A New Lease of Life: Complete Resolution of Cluster Headaches with Pulsed Radiofrequency
Case Study Series
Patient Case Report • Cluster Headache • Occipital Nerve Block • Pulsed Radiofrequency
Twenty-five years of cluster attacks — stopped in their tracks by a targeted nerve intervention
How a diagnostic right occipital nerve block, followed by pulsed radiofrequency, delivered the longest sustained headache-free period a 57-year-old man had known in a quarter of a century
25 yrs
Of right-sided cluster attacks
2–4
Cluster bouts per year
12 mo
Headache-free post-PRF
✓
Complete remission
James M. — Aged 57
Long-standing chronic cluster headache • Strictly right-sided • Referred from regional Neurology • Failed maximal medical therapy
Chronic cluster headacheAutonomic featuresVerapamil intolerance at high dose
Complete remission post-PRF
The Presentation
A textbook cluster phenotype, unchanged for a quarter of a century
James, a man in his late fifties, was referred to PainSpa through the regional Neurology service after living with strictly right-sided cluster headaches for more than twenty-five years. His attacks were stereotyped and severe: a hot, stabbing, burning pain behind the right eye, with prominent ipsilateral autonomic features — visible facial droop, eye-watering and rhinorrhoea on the same side.
Each cluster bout would typically deliver one to two attacks per day over six or seven days, although on several occasions an active phase had extended over months. Bouts recurred two to four times every year and were severe enough to interrupt work, sleep and family life. Over twenty-five years he had never experienced a meaningful headache-free period.
Under the care of his consultant neurologist he had progressed through the full medical pathway for cluster headache without sustained benefit. He was referred to Dr. Krishna for further treatment, including consideration of a greater occipital nerve intervention — first as a diagnostic and therapeutic block, with the possibility of a longer-acting pulsed radiofrequency procedure if the response was favourable.
Clinical Background
A long road through maximal medical therapy
Cluster headache is widely regarded as one of the most severe pain conditions described in medicine. For James, the condition had defined his adult life. Under neurology supervision he had worked methodically through the established evidence-based options — abortive, transitional and preventive — with only partial control of his attacks.
Home high-flow oxygen at 15 L/min via a non-rebreathe mask was used as his primary abortive measure during attacks, supplemented by subcutaneous sumatriptan as needed for breakthrough pain. For preventive cover, verapamil had been carefully titrated upward, before dose-limiting side-effects forced a reduction back to lower dosages. Despite this aggressive regimen, his cluster cycles continued to break through, and the cumulative impact on his quality of life was significant.
With pharmacological options effectively exhausted, the case for an interventional approach targeting the greater occipital nerve was strong. Greater occipital nerve interventions are an established option in cluster headache because of the way pain signalling from the occipital region converges with the trigeminal system in the upper cervical cord — a convergence that allows posterior interventions to modulate front-of-head pain.
The neurobiology of occipital nerve interventions in cluster headache
The trigeminocervical complex
Sensory fibres from the greater occipital nerve converge with trigeminal afferents in the upper cervical spinal cord. This anatomical overlap is why a posterior intervention at the occipital nerve can dampen front-of-head pain signalling in cluster headache and migraine.
The diagnostic-therapeutic block
A targeted local anaesthetic and steroid injection around the greater occipital nerve confirms that the nerve is a meaningful contributor to the patient’s pain. A robust response also predicts a worthwhile yield from a longer-acting radiofrequency procedure.
Pulsed radiofrequency (PRF)
PRF delivers short, high-frequency electric field bursts at a sub-neurolytic temperature (typically ≤42°C). Unlike conventional thermal radiofrequency, it modulates nerve signalling without producing destructive lesioning — making it well suited to a sensory nerve like the occipital.
A staged, image-guided plan
Performing the block first and the PRF second — both under real-time ultrasound — allows the response to be assessed before any longer-acting intervention is committed to. It is precise, conservative and patient-centred.
Symptom Assessment
A stereotyped attack profile across every clinical domain
James’s history mapped cleanly onto the International Classification of Headache Disorders criteria for cluster headache. His pain was strictly unilateral, intensely severe, anchored in and around the right eye, and accompanied by prominent same-side autonomic features. The attack profile had remained remarkably stereotyped over twenty-five years — a consistency that helps both diagnosis and treatment planning.
Pain quality
The defining sensory profile
Severe right-sided pain • Hot, stabbing and burning quality • Centred behind the right eye • Strictly side-locked across all bouts
Autonomic features
Ipsilateral cranial autonomic signs
Right-sided lacrimation • Right nostril rhinorrhoea • Visible right-sided facial droop during attacks • Consistent through every cluster bout
Attack pattern
Cluster timing and intensity
One to two attacks per day during a cluster • Bouts typically lasting six to seven days • Occasional extended phases lasting months • Severe enough to disrupt work and sleep
Cycle frequency & treatment burden
Long-term burden of disease
Two to four cluster bouts every year • Home high-flow oxygen and subcutaneous sumatriptan for acute relief • Verapamil titrated to high dose with intolerance • No sustained headache-free period in 25 years
The defining clinical feature: a maximally treated patient still living inside his cluster cycles
Despite high-flow oxygen, subcutaneous sumatriptan and verapamil pushed to the limit of tolerability, James was still experiencing two to four cluster bouts a year and had never known a sustained headache-free period. He was the prototypical candidate for an image-guided greater occipital nerve intervention — a patient in whom medical therapy had reached its ceiling and where a targeted procedural approach offered a genuinely different option.
The Treatment Journey
A staged, image-guided pathway from diagnostic block to durable relief
Dr Krishna’s approach reflected the complexity and chronicity of James’s condition: a detailed assessment, a transparent discussion of what a greater occipital nerve intervention could and could not offer, and a stepwise plan that used the response to a diagnostic block to inform the decision about pulsed radiofrequency.
Initial Consultation
Comprehensive assessment and clinical formulation
Dr Krishna took a detailed history of James’s cluster phenotype, prior preventives and abortive medications, and the impact of disease on his work and family life. The presentation was consistent with chronic, strictly right-sided cluster headache that had reached the ceiling of medical therapy. A staged interventional plan was discussed: a diagnostic and therapeutic right greater occipital nerve block in the first instance, with pulsed radiofrequency held in reserve if the response was meaningful.
Expectation-setting
Honest discussion of what nerve interventions can and cannot achieve
Dr Krishna was careful to frame the procedures realistically. He explained that not all patients respond to occipital nerve blocks, that the duration of any benefit is variable, and that a temporary flare-up after the injection is possible. He was clear that interventional treatment supports — rather than replaces — ongoing preventive medical care, and that the underlying tendency to cluster headache would not be cured by a procedure.
Procedure One
Right greater occipital nerve block under ultrasound guidance
An ultrasound-guided right greater occipital nerve block was performed as a day case under Dr Krishna’s care. The procedure was well tolerated, with no relevant allergies and no anticoagulation in use. The response was striking: James reported the longest continuous headache-free interval he had ever known in twenty-five years of living with cluster headache. In his own words, he had never been headache-free for this length of time before.
Telephone Follow-up
Treatment escalation discussed and offered
At telephone follow-up, James reported sustained benefit from the block but, as expected, his cluster symptoms had begun to nudge back. Given the strikingly favourable response to the initial block — a strong positive prognostic indicator — Dr Krishna offered pulsed radiofrequency of the right greater occipital nerve as a means of converting that response into longer-lasting relief. The rationale, expected duration of benefit and possibility of a temporary flare-up were discussed.
Procedure Two
Pulsed radiofrequency of the right greater occipital nerve
The pulsed radiofrequency procedure was carried out as a day case under ultrasound guidance. PRF delivers short, high-frequency electric field bursts at a sub-neurolytic temperature, producing a neuromodulatory effect on the targeted nerve without destructive lesioning. The procedure was well tolerated with no significant complications, and James was discharged the same day with clear post-procedure advice.
The PainSpa Approach
Four pillars of cluster headache management at PainSpa
Managing severe, medically refractory cluster headache requires more than a single procedure. It calls for a framework that combines accurate phenotyping, conservative escalation, technical precision and honest communication. Dr Krishna’s care pathway is grounded in a structured model that positions targeted nerve interventions as an adjunct to — not a replacement for — ongoing neurology-led medical care.
1. Diagnostic clarity first
Confirming a textbook cluster phenotype and carefully reviewing the response to oxygen, triptans and verapamil before any interventional treatment is considered.
2. Staged interventional plan
Using a diagnostic and therapeutic greater occipital nerve block to predict the value of a longer-acting pulsed radiofrequency procedure before escalating.
3. Image-guided precision
Performing every procedure under real-time ultrasound guidance to maximise accuracy on the targeted nerve and minimise the risk of complications.
4. Shared decision-making
Realistic discussion of expected benefit, the possibility of temporary flare-up, the limits of injection therapy and the continued role of preventive medical care.
When verapamil, oxygen and triptans have all been pushed to their ceiling and cluster bouts are still breaking through, an image-guided greater occipital nerve intervention can change the trajectory of a patient’s life. A meaningful response to a diagnostic block is one of the most useful predictors we have — and in the right patient, taking the next step to pulsed radiofrequency can convert a few weeks of relief into a year or more.
Dr Murli Krishna — Consultant in Pain Medicine, PainSpa
Outcome
What changed for James at twelve months
Approximately twelve months following his pulsed radiofrequency procedure, James remained completely free of cluster attacks. The transformation from his baseline — two to four bouts a year for twenty-five years — was striking. The benefit had been clinically meaningful from the outset and had been sustained well past the point at which his next cluster bout would normally have been expected.
Key improvements at twelve-month follow-up
● Complete cessation of right-sided cluster attacks — no cluster bouts since the pulsed radiofrequency procedure, in a man who had previously experienced two to four bouts every year for more than twenty-five years
● Longest sustained headache-free period in 25 years — first established after the diagnostic block and now extended further by the radiofrequency procedure
● No requirement for acute abortive medication during the post-procedure period — high-flow oxygen and subcutaneous sumatriptan have not been needed
● Substantial improvement in work, sleep and family life — with the lived experience of a year without cluster bouts
● Both procedures well tolerated, with no significant complications and no procedural flare-up of note
● A clear and reassuring response pattern: a strong reaction to the diagnostic block, followed by an even more durable response to the pulsed radiofrequency — an ideal trajectory for this type of staged approach
It is important to note that pulsed radiofrequency does not cure the underlying tendency to cluster headache. The expectation, transparently discussed with James from the outset, is that cluster activity may return at some point in the future. If and when it does, repeat pulsed radiofrequency can be considered — patients who respond well to an initial treatment often respond again to a repeat procedure.
Dr Krishna was particularly encouraged by the depth and durability of James’s response. After twenty-five years of cluster headache and a fully exhausted medical ladder, regaining a full year of normal life is a meaningful and patient-defining outcome.
Looking Ahead
The next steps in James’s long-term care
The combined occipital nerve block and pulsed radiofrequency have achieved their primary goal: a complete and durable reduction in cluster activity, a clear improvement in quality of life, and a foundation for sustained, well-monitored long-term care alongside his neurology team.
Recommended ongoing management plan
PriorityAnnual telephone review with Dr Krishna to monitor for any recurrence of cluster activity and to plan ahead if symptoms return.
OngoingContinued shared care with neurology, keeping his preventive medication regimen and home oxygen plan under regular review.
Stand-byHome high-flow oxygen and subcutaneous sumatriptan retained as on-demand abortive cover, in case any breakthrough attacks occur in the future.
If neededOption to repeat pulsed radiofrequency if cluster activity recurs in the future. A previous good response is generally a positive predictor for a repeat procedure.
OpenAn open follow-up appointment remains available under Dr Krishna’s care, allowing James to re-engage with specialist input at any point.
Your Specialist
About Dr Murli Krishna
Dr Murli Krishna
Consultant in Pain Medicine — PainSpa
MBBS • FRCA • FFPMRCA • Fellow of the Faculty of Pain Medicine
Dr Krishna is a highly experienced Consultant in Pain Medicine practising at PainSpa’s clinics in Bristol, including Willow Surgery in Downend and the Chesterfield Nuffield Hospital in Clifton. He specialises in the diagnosis and image-guided interventional management of complex headache disorders — including cluster headache, chronic migraine and occipital neuralgia — alongside the wider range of chronic pain conditions.
His approach to medically refractory cluster headache is grounded in detailed phenotyping, a staged interventional plan and close collaboration with each patient’s neurology team. Every procedure is performed under real-time ultrasound or fluoroscopic guidance, and every plan is built around a frank, realistic conversation about expected benefit and the limits of injection therapy.
Dr Krishna consults in person and via telephone or videolink. Patients interested in exploring greater occipital nerve block or pulsed radiofrequency for cluster headache or related conditions are encouraged to contact PainSpa to arrange an initial assessment consultation.
Please note: This case study is published for educational and informational purposes. All patient-identifying details — including name, age, occupation and location — have been changed or generalised to protect patient confidentiality. Patient consent to publish has been obtained. Individual results from greater occipital nerve block and pulsed radiofrequency vary considerably; these procedures do not guarantee improvement and are not effective for every patient. They are an adjunct to, and not a replacement for, ongoing medical care under neurology. This does not constitute medical advice. Please contact PainSpa to discuss your individual circumstances. For complaints or queries, please write to clinic@painspa.co.uk.
Painspa
Willow Surgery, Downend • Chesterfield Nuffield, Clifton • clinic@painspa.co.uk • www.painspa.co.uk
© 2026 PainSpa • 0117 2872383