Temple injection sites. ZTBTN zygomaticotemporal branch of the trigeminal nerve, ATN auriculotemporal nerve
Occipital injection sites. OP occipital protuberance, GON greater occipital nerve, TGON tail of greater occipital nerve, LON lesser occipital nerve, TLON tail of lesser occipital nerve
Frontal injection sites. FH forehead, SON supraorbital nerve, STN supratrochlear nerve
Positioning for occipital injection
8.2 Occipital
Marking on greater occipital nerve (GON) and lesser occipital nerve (LON) is based on anatomical/topographical location of the nerve [2–6] in addition to manual palpation to better target the injection. The LON is found behind the sternocleidomastoid muscle. Ice is applied only after markings are done to not affect tender areas
Markings of the emergence of the LON is shown in the bottom right of the image. As it tracks cephalically, there is another tender area in the mastoid groove which we call the tail of the LON (TGON). The GON is marked lateral and inferior to the occipital protuberance (1.5 cm lateral (this is commonly variable based on palpation) and 3 cm inferior). The distal tail of the GON is above the mastoid area defined by manual palpation, almost always medial to tail of LON
Setup for 155 unit injection (standard dose if all regions are injected). The dosage can be lowered based on the regions injected. It can also be increased to 200 units when more is needed in certain areas, including when the third occipital nerve or the masseter muscle is injected as well. The Botox bottles come in 100 and 200 neurotherapeutic units. Ice packs are used. It is important the skin does not come in direct contact with regular freezer ice or freezer frost to avoid any mycobacterial contamination. The Botox can be mixed between 2.2 and 4 cc per 100 units. Our preference is 4 cc per 100 units. The syringes for the occipital area are 27-gauge 1.5 in. (27 gauge is needed to penetrate the trapezius fascia). The needles for the frontal and temporal region are two 30-gauge 0.5 in. and one 30-guage 1 in.; alcohol, marking pen, and gauze are other equipment needed
Ice pack is placed right before injection to decrease discomfort, which is of upmost importance in patients having active migraines. Increased blood pressure due to pain or an anxiety attack can impede a successful injection session. This also decreases the risk for microhematomas that can increase nerve irritation
The GON is injected deep to the trapezius fascia with the needle moving back and forth constantly in a perimeter of 1 cm. Movement of the needle decreases the chances of direct injection into the nerve. The main trunk requires 25 units on each side (1 mL)
The tail of the GON injection is done through the hair. 2.5 units are injected into the tail on each side. The needle is buried only minimally as the nerve is housed in the limited space between the skin and bone. There are no muscles in this area
Related posts:
Approach for Auriculotemporal Nerve Decompression, Amirlak Modification
Anatomy of Craniofacial Nerves Regarding Migraine Surgery
Anatomy of the Vascularization and Innervation of the Human Scalp
Modification of Site 4 Decompression: Endoscopic Assisted Decompression of the Greater Occipital Nerve (GON) with Radical Excision of the Occipital Artery
of Temporal Trigger Sites
of Occipital Trigger Sites
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