Occurrence of cervicogenic headache following radio-frequency ablation of medial nerve branches for neck pain is not uncommon. It is reasonable to consult with the patient about the likelihood of a headache occurring and its causes before performing the procedure and to give him or her the necessary information to make an informed decision.

1. Reza Aminnejad; MD.

2. Introduction
• 15% of adults have experienced recent neck pain.
• 34.4% of the respondents had experienced neck pain within the last
year, and 13.8% reported neck pain that lasted for more than 6
months.
• Neck pain is a common condition that causes substantial disability.
• Of all 291 conditions studied in the Global Burden of Disease 2010
Study, neck pain ranked fourth-highest in terms of disability as
measured by years lived with disabilities, and 21st in terms of overall
burden.
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3. Sources of Neck Pain
• Nerves
• Muscles
• Intervertebral disks
• Facet joints
The facet or zygapophysial joints are estimated to contribute to chronic
cervical spine pain in about 55% of all cases.
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4. Cervicogenic HA
• Available data suggest that the prevalence of cervicogenic headache in the
general population is 0.4 to 4 percent.
• The anatomic locus for cervicogenic headache is the trigeminocervical
nucleus in the upper cervical spinal cord.
• Involvement of the C2-3 zygapophyseal joint is the most frequent source of
cervicogenic headache, accounting for up to 70 percent of cases.
• Involvement of the atlanto-axial joint is probably the second most common
source of cervicogenic headache.
• Uncommon sources of cervicogenic headache include the C3-4
zygapophyseal joint, upper cervical intervertebral discs, and lower cervical
zygapophyseal joints.
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5. Copyrights apply

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7. Copyrights apply

8. Pain referral from C2 and C3 nerve roots
Principles of Pain Management. Dinakar, Pradeep,
Bradley's Neurology in Clinical Practice, 54, 720-741.e2

9. Referred pain patterns after noxious stimulation of upper cervical joints
and the C2–3 intervertebral disc
Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and
treatment. Bogduk, Nikolai, MD, Lancet Neurology, The, Volume 8, Issue 10, 959-968

10. Pain referral pattern from the cervical
facet joints
Principles of Pain Management. Dinakar, Pradeep,
Bradley's Neurology in Clinical Practice, 54, 720-741.e2

11. What is PRN?
Percutaneous radiofrequency
neurotomy (PRN) introduces
probes through the skin and
overlying soft tissues to generate
friction, using thermal energy to
ablate the medial branch nerves
via a conducting element.
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12. • Mechanical or thermal injuries of
these structures during treatment
could lead to new onset of pain,
including cervicogenic headache
(CGH).
• Multiple structures within the
cervical spine could simultaneously
be sources of pain after an injury or
due to chronic degenerative
changes. Treatment of one source
of neck pain could lead to
unmasking or even perceived
exacerbation of nociception from
other pain generators.
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14. Inclusion criteria were:
• Age over 18 years
• Documentation of follow-up
after the procedure.
Exclusion criteria were:
• Diagnosis of chronic headache
condition prior to presentation
at the clinic
• Acute headache on presentation
• Treatment of levels other than
C3-C7
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15. Results
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21. Discussion
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22. Importance of informed consent prior to PRN
• In this study, incidence of cervicogenic headache following cervical
radiofrequency neurotomy at levels C3-C7 was 13.6%.
• The rates of cervicogenic headache in the general population have
been previously described as 0.4 to 4.5% of the general population.
• Incidence of CGH may be as high as 33.8% in the cohort of chronic
pain patients.
• Post-procedural pain, cutaneous numbness, ataxia, and dysesthesia
were found to occur in greater than 60% of all patients undergoing
cervical PRN in some other trials.
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23. Non-CGH (11%)
• Migraine headaches
• Caffeine withdrawal headache
• Tension type headache
• Incomplete records
• Lost to follow-up
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24. • Many of the structures in and around the zygapophyseal joint can be
irritated as a result of the procedure itself.
• Neck pain is commonly worsened after the procedure.
• Irritation of convergent areas in the neck could result in new-onset
cervicogenic headache.
• In traumatic neck injuries the mechanism of injury could lead to injuries of
multiple structures within the cervical spine with facetogenic pain
predominating over other minor sources of pain until treated (masking
other sources of pain).
• Preexisting C2/C3 nerve irritation could be unmasked or exacerbated by
treatment.
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25. • Patients with CGH in this cohort were more likely to be female and have a
non-throbbing headache, which are minor diagnostic criteria of CGH.
• There was an association with increased pain at presentation (significantly
higher maximum reported pain score and trend toward higher average
pain scores) and CGH following neurotomy.
• CGH patients reported a moderate therapeutic benefit of exercise and no
benefit of rest in improving their pain prior to cervical PRN compared to
the rest of the cohort, which reported a moderate response to rest and no
benefit of exercise.
• There was an association of diabetes with the risk of developing CGH
(proinflammatory state/masking phenomenon).
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26. Limitations:
• Single-center design
• Small size of the cohort
• The lack of data on some of the patients who presented with
headache
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30. Thanks for your attention
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