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19 Articles in Volume 20, Issue #2
20/20 with Peter Staats, MD: The Future of Pain Medicine
Ask the APP: How useful and practical are pain assessment tools?
Ask the PharmD: What are the recommendations for preventing and treating pediatric migraine?
Axial Spondyloarthritis: Updated Medication and Imaging Recommendations
CGRP Monoclonal Antibodies for Chronic Migraine Prevention: Evaluation of Adverse Effects Using A Checklist
Chronic Low Back Pain: Can We Find a Treatment Consensus?
Correspondence: Are ESIs Still Worth It? Benzocaine for Orofacial Pain.
Could Pulsed RF Provide Lasting Chronic Headache Relief in Refractory Patients?
Diagnosis Is Everything: Low Back Pain As a Symptom of an Underlying Condition or Conditions
Editorial: From Just Say No, to Say Now and Say Know
Erenumab and Onabotulinumtoxin A Show Additive Effect in Refractory Chronic Migraine
Experts Roundtable: Finding a Bottom Line in Back Pain Care
Inside the Potential of RNAi to Target the Etiology of hATTR Neuropathy
Muscle Dysfunction in Head and Neck: Pain Causes, Osteopathic Options
New Migraine Medications: Oral Gepants, Ditan Tablet, and More
Root Cause of Sacroiliac Joint Dysfunction: Four-Step Exercise Protocol
The Emotional Impact of Chronic Low Back Pain
The Rise in Tianeptine Abuse: Our Next Kratom Problem?
The Sensory Component of Pain: Modifying Its Emotional and Cognitive Meaning

Could Pulsed RF Provide Lasting Chronic Headache Relief in Refractory Patients?

Pulsed radiofrequency may be effective in relieving some head pain and extending the effect of a nerve block.
Pages 59-60


While chronic headache disorders such as cluster headache and migraine are common, they are also largely underestimated and difficult to treat. Many patients experience a poor response to pharmacologic treatment because of inadequate analgesia, intolerable side effects, or the development of drug tolerance.1

Prevention strategies may reduce headache frequency, but a low percentage of patients who are candidates for prophylactic treatment actually receive it.2 The new class of calcitonin gene-related peptide (CGRP) antagonists offers a new pharmacological option in terms of reducing monthly migraine days with minimally significant side effects, but long-term impact remains to be determined (more on this drug class on page 48).3

Neuromodulation is increasingly being developed as an alternative to target central or peripheral nerves or dorsal root ganglia. (Image: iStock)

Regarding interventional treatments, neuromodulation is increasingly being developed as an alternative to target central or peripheral nerves or dorsal root ganglia.4 Peripheral nerve blocks are frequently used and generally effective, safe, and well tolerated; however, injections must be repeated every few weeks, making them unpopular among some patients. Pulsed radiofrequency (PRF) has been shown to be effective in relieving some head pain and extending the effect of a nerve block.

Pulsed Radiofrequency as an Emerging Intervention

Sluijter first described PRF in 1997 as a treatment for various types of neuropathic pain, but the technique has since become part of the clinician’s armamentarium of minimally invasive options for conditions ranging from occipital neuralgia to chronic ankle instability.5-7 PRF works by delivering an electrical field and heat bursts to targeted nerves or tissues without damaging these structures.6 Conventional radiofrequency (RF) exposes target nerves or tissues to continuous electrical stimulation and ablates the structures by increasing the temperature around the RF needle tip. In contrast to conventional RF, PRF applies brief electrical stimulation followed by a long resting phase, which does not produce sufficient heat to result in structural damage. The proposed mechanism of PRF is that its produced electrical field can alter pain signals and decrease the activity of microglia and pro-inflammatory cytokines.6

Studies of PRF treatment have demonstrated its effectiveness on alleviating neuralgia and joint pain not responding to conventional therapies.6 When applied to the greater occipital nerve (GON), PRF has also shown efficacy in managing various types of headaches, including occipital neuralgia, cervicogenic headache (CHA), and intracranial hypotension headache. However, little is known about the effect of this technique on managing chronic headaches such as migraine. A 2018 report of two refractory migraine cases successfully treated with ultrasound-guided PRF applied to the GON showed relief of pain for 3 months with no adverse effects.8

In a recent study by Li and colleagues, 20 patients with chronic headache who did not respond to medication or peripheral nerve blocks were treated with ultrasound-guided PRF of the C2 dorsal root ganglion (DRG), an optimal site for occipital nerve regulation.9 PRF was then applied along with an injection of corticosteroids.

PRF has provided long-term pain relief in various chronic pain conditions under chromatography (CT) or C-arm guidance to assure accuracy and safety. Visualizing the nerve with ultrasound increases accuracy of the procedure and may help to avoid complications such as bleeding, tissue injury, and infection. According to Li and colleagues, ultrasound is preferable over x-ray or CT because it avoids radiation exposure and can visualize not only the dorsal root nerve and atlantoaxial joint, but can also help to identify the blood vessels accompanying the nerve and the vertebral artery that runs alongside the atlantoaxial joint.10 This approach may help to avoid vascular injury, especially to the vertebral artery. In Li’s study, the technical success rate was 100%, and the technique was effective in 93.4% of cases (P < 0.0009). Brief pain inventory (BPI) scores decreased throughout the 6-month follow-up compared to pre-operative baseline (45.05 ± 3.437). BPI scores were 10.06 ± 2.37 at 1 week; 12.50 ± 2.46 at 1 month; 12.90 ± 2.62 at 3 months; and 11.63 ± 2.98 at 6 months (P < 0.05 for all).9

A previous case report by Li’s group published in 2018 described a patient with chronic migraine and occipital pain who was successfully treated with C2 DRG PRF. During the 1-year follow-up, the patient remained pain-free with no major side effects and was able to return to full-time work.10

In Context

To put the findings into context, a 2015 review of 25 studies found that of five non-randomized trials that met inclusion criteria, only three showed RF ablation and only one showed PRF as an effective intervention for CHA. Of four randomized trials in the group of 25, only two were high quality, only three investigated RF ablation as an intervention for CHA, and only 1 investigated PRF ablation as an intervention for CHA; none of the randomized studies showed strong evidence for RF and PRF ablation as an effective intervention for CHA.11 

Last updated on: May 14, 2020
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Erenumab and Onabotulinumtoxin A Show Additive Effect in Refractory Chronic Migraine
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