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ORLANDO, Fla. — Adding dexamethasone to occipital nerve block offered no additional reduction in headache days in patients with headache disorders, a new randomized controlled trial showed.

Participants reported approximately 2 fewer headache days per week at 1 week after the nerve block, regardless of dexamethasone use. At 1 month after the nerve block, both groups reported 2.5 fewer headache days per week.

Current American Headache Society practice guidelines advise that steroids are not necessary with occipital nerve blocks, but the guidance is based primarily on studies of particulate steroids, such as triamcinolone, said lead investigator Stephanie J. Steel, MD, general community neurologist and headache subspecialist at the Mayo Clinic Department of Neurology in Rochester, Minnesota.

“Our study suggests that dexamethasone, a nonparticulate steroid, also does not provide additional benefit,” Steel said.

The findings were presented June 6 at the American Headache Society (AHS) Annual Meeting 2026.

Filling a Gap

Occipital nerve blocks are widely used in the treatment of various headache disorders because they are well tolerated and can provide pain relief for days or weeks beyond the duration of the local anesthetic, Steel said.

However, there is no gold standard established for the type of injectate to use. While previous trials have shown no benefit from particulate steroids, no large randomized controlled trials have investigated nonparticulate steroids, specifically dexamethasone.

“Dexamethasone is known to have less adverse effects for local injections, perineural dexamethasone prolongs duration of peripheral nerve blocks in the treatment of other types of pain, and IV dexamethasone for migraine has been shown to reduce headache recurrence in the emergency department,” she said.

To learn more, researchers enrolled 110 participants who received 120 total bilateral occipital nerve blocks with either anesthetic alone (n = 58; mean age, 48.5 years; 88% female) or anesthetic plus dexamethasone (n = 60; mean age, 45 years; 93% female).

All the participants were stable on other headache preventative treatment, and all headache disorders except cluster headache were represented among the patients.

History of nerve block, average monthly headache days, number of headache days or severe headache days in the past week, acute use of medication in the past week, and pre-procedure pain levels were similar between groups.

Sixty of the injections included 2 mL of bupivacaine 0.5%, 0.5 mL of lidocaine 1%, and 0.5 mL of dexamethasone. Two injections were excluded because of loss of randomization, and the other 58 injections included the same amounts of bupivacaine and lidocaine but with 0.5 mL of saline 0.9% instead. The landmark-based technique was used for the occipital nerve blocks.

Telephone follow-ups occurred at 1, 2, and 4 weeks after the procedure and the primary outcome was the number of weekly headache days at each follow-up.

No Differences With Dexamethasone

At 1 week, the dexamethasone group had an average of 1.9 fewer weekly headache days compared to 1.8 fewer weekly headache days in the placebo group (P = .839). The reduction in weekly headache days was identical between groups at 2 weeks (2.3 fewer) and 4 weeks (2.5 fewer).

Reductions in severe headache days also did not differ significantly between the dexamethasone and control groups, with both reporting an average of 2.7 fewer severe headache days at 2 weeks and nearly the same reductions at 4 weeks (2.3 vs 2.4 fewer, respectively). Average headache severity and use of acute medication were also similar between groups.

The researchers examined patients’ response to the nerve block based on the initial location of their headache pain. Forty patients had posterior predominant pain and 78 had anterior or holocephalic pain. Both groups responded similarly at the first follow-up visit with no significant change in headache days or headache severity.

Adverse events were few, with nine patients reporting tenderness to palpation at the injection sites and/or neck soreness that resolved within a few days. Five of those patients received dexamethasone, three received anesthetic alone, and one was lost to follow-up.

Also, one patient in the anesthetic-alone group experienced throat numbness immediately after the block that resolved within hours.

Some Questions Answered, Others Unresolved

These data are helpful in resolving an outstanding question in headache management, said Nan Cheng, MD, assistant professor of neurology at the University of California Irvine, who was not involved in the study.

“In our field for a long time, there’s always been this debate of whether you use steroids or not with these blocks, and I think this goes to show that you don’t have to do it with steroids,” Cheng told Medscape Medical News.

“In my personal practice, I think, ‘why expose a patient to something additional if you can get away with this bare minimum?’” she added. “I think this result is really positive toward lowering the risk that you’re exposing patients to.”

However, Hsiangkuo Yuan, MD, PhD, associate professor of neurology and the clinical research director at Jefferson Headache Center in Philadelphia, noted the study’s relatively short follow-up period.

“There may be a long-term benefit that we don’t see,” said Yuan, who was also not involved in the study. He also pointed out that the dosing was not optimized in the study.

“Maybe there’s a different combination ratio that could happen to be beneficial,” he said. “At this dose, we know the addition of the steroid does not change the 4-week response, but after that or any other combinations we don’t know yet.”

No external funding was noted for the research. Steel reported no disclosures. Cheng reported consulting for AbbVie. Yuan has been a site investigator for Teva, AbbVie, Ipsen, Parema, Pfizer, Shiratronics, and Johnson & Johnson, and he has consulting or advisory board disclosures with Salvia, Pfizer, AbbVie, and Cerenovus.