Radiofrequency ablation of C2–3 medial branches/third occipital nerve to treat cervicogenic headache

Cervicogenic headache (CGH) is a secondary headache disorder arising from dysfunction of the C2–3 facet joint. First-line management options include conservative and multidisciplinary therapies including physical therapy, pharmacologic analgesic agents, and other noninvasive modalities. However, some patients experience persistent, refractory pain despite first-line management options. More invasive, interventional approaches including nerve blocks and steroid injections targeting the C2–3 joint have demonstrated relief, but their limited duration poses a challenge for managing chronic pain. Radiofrequency ablation (RFA) has emerged as a promising, minimally invasive, treatment for chronic pain relief in CGH. In this technical report, we describe the use of cooled RFA targeting the third occipital nerve (TON) and, when applicable, the C2 medial branch, for the treatment of chronic refractory CGH. We review relevant anatomy of the C2–3 facet joint implicated in CGH, as well as the anatomic variability of it is innervation, the TON and C2 medial branch, which can influence procedural efficacy. Compared with other RFA methods such as thermal or pulsed, cooled RFA allows for the creation of more precise treatment areas with the goal of improving efficacy and pain relief. A thorough understanding of anatomy, visualization, and procedural technique are important in optimizing outcomes and minimizing adverse effects. By generating more precise and effective lesion fields, cooled RFA may enhance treatment success. This report highlights cooled RFA as a promising treatment option for patients with CGH refractory to more conservative therapies and aims to provide a framework that promotes safe implementation and future research into its effectiveness.