches after receiving a single SGB treatment and gave up follow-up treatment. Among the 81 patients who were included in the final analysis, there were 6 cases of hoarseness, 3 cases of local bruise and 2 cases of transient upper limb numbness. There were no serious complications such as gastrorrhagia, general spinal anesthesia, epidural block and pneumothorax.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAlthough migraine is not the most frequent primary headache in the world, its incidence is quite high, affecting more than 10% of the world\u0026rsquo;s population. Migraine is usually unilateral and moderate to severe. It worsens with daily physical activities, such as walking and climbing stairs, seriously affecting patients\u0026rsquo; work and quality of life [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to prophylactic (e.g., flunarizine, topiramate and amitriptyline) and acute (e.g., diclofenac sodium and triptans) migraine therapies, treatment of migraine triggers and other lifestyle factors that may aggravate the migraine tendency in patients is critical. Specific behavioral therapies, including biofeedback, teaching relaxation techniques and cognitive behavioral therapy (CBT), are also beneficial [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, these treatment modalities require patient education and, in some cases, specific behavioral skills. This may cause great confusion for elderly patients or patients who do not receive proper education.\u003c/p\u003e \u003cp\u003eFurthermore, the effect of nerve block on migraine has been documented. The cranial nerve block was an effective adjuvant therapy, which could reduce the intensity, duration and frequency of pain, and improve the satisfaction of migraine and central sensitization patients [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A large retrospective cohort study showed that greater occipital nerve block can effectively reduce migraine [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Li et al. reported a case of long-term effective treatment with pulsed radiofrequency of C2 dorsal root ganglion under ultrasound guidance [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The application of trigger point therapy in migraine has also been reported [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Moreover, SGB block has been confirmed to effectively treat migraine [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, studies evaluating SGB in the treatment of migraine are limited, and even a case report shows that SGB causes migraine attacks [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In the present study, we found that ultrasound-guided SGB, once a week for four weeks, can significantly relieve the pain of migraine patients.\u003c/p\u003e \u003cp\u003eUltrasound is a valuable tool for imaging soft tissue structures and nerves, guiding needle advancement and confirming the spread of the injectate around the target without exposing physicians and patients to the risks of radiation. There is a rapidly growing interest in ultrasound-guided SGB, as evidenced by the surging number of publications in the last few years [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. It has been reported that 2 ml of 2% mepivacaine can be effective when SGB is performed at the level of the 6th cervical transverse process under ultrasound [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. About 6 ml of 0.15% ropivacaine was found to be sufficient for a successful SGB with fewer complications, which coincides with the present study [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe stellate ganglion is extensively connected with the cerebral cortex, hypothalamus, amygdala and hippocampus [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. SGB can effectively treat postherpetic neuralgia, hot flushes and night awakenings in survivors of breast cancer, tension headache and PTSD, in part by improving blood supply and inhibiting the connection between the stellate ganglion and the brain through sympathetic action within its innervation; however, the exact mechanism remains unclear [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR30 CR31\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Low melatonin levels have been reported in migraine patients and SGB has been shown to restore melatonin rhythm. Melatonin can effectively prevent migraines by inhibiting the synthesis of nitric oxide and the release of calcitonin-related peptides and antagonizing excitotoxicity caused by glutamate [\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In addition, stress is the most common migraine trigger. In response to stress, sympathetic activity increases, leading to the release of migraine-associated neurotransmitters, such as dopamine and prostaglandins [\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. High dopamine levels can lead to nausea and vomiting, while increased prostaglandins can increase pain sensitivity and inflammation in migraine patients. SGB can regulate sympathetic nerve activity, thereby alleviating most of the symptoms in migraine patients.\u003c/p\u003e \u003cp\u003eMIDAS was designed to quantify headache-related disability over 3 months. The reliability and internal consistency of the MIDAS score are comparable to those of a previous questionnaire (Headache Impact Questionnaire). However, the MIDAS score requires fewer questions, is easier to score and provides intuitively meaningful information on lost days of activity in three domains [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. The MIDAS questionnaire was considered highly reliable and effective and was relevant to clinical judgment on medical care needs. In our study, the MIDAS score of patients was significantly decreased at 3-months follow-up. Besides, NRS scores decreased significantly one day and 3 months after SGB. The frequency of analgesic use was also significantly decreased after 3 months. These results suggest that SGB once a week for 4 weeks can reduce the headache and disability among migraine patients and improve their work and quality of life.\u003c/p\u003e \u003cp\u003eTwo patients who were recruited but not included in the analysis experienced migraine aggravation after a single SGB treatment, suggesting that migraine has more complex mechanisms. Wulf et al. detailed complications after SGB. Most of them were related to the central nervous system (such as convulsions). Other serious complications included high-level subarachnoid block, high-level epidural block, pneumothorax and allergic reaction. All SGBs were performed without fluoroscopy [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. In our study, serious complications such as subarachnoid block, epidural block and convulsion were not observed. It is suggested that ultrasound-guided SGB is safer than fluoroscopy because ultrasound can clearly distinguish nerves, blood vessels and muscles, and monitor the puncture needle in real-time, while fluoroscopy has no such functions.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn summary, the findings of this study suggest that real-time ultrasound-guided SGB may be an effective treatment option for migraine patients without serious complications. However, further studies should be performed to verify this hypothesis.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThis study was not a randomized controlled study, and only a few cases were included.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the ethics committee of Shanghai Sixth People\u0026rsquo;s Hospital (No. 2016-44) and registered in the Chinese Clinical Trial Registry (Identifier: ChiCTR-IOR-17011536). All subjects were from Shanghai Sixth People\u0026rsquo;s Hospital and Shanghai Eighth People\u0026rsquo;s Hospital. All procedures involving human studies were following the ethical standards of the national research committee. Written informed consent was obtained from all subjects according to the Helsinki declaration. All medical records were anonymous and no subject information was extracted except for the study purpose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo conflict of interest exits in the submission of this manuscript, and manuscript is approved by all authors for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are willing to share individual deidentified participant data, such as the age of the subjects and MAIDS score and NRS score. We will share the data within three months after the accept of the article and keep it for at least three years. The data can be accessible at\u0026nbsp;\u003ca href=\"https://weibo.com/u/2759448832/home\"\u003ehttps://weibo.com/u/2759448832/home\u003c/a\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported through a grant from Shanghai Municipal Health Commission, No. 201840248\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJiawei Hou wrote the main manuscript text. Xingguo Xu was responsible for data statistics. Shaofeng Pu and Zhiqiang Lu were responsible for patient recruitment. Junzheng Wu and Zhiqiang Lu were responsible for puncture operation and figures 1-3. Junzheng Wu was responsible for article check. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe gratefully acknowledge Xuan Chen for her comments on the manuscript.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCollaborators GBDMM. Global, regional, and national levels of maternal mortality, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1775\u0026ndash;812.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilberstein SD. Migraine. Lancet. 2004;363:381\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurch RC, Buse DC, Lipton RB. Migraine: Epidemiology, Burden, and Comorbidity. Neurologic clinics. 2019;37:631\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoon S, Lee J, Jeon Y. Bilateral stellate ganglion block for migraine: A case report. Medicine. 2020;99:e20023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLynch JH, Mulvaney SW, Kim EH, et al. Effect of Stellate Ganglion Block on Specific Symptom Clusters for Treatment of Post-Traumatic Stress Disorder. Military medicine. 2016;181:1135\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark MW, Lee SU, Kwon S, et al. Comparison Between the Effectiveness of Complex Decongestive Therapy and Stellate Ganglion Block in Patients with Breast Cancer-Related Lymphedema: A Randomized Controlled Study. Pain physician. 2019;22:255\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAeschbach A, Mekhail NA. Common nerve blocks in chronic pain management. Anesthesiology clinics of North America. 2000;18:429-59, viii.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNarouze S. Ultrasound-guided stellate ganglion block: safety and efficacy. Current pain and headache reports. 2014;18:424.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSlappendel R, Thijssen HO, Crul BJ, et al. The stellate ganglion in magnetic resonance imaging: a quantification of the anatomic variability. Anesthesiology. 1995;83:424\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu Q, Zheng E, Li X, et al. Ultrasound image guided lateral cervical approach to stellate ganglion block for cervical headache. Neuroscience letters. 2020;735:135139.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeadache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia: an international journal of headache. 2018;38:1-211.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStewart WF, Lipton RB, Kolodner KB, et al. 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Behavioral treatments for migraine management: useful at each step of migraine care. Current neurology and neuroscience reports. 2015;15:14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDach F, Eckeli AL, Ferreira Kdos S, et al. Nerve block for the treatment of headaches and cranial neuralgias - a practical approach. Headache. 2015;55 Suppl 1:59\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllen SM, Mookadam F, Cha SS, et al. Greater Occipital Nerve Block for Acute Treatment of Migraine Headache: A Large Retrospective Cohort Study. Journal of the American Board of Family Medicine: JABFM. 2018;31:211\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi J, Yin Y, Ye L, et al. Pulsed radiofrequency of C2 dorsal root ganglion under ultrasound guidance for chronic migraine: a case report. Journal of pain research. 2018;11:1915\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaposio E, Bertozzi N. Trigger Site Inactivation for the Surgical Therapy of Occipital Migraine and Tension-type Headache: Our Experience and Review of the Literature. Plastic and reconstructive surgery Global open. 2019;7:e2507.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLehmann LJ, Warfield CA, Bajwa ZH. Migraine headache following stellate ganglion block for reflex sympathetic dystrophy. Headache. 1996;36:335\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElmofty DH, Eckmann M. Do not follow the bone, follow the nerve ultrasound-guided stellate ganglion block: a reconfirmation. British journal of pain. 2019;13:226\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark DY, Kang S, Kang HJ, et al. Impact of Neck Position on the Probability of Common Carotid Artery Puncture During Ultrasound-Guided Stellate Ganglion Block. PM \u0026amp; R: the journal of injury, function, and rehabilitation. 2019;11:463\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee MH, Kim KY, Song JH, et al. Minimal volume of local anesthetic required for an ultrasound-guided SGB. Pain medicine. 2012;13:1381\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoo Y, Lee CS, Kim YC, et al. A Randomized Comparison between 4, 6 and 8 mL of Local Anesthetic for Ultrasound-Guided Stellate Ganglion Block. Journal of clinical medicine. 2019;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWesterhaus MJ, Loewy AD. Central representation of the sympathetic nervous system in the cerebral cortex. Brain research. 2001;903:117\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMakharita MY, Amr YM, El-Bayoumy Y. Effect of early stellate ganglion blockade for facial pain from acute herpes zoster and incidence of postherpetic neuralgia. Pain physician. 2012;15:467\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLipov EG, Joshi JR, Sanders S, et al. Effects of stellate-ganglion block on hot flushes and night awakenings in survivors of breast cancer: a pilot study. The Lancet Oncology. 2008;9:523\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUeshima H. A successful case of stellate ganglion block for difficult therapy of refractory tension headache. Journal of clinical anesthesia. 2019;54:149.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLipov EG, Navaie M, Brown PR, et al. Stellate ganglion block improves refractory post-traumatic stress disorder and associated memory dysfunction: a case report and systematic literature review. Military medicine. 2013;178:e260-4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLong R, Zhu Y, Zhou S. Therapeutic role of melatonin in migraine prophylaxis: A systematic review. Medicine. 2019;98:e14099.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUchida K, Tateda T, Hino H. Novel mechanism of action hypothesized for stellate ganglion block related to melatonin. Medical hypotheses. 2002;59:446\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiano S, Parisi P, Pelliccia A, et al. Melatonin to prevent migraine or tension-type headache in children. Neurological sciences: official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology. 2008;29:285\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSherbourne CD, Gonzales R, Goldyne ME, et al. Norepinephrine-induced increase in sympathetic neuron-derived prostaglandins is independent of neuronal release mechanisms. Neuroscience letters. 1992;139:188\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSheridan DC, Laurie A, Pacheco S, et al. Relative Effectiveness of Dopamine Antagonists for Pediatric Migraine in the Emergency Department. Pediatric emergency care. 2018;34:165\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAntonova M, Wienecke T, Olesen J, et al. Prostaglandins in migraine: update. Current opinion in neurology. 2013;26:269\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStewart WF, Lipton RB, Whyte J, et al. An international study to assess reliability of the Migraine Disability Assessment (MIDAS) score. Neurology. 1999;53:988\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFord JH, Jackson J, Milligan G, et al. A Real-World Analysis of Migraine: A Cross-Sectional Study of Disease Burden and Treatment Patterns. Headache. 2017;57:1532\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWulf H, Maier C. [Complications and side effects of stellate ganglion blockade. Results of a questionnaire survey]. Der Anaesthesist. 1992;41:146\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Demographic Characteristics.\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.11552346570397%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.1985559566787%\"\u003e\n \u003cp\u003eFrequency (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"30.685920577617328%\"\u003e\n \u003cp\u003eProportion (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.11552346570397%\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.1985559566787%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"30.685920577617328%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.11552346570397%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.1985559566787%\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"30.685920577617328%\"\u003e\n \u003cp\u003e71.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.11552346570397%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.1985559566787%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"30.685920577617328%\"\u003e\n \u003cp\u003e28.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.11552346570397%\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.1985559566787%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"30.685920577617328%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.11552346570397%\"\u003e\n \u003cp\u003e18-28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.1985559566787%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"30.685920577617328%\"\u003e\n \u003cp\u003e23.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.11552346570397%\"\u003e\n \u003cp\u003e29-38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.1985559566787%\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"30.685920577617328%\"\u003e\n \u003cp\u003e56.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.11552346570397%\"\u003e\n \u003cp\u003e39-48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.1985559566787%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"30.685920577617328%\"\u003e\n \u003cp\u003e14.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.11552346570397%\"\u003e\n \u003cp\u003e＞48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.1985559566787%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"30.685920577617328%\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003eFrequency of severe headache pre quarter (NRS＞7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.11552346570397%\"\u003e\n \u003cp\u003e＜3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.1985559566787%\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"30.685920577617328%\"\u003e\n \u003cp\u003e21.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.11552346570397%\"\u003e\n \u003cp\u003e3-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.1985559566787%\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"30.685920577617328%\"\u003e\n \u003cp\u003e54.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.11552346570397%\"\u003e\n \u003cp\u003e7-12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.1985559566787%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"30.685920577617328%\"\u003e\n \u003cp\u003e13.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.11552346570397%\"\u003e\n \u003cp\u003e＞12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.1985559566787%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"30.685920577617328%\"\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp id=\"isPasted\"\u003eTable 2. Migraine outcomes as assessed by the MIDAS questionnaire\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eMIDAS mean\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eSGB\u0026nbsp;(n=81)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eTb\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTm\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eZ-Value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ep-Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e17.52\u0026plusmn;9.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.12\u0026plusmn;4.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.553\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOn how many days in the last 3 months did you miss work or school because of your headaches?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.96\u0026plusmn;0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.18\u0026plusmn;0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.781\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHow many days in the last 3 months was your productivity at work or school reduced by half or more because of your headaches?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e4.15\u0026plusmn;2.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.21\u0026plusmn;1.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.955\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOn how many days in the last 3 months did you not do household work because of your headaches?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e3.70\u0026plusmn;2.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.22\u0026plusmn;1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.026\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHow many days in the last 3 months was your productivity in household work reduced by half or more because of your headaches?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e6.76\u0026plusmn;4.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.32\u0026plusmn;1.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.656\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOn how many days in the last 3 months did you miss family, social, or leisure activities because of your headaches?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1.85\u0026plusmn;1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.98\u0026plusmn;0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.276\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTb: Baseline, Tm: Three-months follow-up. MIDAS: Migraine Disability Assessment Scale. SGB: stellate ganglion block.\u003c/p\u003e\n\u003cp id=\"isPasted\"\u003eTable 3. NRS of migraine\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003eTb (Baseline)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003eTd (24h after treatment)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003eTm (3 months follow-up)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003eNRS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e6.91\u0026plusmn;1.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e2.84\u0026plusmn;1.57\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e2.27\u0026plusmn;1.52\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eValues present the mean\u0026plusmn;SD; \u003csup\u003e*\u003c/sup\u003ep\u0026lt;0.01, vs NRS at baseline; NRS, numeric pain scale.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ultrasound guidance, Stellate ganglion block (SGB), Migraine, XYZ","lastPublishedDoi":"10.21203/rs.3.rs-1122553/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1122553/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective. \u003c/strong\u003eTo observe whether ultrasound-guided stellate ganglion block (SGB) can effectively relieve migraine pain and improve the quality of migraine patients’ life.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods. \u003c/strong\u003e81 patients with migraines were enrolled in this trial. The patients received SGB with 6 ml of 0.15% ropivacaine once every week for four times. Migraine was assessed with the Migraine Disability Assessment Scale (MIDAS) at baseline and three-months follow-up (Tm). The numerical rating scale (NRS) score at baseline, one day after treatment (Td) and Tm, the frequency of analgesic use in 3 months and the side effects were also recorded at the same time.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults. \u003c/strong\u003eThe NRS score of migraine subjects decreased significantly from 7.0 (2.0) to 3.0 (1.0) at Td and 2.0 (2.0) at Tm (vs baseline, P\u0026lt;0.01). The MIDAS total scores were 14.0 (10.5) at baseline and 7.0 (4.5) at Tm (P\u0026lt;0.001). During the three months, the frequency of analgesic consumption was decreased from 6.2 ± 2.8 to 1.9±1.8. There were no serious side effects. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions. \u003c/strong\u003eThis study confirmed that ultrasound-guided SGB is an effective method to treat migraines. This technique can reduce pain and disability and then improve the quality of life of patients with migraines.\u003c/p\u003e","manuscriptTitle":"Real-Time Ultrasound-Guided Stellate Ganglion Block for Migraine: An Observational Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-12-20 15:56:53","doi":"10.21203/rs.3.rs-1122553/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-02-28T05:44:26+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-02-27T16:50:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-12-29T15:02:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73a7547e-9206-45df-8a2f-7cfbcaf71dca","date":"2021-12-20T12:51:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-12-20T03:06:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-12-20T02:54:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-12-17T00:01:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-12-16T23:53:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Anesthesiology","date":"2021-11-29T04:38:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d8d34d16-de7f-43c2-8440-91c45dc2b992","owner":[],"postedDate":"December 20th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":9266423,"name":"Anesthesiology \u0026 Pain Medicine"}],"tags":[],"updatedAt":"2022-03-24T23:49:08+00:00","versionOfRecord":{"articleIdentity":"rs-1122553","link":"https://doi.org/10.1186/s12871-022-01622-8","journal":{"identity":"bmc-anesthesiology","isVorOnly":false,"title":"BMC Anesthesiology"},"publishedOn":"2022-03-24 23:49:08","publishedOnDateReadable":"March 24th, 2022"},"versionCreatedAt":"2021-12-20 15:56:53","video":"","vorDoi":"10.1186/s12871-022-01622-8","vorDoiUrl":"https://doi.org/10.1186/s12871-022-01622-8","workflowStages":[]},"version":"v1","identity":"rs-1122553","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1122553","identity":"rs-1122553","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}