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Section IconLower Paraspinal Cervical Injections
Low paraspinal cervical injections are thought to work through the dorsal root fibers of the cervical spine by downregulating the trigeminocervical complex efferent output to the higher cortical levels.1-7 Figure 1
Orofacial Pain
Trigeminal Neuralgia
Traumatic Headache
Suspicion for SAH
Meningismus or suspicion of meningitis
Altered Mental Status
Focal Neuro Deficits
Procedure & Administration
With the patient in a seated position, locate the prominent spinous process of C7.
Mark 1 inch lateral to the spinous process on both sides, being sure to stay over the belly of the trapezius muscle overlying the transverse process.
Clean the area with an alcohol swab/chlorhexidine.
Fill a 3-cc syringe with 0.5% bupivacaine.
Using a 1.5-in 23- or 25-gauge needle, inject at your marked location 2 to 3 cm deep, making sure your needle entry is parallel to the floor.
Aspirate to confirm you are not in a vessel. Then inject 1.5 mL of bupivacaine.
Repeat this process at the other marked site.
Withdraw the needle. Then compress and massage the injection site to both stop bleeding and help diffuse the local anesthetic into the tissue.
Dress each site.
Local site irritation
Muscle soreness at site
Discharge Procedure
Patient should be instructed they may have soreness at the injection site.
  1. Mellick GA, Mellick LB. Lower cervical injections for headache relief. Letter. Headache. 2001 Nov–Dec;41(10):992–4.
  2. Mellick GA, Mellick LB. Regional head and face pain relief following lower cervical intramuscular anesthetic injection. Headache. 2003 Nov–Dec;43(10):1109–11.
  3. Noseida R, Burstein R. Migraine pathophysiology: anatomy of the trigeminovascular pathway and associated neurological symptoms, CSD, sensitization and modulation of pain. Pain. 2013 Dec;154 Suppl 1.
  4. Mellick GA, Mellick LB. Lower cervical intramuscular bupivacaine injections – another treatment option for headaches. Business Briefing: Emergency Medicine Review. 2005; 39–42.
  5. Mellick LB, McIlrath ST, Mellick GA. Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections; a 1-year retrospective review of 417 patients. Headache. 2006 Oct;46(9):1441–9.
  6. Hipskind J. Paraspinous cervical nerve block for primary headache. Emerg Med. 2017 April; 49(4):162–5.
  7. Bond C. 2014. Paraspinous cervical block for headache.
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Figure 1

Paraspinous cervical nerve blocks are thought to relieve pain associated with migraine via blockage of nerve fibers near the trigeminocervical complex.

Figure Image 1

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