Cervicogenic Headache, Facial and Neck Pain Without Surgery

Cervicogenic headache is pain that starts in the joints of the neck and spreads to the back of the head, the eyes or the forehead. Dr. Ashu Kumar Jain, Chief – Pain Medicine & Palliative Care, Artemis Hospitals, Gurugram, India, believes it is widely mistaken for migraine, and treats it with radiofrequency ablation of the cervical facet joints rather than surgery.

The same principle, find the nerve or joint that generates the pain and treat it through a needle, runs through his approach to the face, the neck, the shoulder and the chest wall. This article covers each region in turn. The overview of the specialty, its safety record and its costs is in the interventional pain management guide.

Cervicogenic headache vs migraine: when the neck causes the headache

Cervicogenic headache typically begins at the back of the head and travels forward to the eye or the forehead. Cervicogenic headache accounts for an estimated 15 to 20 per cent of chronic headaches and is frequently mislabelled as migraine, with pain that in fact starts in the neck. For a doctor managing a patient whose "migraine" has not responded to migraine treatment, that is the first diagnosis to reconsider.

The source is usually the facet joints: the small paired joints at the back of each spinal segment. The upper cervical joints, at the C2 to C3 level, refer pain into the head. Lower cervical facet joints refer pain to the neck, the shoulder and the back of the chest. Dr. Jain links the rising number of these patients to screen time: long hours spent looking down at a mobile phone with the neck bent load the cervical facet joints.

Cervical facet radiofrequency ablation

The treatment Dr. Jain uses is radiofrequency ablation (RFA) of the cervical facet joints, in which radiofrequency current heats and interrupts the small nerves that carry pain from the joints. Needles are placed over those nerves under fluoroscopy (live X-ray imaging) in the cath lab (catheterisation laboratory). Before any lesion is made, the nerves are stimulated to reproduce the patient's pain: in the case he showed, stimulation at the upper electrode sent pain into the head and stimulation at the lower electrode sent it into the neck, which confirmed both targets.

Dr. Jain put the success rate of cervical facet RFA at 90 to 95 per cent, with very good pain relief. The procedure suits elderly patients with severe neck pain from degenerated cervical spines, patients for whom, as he put it, nobody will operate.

Does neck pain need surgery?

Dr. Jain's figure is that 95 to 97 per cent of neck pain can be managed without surgery, through conservative care or interventional pain management, and that neck pain on its own is not an indication for surgery. That position frames the rest of this article: the neck procedures below are alternatives for patients who have pain without the neurological findings that call for an operation.

Arm pain from a cervical disc: cervical epidural injection

Pain that travels from the neck into the arm, forearm and fingers usually comes from a cervical disc irritating a nerve root. Dr. Jain's rule is clear: if there is no cervical myelopathy (compression of the spinal cord itself) and no weakness, the patient does not need surgery, and the pain can be managed with a cervical epidural injection.

In the epidural procedure, medication is delivered into the epidural space around the affected nerve root under imaging. He described the effect as releasing the nerve, and reports very good pain relief for disc-related arm pain. One of the patients he showed was a woman with severe pain travelling from the neck to the hand, who became pain-free after the injections.

Facial pain: trigeminal neuralgia and related conditions

The face was the first region Dr. Jain covered, because some of the most disabling pain conditions arise there.

Trigeminal neuralgia

Trigeminal neuralgia is a sharp, shooting, electric current-like pain in one or more divisions of the trigeminal nerve, usually on one side of the face, that comes and goes. It is triggered by ordinary activities: eating, brushing the teeth, washing the face. The severity has earned it the name "suicide disease".

Many such patients used to undergo microvascular decompression (MVD), an open operation in which a neurosurgeon separates a blood vessel from the trigeminal nerve. Dr. Jain's practice is radiofrequency ablation of the trigeminal ganglion as a day-care procedure. A fine needle is guided through the face to the ganglion at the base of the skull, the patient confirms that stimulation reproduces their pain in the right area, and the ablation is completed within about half an hour.

He put the immediate success rate at 95 per cent or more, with minimal complications, although some numbness in the treated area of the face is expected. After a single procedure about half of patients remain pain-free at five years, and most recurrences respond to a repeat ablation. A separate guide from his later masterclass weighs trigeminal neuralgia radiofrequency ablation against surgery in more detail.

Glossopharyngeal neuralgia and Eagle syndrome

Glossopharyngeal neuralgia produces deep pain in the throat and the ear on eating and swallowing. Patients may be unable to eat. Dr. Jain treats it with radiofrequency ablation of the glossopharyngeal nerve.

He uses the same approach for Eagle syndrome, which ear, nose and throat surgeons see: an elongated styloid process causes pain on swallowing. RFA of the nerve relieves the pain.

Sphenopalatine ganglion RFA

The sphenopalatine ganglion is a nerve cluster in the pterygopalatine fossa, deep behind the nose, which is involved in several headache and facial pain syndromes. Dr. Jain performs sphenopalatine ganglion RFA for:

• cluster headache;
• migraine that has not responded to conservative treatment;
• burning mouth syndrome, in which the patient feels persistent burning inside the mouth and on the tongue;
• atypical facial pain.

He showed a young international patient with severe burning on both sides of the tongue who could not eat. After sphenopalatine ganglion RFA in the cath lab, the burning in the mouth and tongue resolved.

Thoracic facet pain: the under-diagnosed pain at the back of the chest

The facet joints of the thoracic spine can cause pain at the back of the chest that wraps around to the front. Dr. Jain calls this thoracic facetogenic pain and describes it as a much under-diagnosed and under-treated pain condition. After he published a video on the subject, patients contacted his clinic from around the world, and he receives many international patients with mid-back pain that travels to the front of the chest.

The treatment is thoracic facet RFA as a day-care procedure. He reports results above 90 per cent, with minimal complications.

Chest wall pain: intercostal neuralgia

Pain that travels from the back of the chest along a rib to the front, and sometimes to the abdomen, is intercostal neuralgia. Dr. Jain sees it in three main settings:

1. post-herpetic neuralgia, the persistent nerve pain that can follow shingles;
2. fractured ribs;
3. pain after chest surgery (post-thoracotomy pain).

These patients are often in serious distress. He treats them with intercostal nerve RFA.

Frozen shoulder and shoulder arthritis without surgery

Dr. Jain treats many painful shoulders, including frozen shoulder and the arthritic shoulder, without an operation, provided the anatomy allows it. His criteria are:

• no tear of the rotator cuff larger than 50 per cent;
• no dislocation;
• or an elderly patient with severe osteoarthritis of the shoulder joint.

Within those limits, a single needle approach can address several problems at once. For pain, he performs shoulder RFA, which he describes as a very successful procedure with results above 90 per cent. For adhesive capsulitis, or frozen shoulder, he releases the tight joint capsule through a needle, and he showed the capsule being released on imaging. Tendinitis is treated with the same needle-based approach. He also performs regenerative therapy of the shoulder with platelet-rich plasma (PRP) and stem cells.

Choosing the procedure: a summary for referring doctors

The common thread is that each of these conditions has a defined generator that can be tested and treated with a needle. Sympathetic pain in the arm, such as Raynaud's disease or complex regional pain syndrome, is treated differently, through the sympathetic chain; that is covered in percutaneous sympathectomy, visceral nerve blocks and pumps. Pain in the lower back, the legs and the knee is covered in failed back surgery syndrome, sciatica and disc pain. Questions doctors asked at the end of the session are in the Live Discussion.