Successful Treatment of Refractory Cluster Headaches with Occipital Nerve Pulsed Radiofrequency
Case Report: Successful Treatment of Refractory Cluster Headaches with Occipital Nerve Block and Pulsed Radiofrequency
Patient: 36-year-old lady • Laterality: Right-sided • Intervention: Ultrasound-guided occipital nerve block → Pulsed Radiofrequency (PRF)
Background
Cluster headache is a trigeminal autonomic cephalalgia (TAC) and is widely recognised as one of the most severe pain conditions experienced by humans.
It is often described as excruciating, disabling, and profoundly life-altering. In many patients, symptoms persist despite specialist assessment and guideline-based medical management, making cluster headache particularly challenging to treat.
Refractory cluster headache can be associated with significant psychological distress and a major reduction in quality of life.
Patient Presentation
A 36-year-old lady was referred to Pain Spa with a diagnosis of right-sided cluster headache, experiencing severe, recurrent attacks with substantial impact on sleep, function, and day-to-day quality of life.
She had already been assessed by the neurology team and underwent an MRI brain scan which
did not show any specific abnormality.
Previous Treatments and Response
Acute (Abortive) treatments trialled
- High-flow 100% oxygen via non-rebreather mask
- Intranasal zolmitriptan
These measures were helpful in aborting individual attacks, but did not prevent the recurrence or clustering of headaches, and symptoms remained frequent and disabling.
Preventive medications trialled
- Verapamil
- Topiramate
Unfortunately, these preventive therapies did not provide meaningful or sustained benefit.
Clinical Rationale for Interventional Treatment
Cluster headache is believed to involve dysregulation within trigeminal and autonomic pain pathways, with important connections through the trigeminocervical complex. There is recognised convergence between upper cervical afferents (including the greater occipital nerve) and trigeminal nociceptive pathways, providing a rationale for targeting the occipital nerve in carefully selected patients.
Occipital nerve blocks are established as an effective transitional strategy in cluster headache, and neuromodulatory techniques can be considered in refractory cases.
Treatment Performed at Pain Spa
1) Ultrasound-guided right occipital nerve block
Performed with real-time ultrasound guidance to maximise accuracy and safety.
The patient experienced significant early improvement in headache severity and frequency,
supporting the occipital nerve as an important contributor.
2) Pulsed radiofrequency (PRF) of the right occipital nerve
Following the successful diagnostic/therapeutic block, the patient underwent pulsed radiofrequency neuromodulation.
PRF is a non-destructive technique designed to modulate pain signalling while preserving nerve structure—particularly suitable in headache disorders.
Outcome and Follow-Up
- Marked reduction in frequency and intensity of cluster headaches
- Improved sleep, function, and quality of life
- No complications from the procedures
This represented a clinically meaningful and life-changing improvement for a condition recognised as one of the most painful syndromes known.
Pain Spa Expertise
At Pain Spa, complex headache disorders are managed with a precision-based, interventional approach.
Dr Krishna is highly experienced in performing ultrasound-guided occipital nerve blocks and—importantly—pulsed radiofrequency (PRF) treatments, with excellent outcomes in appropriately selected patients with cluster headaches and other refractory pain conditions.
Ultrasound guidance supports accurate needle placement, enhances safety, and helps deliver targeted therapy to maximise clinical benefit.
Summary
This case demonstrates the value of a stepwise approach to refractory cluster headache, including:
- Specialist neurological assessment and normal MRI brain imaging to exclude secondary causes
- Failure of standard therapies (including high-flow oxygen, intranasal zolmitriptan, verapamil, and topiramate)
- Excellent response to ultrasound-guided occipital nerve block followed by pulsed radiofrequency