Chronic Headache: a Review of Interventional Treatment Strategies in Headache Management

  • Ruchir Gupta
  • Kyle Fisher
  • Srinivas PyatiEmail author
Chronic Daily Headache (SJ Wang, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Chronic Daily Headache


Purpose of the Review

To provide an overview of current interventional pain management techniques for primary headaches with a focus on peripheral nerve stimulation and nerve blocks.

Recent Findings

Despite a plethora of treatment modalities, some forms of headaches remain intractable to conservative therapies. Interventional pain modalities have found a niche in treating headaches. Individuals resistant to common regimens, intolerant to pharmaceutical agents, or those with co-morbid factors that cause interactions with their therapies are some instances where interventions could be considered in the therapeutic algorithm. In this review, we will discuss these techniques including peripheral nerve stimulation, third occipital nerve block (TON), lesser occipital nerve block (LON), greater occipital nerve block (GON), sphenopalatine block (SPG), radiofrequency ablation (RFA), and cervical epidural steroid injections (CESI).


Physicians have used several interventional techniques to treat primary headaches. While many can be treated pharmacologically, those who continue to suffer from refractory or severe headaches may see tremendous benefit from a range of more invasive treatments which focus on directly inhibiting the painful nerves. While there is a plethora of evidence suggesting these methods are effective and possibly durable interventions, there is still a need for large, prospective, randomized trials to clearly demonstrate their efficacy.


Cervicogenic headache Peripheral nerve stimulation Radiofrequency ablation Greater occipital nerve block Lesser occipital nerve block Sphenopalatine block 


Compliance with Ethics Guidelines

Conflict of Interest

Ruchir Gupta, Kyle Fisher, and Srinivas Pyati declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Ahmed F. Headache disorders: differentiating and managing the common subtypes. Br J Pain. 2012;6(3):124–32.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Wahezi SE, Silva K, Shaparin N, Lederman A, Emam M, Haramati N, et al. Currently recommended TON Injectate volumes concomitantly block the GON: clinical implications for managing cervicogenic headache. Pain Physician. 2016;19(7):E1079–86.PubMedGoogle Scholar
  3. 3.
    •• Levin M. The International Classification of Headache Disorders, (ICHD III)–changes and challenges. Headache. 2013;53(8):1383–95. This artcle provides rationale behind ICHD classification, a guide to its use; and summary of improtant diagniostic features. Google Scholar
  4. 4.
    Nelson S, Taylor LP. Headaches in brain tumor patients: primary or secondary? Headache. 2014;54(4):776–85.PubMedGoogle Scholar
  5. 5.
    Lipton R, Bigal M, Steiner T, Silberstein S, Olesen J. Classification of primary headaches. Neurology. 2004;63(3):427–35.PubMedGoogle Scholar
  6. 6.
    Franco AL, Gonçalves DA, Castanharo SM, Speciali JG, Bigal ME, Camparis CM. Migraine is the most prevalent primary headache in individuals with temporomandibular disorders. J Orofac Pain. 2010;24(3).Google Scholar
  7. 7.
    •• Becker WJ. Cervicogenic headache: evidence that the neck is a pain generator. Headache. 2010;50(4):699–705. This article takes a pro stance that abnormalities in the neck is a significant source of headache, particlarly the upper cervical zygophyseal joints. PubMedGoogle Scholar
  8. 8.
    Becker G, Blum HE. Novel opioid antagonists for opioid-induced bowel dysfunction and postoperative ileus. Lancet. 2009;373(9670):1198–206.PubMedGoogle Scholar
  9. 9.
    Bogduk N, Windsor M, Inglis A. The innervation of the cervical intervertebral discs. Spine (Phila Pa 1976). 1988;13(1):2–8.Google Scholar
  10. 10.
    Wu B, Yang L, Peng B. Ingrowth of nociceptive receptors into diseased cervical intervertebral disc is associated with discogenic neck pain. Pain Med. 2019.Google Scholar
  11. 11.
    • Peng B, Bogduk N. Cervical discs as a source of neck pain. An analysis of the evidence. Pain Med. 2019;20(3):446–55. This article describes basic science evidence that cervical discs contain nociceptive innervation and potentially be an important source of neck pain. PubMedGoogle Scholar
  12. 12.
    Özge A, Termine C, Antonaci F, Natriashvili S, Guidetti V, Wöber-Bingöl C. Overview of diagnosis and management of paediatric headache. Part I: diagnosis. J Headache Pain. 2011;12(1):13–23.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Koehler PJ, Boes CJ. A history of non-drug treatment in headache, particularly migraine. Brain. 2010;133(8):2489–500.PubMedGoogle Scholar
  14. 14.
    •• Silberstein SD, Dodick DW, Saper J, Huh B, Slavin KV, Sharan A, et al. Safety and efficacy of peripheral nerve stimulation of the occipital nerves for the management of chronic migraine: results from a randomized, multicenter, double-blinded, controlled study. Cephalalgia. 2012;32(16):1165–79. In a randomized study investigators demonstrate that there was no difference between active and control group as far as PNS is concerned but showed 30% reduction (as opposed to 50%) in pain, decrease in headache days and improvement in diasbility. PubMedGoogle Scholar
  15. 15.
    Popeney CA, Aló KM. Peripheral neurostimulation for the treatment of chronic, disabling transformed migraine. Headache. 2003;43(4):369–75.PubMedGoogle Scholar
  16. 16.
    Matharu MS, Bartsch T, Ward N, Frackowiak RS, Weiner R, Goadsby PJ. Central neuromodulation in chronic migraine patients with suboccipital stimulators: a PET study. Brain. 2004;127(1):220–30.PubMedGoogle Scholar
  17. 17.
    Schwedt T, Dodick D, Hentz J, Trentman T, Zimmerman R. Occipital nerve stimulation for chronic headache—long-term safety and efficacy. Cephalalgia. 2007;27(2):153–7.PubMedGoogle Scholar
  18. 18.
    Saper JR, Dodick DW, Silberstein SD, McCarville S, Sun M, Goadsby PJ, et al. Occipital nerve stimulation for the treatment of intractable chronic migraine headache: ONSTIM feasibility study. Cephalalgia. 2011;31(3):271–85.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Dworkin RH, Turk DC, Wyrwich KW, Beaton D, Cleeland CS, Farrar JT, et al. Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. J Pain. 2008;9(2):105–21.PubMedGoogle Scholar
  20. 20.
    •• Mekhail NA, Estemalik E, Azer G, Davis K, Tepper SJ. Safety and efficacy of occipital nerves stimulation for the treatment of chronic migraines: randomized, double-blind, controlled single-center experience. Pain Pract. 2017;17(5):669–77. This study showed 60% of patients received atleast 30 % reduction in pain at 52 weeks for chronic migraine, albeit in a smaller study of 20 patients. PubMedGoogle Scholar
  21. 21.
    •• Dodick DW, Silberstein SD, Reed KL, Deer TR, Slavin KV, Huh B, et al. Safety and efficacy of peripheral nerve stimulation of the occipital nerves for the management of chronic migraine: long-term results from a randomized, multicenter, double-blinded, controlled study. Cephalalgia. 2015;35(4):344–58. This is a long-term follow up study of Silberstein et al showing larger percentage patients received 30% pain relief but 70% of patients expericnced an adverse event during 12-month follow up. PubMedGoogle Scholar
  22. 22.
    Fontaine D, Blond S, Lucas C, Regis J, Donnet A, Derrey S, et al. Occipital nerve stimulation improves the quality of life in medically-intractable chronic cluster headache: results of an observational prospective study. Cephalalgia. 2017;37(12):1173–9.PubMedGoogle Scholar
  23. 23.
    Rodrigo D, Acin P, Bermejo P. Occipital nerve stimulation for refractory chronic migraine: results of a long-term prospective study. Pain Physician. 2017;20(1):E151–E9.PubMedGoogle Scholar
  24. 24.
    Miller S, Watkins L, Matharu M. Long-term outcomes of occipital nerve stimulation for chronic migraine: a cohort of 53 patients. J Headache Pain. 2016;17(1):68.PubMedPubMedCentralGoogle Scholar
  25. 25.
    Levin M. Nerve blocks in the treatment of headache. Neurotherapeutics. 2010;7(2):197–203.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Ashkenazi A, Matro R, Shaw JW, Abbas MA, Silberstein SD. Greater occipital nerve block using local anaesthetics alone or with triamcinolone for transformed migraine: a randomised comparative study. J Neurol Neurosurg Psychiatry. 2008;79(4):415–7.PubMedGoogle Scholar
  27. 27.
    Naja ZM, El-Rajab M, Al-Tannir MA, Ziade FM, Tawfik OM. Occipital nerve blockade for cervicogenic headache: a double-blind randomized controlled clinical trial. Pain Pract. 2006;6(2):89–95.PubMedGoogle Scholar
  28. 28.
    •• Schoenen J, Jensen RH, Lanteri-Minet M, Láinez MJ, Gaul C, Goodman AM, et al. Stimulation of the sphenopalatine ganglion (SPG) for cluster headache treatment. Pathway CH-1: a randomized, sham-controlled study. Cephalalgia. 2013;33(10):816–30. This study showed 67% reduction in pain (vs 7.4%) with full stimulation on demand with acceptable safety profile. PubMedPubMedCentralGoogle Scholar
  29. 29.
    Narouze SN. Role of sphenopalatine ganglion neuroablation in the management of cluster headache. Curr Pain Headache Rep. 2010;14(2):160–3.PubMedGoogle Scholar
  30. 30.
    Sanders M, Zuurmond WW. Efficacy of sphenopalatine ganglion blockade in 66 patients suffering from cluster headache: a 12- to 70-month follow-up evaluation. J Neurosurg. 1997;87(6):876–80.PubMedGoogle Scholar
  31. 31.
    Narouze S, Kapural L, Casanova J, Mekhail N. Sphenopalatine ganglion radiofrequency ablation for the management of chronic cluster headache. Headache. 2009;49(4):571–7.PubMedGoogle Scholar
  32. 32.
    Salar G, Ori C, Iob I, Fiore D. Percutaneous thermocoagulation for sphenopalatine ganglion neuralgia. Acta Neurochir. 1987;84(1–2):24–8.PubMedGoogle Scholar
  33. 33.
    Costa A, Pucci E, Antonaci F, Sances G, Granella F, Broich G, et al. The effect of intranasal cocaine and lidocaine on nitroglycerin-induced attacks in cluster headache. Cephalalgia. 2000;20(2):85–91.PubMedGoogle Scholar
  34. 34.
    Ho KWD, Przkora R, Kumar S. Sphenopalatine ganglion: block, radiofrequency ablation and neurostimulation - a systematic review. J Headache Pain. 2017;18(1):118.PubMedPubMedCentralGoogle Scholar
  35. 35.
    Manolitsis N, Elahi F. Pulsed radiofrequency for occipital neuralgia. Pain Physician. 2014;17(6):E709–17.PubMedGoogle Scholar
  36. 36.
    Asopa A. Systematic review of radiofrequency ablation and pulsed radiofrequency for management of cervicogenic headache. Pain Physician. 2015;18:109–30.PubMedGoogle Scholar
  37. 37.
    • Grandhi RK, Kaye AD. Abd-Elsayed a. systematic review of radiofrequency ablation and pulsed radiofrequency for management of cervicogenic headaches. Curr Pain Headache Rep. 2018;22(3):18. This comprehensive review shows that both techniques provide limited benefit and identifies an urgent need for a high quality RCT. PubMedGoogle Scholar
  38. 38.
    Abd-Elsayed A, Kreuger L, Wheeler S, Robillard J, Seeger S, Dulli D. Radiofrequency ablation of pericranial nerves for treating headache conditions: a promising option for patients. Ochsner J. 2018;18(1):59–62.PubMedPubMedCentralGoogle Scholar
  39. 39.
    •• Cohen SP, Peterlin BL, Fulton L, Neely ET, Kurihara C, Gupta A, et al. Randomized, double-blind, comparative-effectiveness study comparing pulsed radiofrequency to steroid injections for occipital neuralgia or migraine with occipital nerve tenderness. Pain. 2015;156(12):2585–94. This study demonstrates greater reduction in pain up to 6 months with PRF compared to steroid injections, but analgesia was not accompanied by improvement in other outcome measures. PubMedPubMedCentralGoogle Scholar
  40. 40.
    Odonkor CA, Tang T, Taftian D, Chhatre A. Bilateral intra-articular radiofrequency ablation for cervicogenic headache. Case Rep Anesthesiol. 2017;2017:1483279.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Fadayomi O, Kendall MC, Nader A. Ultrasound-guided pulsed radiofrequency of C2 dorsal root ganglion as adjuvant treatment for chronic headache disorders: a case report. A A Pract. 2018:1.Google Scholar
  42. 42.
    • Nagar VR, Birthi P, Grider JS, Asopa A. Systematic review of radiofrequency ablation and pulsed radiofrequency for management of cervicogenic headache. Pain Physician. 2015;18(2):109–30. Because of the lack of high quality studies (RCTs) this review showed limited evidence to show the benefit of RFA and PRF for cervicogenic headache. PubMedGoogle Scholar
  43. 43.
    Gabrhelik T, Michalek P, Adamus M. Pulsed radiofrequency therapy versus greater occipital nerve block in the management of refractory cervicogenic headache - a pilot study. Prague Med Rep. 2011;112(4):279–87.PubMedGoogle Scholar
  44. 44.
    Stovner LJ, Kolstad F, Helde G. Radiofrequency denervation of facet joints C2-C6 in cervicogenic headache: a randomized, double-blind, sham-controlled study. Cephalalgia. 2004;24(10):821–30.PubMedGoogle Scholar
  45. 45.
    Haspeslagh SR, Van Suijlekom HA, Lame IE, Kessels AG, van Kleef M, Weber WE. Randomised controlled trial of cervical radiofrequency lesions as a treatment for cervicogenic headache [ISRCTN07444684]. BMC Anesthesiol. 2006;6(1).Google Scholar
  46. 46.
    Lee JB, Park JY, Park J, Lim DJ, Kim SD, Chung HS. Clinical efficacy of radiofrequency cervical zygapophyseal neurotomy in patients with chronic cervicogenic headache. J Korean Med Sci. 2007;22(2):326–9.PubMedPubMedCentralGoogle Scholar
  47. 47.
    van Suijlekom HA, van Kleef M, Barendse GA, Sluijter ME, Sjaastad O, Weber WE. Radiofrequency cervical zygapophyseal joint neurotomy for cervicogenic headache: a prospective study of 15 patients. Funct Neurol. 1998;13(4):297–303.PubMedGoogle Scholar
  48. 48.
    Govind J, King W, Bailey B, Bogduk N. Radiofrequency neurotomy for the treatment of third occipital headache. J Neurol Neurosurg Psychiatry. 2003;74(1):88–93.PubMedPubMedCentralGoogle Scholar
  49. 49.
    •• Wang E, Wang D. Treatment of cervicogenic headache with cervical epidural steroid injection. Curr Pain Headache Rep. 2014;18(9):442. This article describes neuroanatomy, neurophysiology and classification of CGH and comprehensive review of the efficacy of cervical epidural steroid injections. PubMedPubMedCentralGoogle Scholar
  50. 50.
    Martelletti P, Di Sabato F, Granata M, Alampi D, Apponi F, Borgonuovo P, et al. Epidural corticosteroid blockade in cervicogenic headache. Eur Rev Med Pharmacol Sci. 1998;2(1):31–6.PubMedGoogle Scholar
  51. 51.
    He MW, Ni JX, Guo YN, Wang Q, Yang LQ, Liu JJ. Continuous epidural block of the cervical vertebrae for cervicogenic headache. Chin Med J. 2009;122(4):427–30.PubMedGoogle Scholar
  52. 52.
    Mehnert MJ, Freedman MK. Update on the role of z-joint injection and radiofrequency neurotomy for cervicogenic headache. PM R. 2013;5(3):221–7.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of AnesthesiologyStonybrook UniversityStony BrookUSA
  2. 2.Department of AnesthesiaDuke UniversityDurhamUSA
  3. 3.Department of AnesthesiologyDuke University School of Medicine and Durham Veterans Affairs Health SystemsDurhamUSA

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