Efficacy of Greater Occipital Nerve Radiofrequency for Refractory Migraine Treatment
Condition: Migraine; Headache Disorders, Primary
MeSH terms: Migraine Disorders; Headache Disorders; Headache Disorders, Primary; Headache
Study type: Observational

Summary: 
      Objective: Ultrasound-guided pulsed radiofrequency therapy can be used on the
      greateroccipital nerve (GON) in patients with chronic migraine (CM) who are unresponsive to
      conservative treatments. In this study, we aimed to demonstrate the change in pain intensity,
      duration of migraine episodes, frequency of attacks,migraine disability, depression,and sleep
      disturbance scores before and after treatment in patients with CM who underwent
      ultrasound-guided GON pulsed radiofrequency and the effectiveness of treatment. Patients and
      methods:The study included 25 patients who were diagnosed as having CMaccording to the
      International Classification of Headache Disorders III beta version diagnostic criteria. The
      Migraine Disability Assessment Scale (MIDAS), Beck Depression Inventory(BDI), Pittsburgh
      Sleep Quality Index (PSQI),and a visual analog scale (VAS) were used on patients before GON
      pulsed radiofrequency treatment and at post treatment months 1 and 3. Results:The median
      duration and number of migraine episodes in the post-interventional 1st month and 3rd month
      were significantly shorter and fewer compared with the pre intervention period (p<0.001). In
      the comparison with the pre intervention values, all of the scoring concepts, namely the
      MIDAS, VAS, BDI, and PSQI, revealed a significant drop in the post intervention 1st and 3rd
      month (p<0.001). Conclusion: In this study, we observed that ultrasound-guided GON pulsed
      radiofrequency therapy applied at the proximal (C2) level was a safe and effective treatment
      option.With GON pulsed radiofrequency, we observed a decrease in pain intensity, pain
      frequency, andduration of episodes, and an improvement in depression symptoms, migraine
      disability, and sleep disorder scores accompanying chronic migraine.
    

Detailed description: 
      Design and Study Population:

      The ethical approval of the current study was obtained from the Local Ethics Committee of
      Tepecik Education and Research Hospital. In this study, 25 patients who were diagnosed as
      having chronic refractory migraine and were refractory to conventional treatments, such as
      oral medications, GONB,and botulinum toxin injection were evaluated.All patients received
      pulsed RFtherapy to the GON from the proximal (C2) level in the pain clinic between September
      2020 and September 2021. In the current study, patients who were highly likely to have a
      chronic systemic disease that might be the cause of headache, such as hypertension, were
      excluded from the study. Additionally, patients who already had other primary headache
      conditions were also excluded.

      To assess the outcomes of the intervention, the patients were evaluated in terms of
      Beck'sDepression Inventory (BDI) scores,Migraine Disability Assessment Score (MIDAS), visual
      analog scale (VAS) scores, and Pittsburgh Sleep Quality Index (PSQI) scores.VASsare
      measurement instruments that try to measure a characteristic or attitude that is believed to
      range across a continuum of values and cannot easily be directly measured. They are often
      used in epidemiologic and clinical research to measure the intensity or frequency of various
      symptoms such as pain. MIDAS is a brief, self-administered questionnaire designed to quantify
      headache-related disability over 3 months. The MIDAS score has been shown to have moderately
      high test-retest reliability in patients with headaches. Psychological symptoms often coexist
      in patients with migraine. Symptoms of depression may reinforce comorbidity between
      depression and chronic refractory migraine. Therefore, we used BDI scores .The PSQI was
      developed by Buysse et al. It provides a quantitative measurement of sleep quality to
      identify good and poor sleep. We wanted to evaluate sleep quality in our patients because
      chronic pain negatively affects sleep quality .These scoring concepts were used
      preintervention, and at the post interventional 1st and 3rd months. Afterward, whether the
      patients benefited from the intervention was assessed by subtracting the preintervention
      score from the post interventional 1st-month score, and the pre intervention score from the
      post interventional 3rd-month score. Demographic data of all patients, the side of the pain,
      and the monthly attack frequency and duration were noted.

      The treatment was performed in the local operating room under sterile conditions, accompanied
      by ultrasonographic imaging with a linear probe (6-12-Mhz Philips DC7 color Doppler
      ultrasound machine), in the prone position, at the C2 level, with the head slightly flexed.
      No sedation is needed for this intervention.We start visualizing from the occipital
      protrusion,then we slide the probe inferiorly to find the first bifid spinous process of C2.
      After finding the C2 level, we move the probe laterally (towards the side where we will use
      the RF) to identify the obliquus capitis inferior muscle and semispinalis capitis muscle of
      the neck .The GON is found superficial to the obliquus capitis inferior muscle and deeperto
      the semispinalis capitis muscle at this level. After identifying the GON, a catheter needle
      (22-gauge 5 cm 5 mm active tip hybrid electrode) is inserted with an in-plane technique from
      lateral to medial. After visualizing the electrode tip placed close to the right or left GON,
      a sensory stimulation test is performed using an RF generator . After the patient reports
      dysesthesia and a tingling sensation at the occipital area with less than 0.2 V, the Pulsed
      RF treatment is administered at 5 Hz and 5 milliseconds pulsed width for 360 seconds at 45 V
      under the constraint that the temperature of the electrode tips does not exceed 42°C
    

Intervention name(s): Ultrasound guided greater occipital nerve (GON) radiofrequency
Intervention type(s): Other
Intervention description(s): After identifying the GON with ultrasound guidance, a catheter needle (22-gauge 5 cm 5 mm active tip hybrid electrode) is inserted with an in-plane technique from lateral to medial.After visualizing the electrode tip placed close to the right or left GON, a sensory stimulation test is performed using an RF generator (URF-3AP Diros Tecnology Inc.). After the patient reports dysesthesia and a tingling sensation at the occipital area with less than 0.2 V, the PRF treatment is administered at 5 Hz and 5 milliseconds pulsed width for 360 seconds at 45 V under the constraint that the temperature of the electrode tips does not exceed 42°C
Other intervention name(s): GON RF
Observational model: Other
Time perspective: Retrospective
Sampling method: Non-Probability Sample
Study population: 
        In this study, 25 patients who were diagnosed as having chronic refractory migraine and
        were refractory to conventional treatments, such as oral medications, GONB,and botulinum
        toxin injection were evaluated.All patients received pulsed RFtherapy to the GON from the
        proximal (C2) level in the pain clinic between September 2020 and September 2021.
      
Keywords: migraine; ultrasound, greater occipital nerve(GON), radiofrequency