Interventional Approaches to the Management of Headache and Neck Pain Gennady Gekht, MD
The Cleveland Clinic
Targets for intervention:Convergence Theory • Caudal portion of the trigeminal nucleus receives input from the upper cervical nerves, creating convergence of cervical and trigeminal afferents • Convergence of sensory inputs from cervical nerves C1C3 with trigeminal afferents, results in the perception of headache consequent to cervical irritation and vice versa
Bogduk N. Curr Pain Headache Rep. 2001;5:382-386
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Pain Generators : Cervical Afferents • • • • • •
C2 Ganglion and AA joint Third Occipital Nerve Cervical Facet Joints Greater and Lesser Occipital nerve Cervical Discs Cervical musculuture
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Experimental Basis for Convergence Theory Headache reproduced in volunteers by noxious stimuli applied primarily to structures innervated by C1-C3 Injection of hypertonic saline into suboccipital muscles of volunteers resulted in referred pain to the head causing headaches Distension of the atlanto-occipital, atlanto-axial and C2-C3 facet joints resulted in pain perceived in the occipital and suboccipital areas. Bogduk N. Curr Pain Headache Rep. 2001;5:382-386 Dreyfuss P et al. Spine. 1994;19:1125-1131 Grubb SA, Kelly CK. Spine. 2000;25:1382-1389
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Occipital Nerves
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Occipital Nerve Blocks • Injection of depot methylprednisolone in the vicinity of the GON (a branch of the dorsal ramus of C2) and the LON (a branch of the dorsal ramus of C3) resulted in excellent headache relief in the majority of idiopathic cervicogenic headache patients • Similar results were obtained with migraine and cluster headache patients subjected to the same treatment in an uncontrolled study by Anthony et al. • However, blocks are short-lasting
Anthony M. Clin Exp Rheumatol. 2000;18:S59-S64 Bovim G, Sand T. Pain. 1992;51:43-48 Gawel MJ, Rothbart PJ. Cephalalgia. 1992;12:9-13
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Occipital Nerve Neurolysis • Permanent neuroablative approaches: • surgery (decompression or neurolysis) • Cryoneurolysis • radiofrequency ablation
• Definite improvement is seen in only one third of surgical patients • U/S guidance and advances in radiofrequency needles will most likely improve outcomes, however this needs to be studied
Austad ED. Plast Reconstr Surg. 2000;105:2600-2603. Silverman SB. Curr Pain Headache Rep. 2002;6:308-314. Blume H et al. Appl Neurophysiol. 1982;45:543-548.
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Lateral Atlanto-Axial Joint
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Figure 4
A. Lateral view showing the tip of the needle and the contrast agent within the lateral AA joint The Cleveland Clinic
AP View
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A. AP view showing the tip of the needle and the contrast agent within the lateral AA joint
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Third Occipital Nerve Blockade Blockade of the third occipital nerve resulted in pain relief in over 50% of patients with cervicogenic headaches occurring following whiplash injury
Lord SM et al. J Neurol Neurosurg Psychiatry. 1994;57:1187-1190
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Third Occipital Nerve Radiofrequency Ablation
• RFA total relief of pain with a median duration of 297 days in 88% of the patients • Side effects to ablation of the third occipital nerve include mild ataxia, numbness and dysesthesia
Lord SM et al. Neurosurgery. 1995;36:732-739 Govind et al. J Neurol Neurosurg Psychiatry 2003;74:88-93
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Sphenopalatine Ganglion
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Anatomy of the Sphenopalatine Ganglion The Cleveland Clinic
