Management of refractory chronic migraine using ultrasound-guided pulsed radiofrequency of greater occipital nerve

Abstract

Rationale:Although various oral medications and procedures are applied for managing migraine, their efficacy remains limited. To control migraine that does not respond to conventional treatments, we conducted pulsed radiofrequency (PRF) stimulation to the greater occipital nerve (GON) in 2 patients.Patient concerns:Patients 1 and 2 complained of chronic throbbing, pulsating, and tight headaches. Their headache intensities scored 8 and 7 on a numeric rating scale (NRS), respectively. Patient 1 experienced the headache bilaterally in the frontal, retro-orbital, parietal, and occipital regions. The initial onset of the symptoms was more than 15 years ago. Patient 2 complained of headaches in the left frontal, retro-orbital, parietal, and occipital regions, which occurred first more than 14 years ago.Diagnoses:According to the International Classification of Headache Disorder-3 beta criteria, the patients were diagnosed with chronic migraine.Interventions:Oral medications, GON block with bupivacaine and dexamethasone, and botulinum toxin injections did not alleviate the patients’ migraine.The PRF stimulation on GON was performed under the guidance of ultrasound, at 5 Hz and 5-millisecond pulsed width for 360 seconds at 45 V. The electrode tip temperature was maintained at or below 42°C.Outcomes:Two weeks after applying PRF, the pain was reduced to NRS 3 in both patients, who also reported that the headache became bearable after PRF. The effectiveness of PRF on GON lasted for at least 3 months in both patients, and no adverse effects were observed.Lessons:Our findings suggested that the application of PRF on GON can be a useful option for treating refractory chronic migraine.

Pulsed Radiofrequency of the Occipital Nerves: Results of a Standardized Protocol on Chronic Headache Management

“…The active tip creates a large electrical current density, producing heat of 42 -44°C (1-3) around the nerves, modulating the synaptic signaling of the analgesic pathways, exerting its action especially on the C, nonmyelinated pain fibers (7,10). Research suggests that PRF also modulates the early gene c-Fos (7,(11)(12)(13)(14)(15)(16)(17), which is responsible for the development of the second m-RNA, "preprodinorphin", of the endogenous opioid system (1,2,11,13). Research proposes proposed that PRFs analgesic properties are also mediated through the noradrenergic, sero-tonergic, and endogenous opioid inhibitory pain pathways.…”

One-day combined botulinum toxin injections and pulsed radiofrequency of greater occipital nerve for treatment refractory chronic migraine

“…Cases of PRF GON have been described in two young women suffering from refractory migraine. They underwent botulinum therapy according to the PREEEMPT protocol at a dose of 155 units and at the same time a block of GON, then after a negative response, performed PRF GON with success in reducing pain intensity by twice for at least 3 months [28]. Another case of a young 34-year-old woman who suffered from a complex headache of the type of chronic migraine, autonomic cephalgia, and occipital neuralgia.…”

Poststroke Pain

“…106 Botulinum toxin injection, occipital nerve block, and trigger point injections are also available for these two types of headache. 106,107 Recently, Kwak and Chang reported that pulsed radiofrequency stimulation to the greater occipital nerve can effectively manage refractory chronic migraine pain, although these were not specifically stroke-related headaches. 107 Cognitive behavioral therapy, biofeedback, and exercise are also known to be beneficial nonpharmacological options for managing persistent poststroke headache.…”

“…106,107 Recently, Kwak and Chang reported that pulsed radiofrequency stimulation to the greater occipital nerve can effectively manage refractory chronic migraine pain, although these were not specifically stroke-related headaches. 107 Cognitive behavioral therapy, biofeedback, and exercise are also known to be beneficial nonpharmacological options for managing persistent poststroke headache. 105,107 In 2015, Harris et al conducted a systematic review of cognitive behavioral therapy for the treatment of chronic headache in adults, and reviewed 10 randomized controlled trials.…”

“…107 Cognitive behavioral therapy, biofeedback, and exercise are also known to be beneficial nonpharmacological options for managing persistent poststroke headache. 105,107 In 2015, Harris et al conducted a systematic review of cognitive behavioral therapy for the treatment of chronic headache in adults, and reviewed 10 randomized controlled trials. 108 They concluded that cognitive behavioral therapy can be an effective treatment option for reducing the intensity, frequency, and duration of headache.…”