PONOS CLINIC · CRANIOFACIAL PROCEDURES
Radiofrequency for craniofacial pain
The right target. The appropriate technique. An individual care pathway.
Trigeminal nerve, sphenopalatine ganglion, auriculotemporal nerve and occipital nerves: different treatments selected after an accurate diagnosis and specialist assessment.
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Before treating pain, we need to understand its source
Pain in the face, temple or back of the head can arise from very different conditions. Neuralgia, headache disorders, temporomandibular disorders and persistent facial pain do not require the same treatment. Even when pain has lasted a long time, chronicity alone does not establish neuropathy.
Radiofrequency may be considered when the diagnosis and distribution of symptoms identify a coherent target, taking previous treatments, tolerability and alternatives into account. Where necessary, assessment includes neurological, dental and ear, nose and throat evaluation, together with imaging.
A defined diagnosis
The quality, location, duration and triggers of pain guide the diagnosis. Treating the place where pain is felt is not enough.
A plausible target
The nerve or ganglion must fit the clinical picture. When indicated, an anaesthetic block helps assess its contribution.
A shared goal
We identify the symptom to reduce, the activities to regain and the balance between expected benefit, risks and alternatives.
Pulsed and thermal radiofrequency: two different objectives
Pulsed radiofrequency · PRF
It delivers pulses of energy with controlled temperature, generally limited to around 42 °C. The aim is to modify activity involved in pain transmission, without intentionally creating a thermal lesion.
It is considered for specific targets and clinical conditions. Its neuromodulatory nature does not mean that it is risk-free or equally effective for every indication.
Thermal radiofrequency
It uses heat to create a controlled lesion at the selected target. Parameters and technique depend on the structure being treated and the indication.
Possible sensory changes and other specific risks must be discussed before treatment. It is not an automatic choice for every severe or persistent pain condition.
Read more about the principles of radiofrequency.
Four targets, four dedicated pathways
This page provides an overview. Each card links to the specific procedure, including indications, patient selection and technical considerations.
Trigeminal radiofrequency
Trigeminal neuralgia and trigeminal neuropathic pain require distinct assessment. In neuralgia, procedural decisions consider the response to medication, imaging and neurosurgical alternatives.
Treatment of the ganglion, major divisions and peripheral branches involves different procedures. The target and technique are selected according to the diagnosis and the function to be preserved.
Explore the trigeminal procedure →Sphenopalatine ganglion · SPG
The sphenopalatine ganglion is involved in cranial autonomic pathways. PRF may be discussed in selected cases of craniofacial pain and refractory headache after specialist assessment.
Anaesthetic blocks, PRF and electrical stimulation are different treatments: results from one technique do not automatically establish the effectiveness of the others. Evidence for PRF remains limited.
Explore sphenopalatine ganglion PRF →Auriculotemporal nerve
The PONOS procedure uses pulsed radiofrequency, following clinical assessment and an ultrasound-guided diagnostic injection. Selected indications include TMJ pain and bruxism-associated pain with auriculotemporal involvement.
Treatment addresses the identified pain component, rather than teeth grinding itself. The nerve may also be assessed within the somatic tinnitus pathway, using specific selection criteria.
Explore auriculotemporal PRF →Occipital nerves
This pathway covers occipital neuralgia and selected cases of migraine with an occipital neuropathic trigger. The third occipital nerve requires specific assessment, including when a contribution to somatic tinnitus is suspected.
The procedure may be performed distally, at the occipital ridge, or proximally, in the upper cervical region. Dr Panagiotakos uses a combined lesioning and neuromodulatory approach after clinical selection and a meaningful response to a diagnostic block.
Explore the occipital nerve procedure →Somatic tinnitus: a specific pathway
The auriculotemporal nerve and the third occipital nerve are distinct targets. Within the PONOS pathway, they are assessed when the clinical picture suggests a jaw-related or cervical somatosensory contribution, following ENT and audiological assessment.
If the aim is to improve tinnitus, the targeted block must document a meaningful response in the auditory symptom as well: improvement in pain alone is not enough. Evidence for radiofrequency procedures in tinnitus is limited and does not support offering them indiscriminately to every patient.
Read about the specialist tinnitus pathway.
The PONOS pathway, from assessment to follow-up
Establish the clinical picture
We review the history and distribution of pain, associated symptoms, examination findings, investigations and previous treatments. Bring your reports, medication list and, for headache disorders, a headache diary.
Assess the target when indicated
A selective anaesthetic block may help guide the decision. We record which symptom changes, the extent and duration of benefit, and how this compares with the expected effect of the anaesthetic. The test is not the same for every procedure and does not guarantee the outcome of RF.
Agree on the technique and alternatives
We discuss PRF, thermal radiofrequency or a combined approach, alongside relevant medication, rehabilitation or surgical options. The decision includes expected benefits, limitations and informed consent.
Perform the targeted procedure
In an appropriately equipped setting with sterile preparation, the electrode is positioned using the appropriate imaging guidance: ultrasound or fluoroscopy, depending on the target. Local anaesthesia, any sedation and stimulation checks are tailored to the individual procedure.
Measure outcomes over time
Follow-up considers pain intensity and frequency, sleep, function and medication use. Headache and tinnitus are assessed using specific measures, keeping the different symptoms separate.
What may improve, and what are the limitations?
A practical benefit
The aim is to reduce the impact of symptoms on daily life: less intense or less frequent attacks, better tolerance of activities and functional recovery. Any reduction in medication is agreed with the treating clinicians.
An individual response
Benefit may be partial, temporary or absent. There is no single duration that applies to every procedure. Repeat treatment requires reassessment of the previous outcome and the alternatives.
Evidence varies between diagnoses and targets. Ablative procedures for trigeminal neuralgia have a role among specialist options; data for other uses, particularly some PRF indications and tinnitus, are less robust. A good response in one condition cannot automatically be extrapolated to another.
Preparation, safety and recovery
Before the procedure, report your medication, anticoagulants and antiplatelet drugs, allergies, infections, pregnancy and implanted devices. Do not stop treatment on your own. You will receive individual instructions on any fasting requirements, an accompanying adult, driving and returning to activities.
Possible adverse effects include local pain, bruising, bleeding, infection, medication reactions, sensory changes and nerve injury. Risks vary with the target: trigeminal procedures, for example, require attention to facial and corneal sensation; third occipital procedures require discussion of possible post-procedural neuropathic pain.
Imaging guidance and safety checks reduce risks without eliminating them. Marked deterioration, fever or new persistent symptoms should be reported to the centre; sudden neurological symptoms require urgent assessment.
A specialist pathway for your pain
The consultation establishes whether there is a treatable target and which procedure makes sense in your case.
Request an assessmentTrigeminal nerve and craniofacial painGuide to radiofrequencyFrequently asked questions
Is radiofrequency suitable for every type of facial pain?
No. A diagnosis and a coherent target are required. Dental pain, TMJ disorders, neuralgia and headache disorders require different pathways.
Is PRF risk-free?
No. It does not aim to create a thermal lesion, but needle placement, medication and treatment can still cause adverse effects.
Is an anaesthetic block always necessary?
It depends on the procedure. In the PONOS auriculotemporal and occipital pathways, the block contributes to patient selection; its indication and interpretation must be specific to the target.
Does the procedure replace migraine treatment?
No. Occipital treatment is considered in selected cases with an occipital neuropathic component and forms part of the neurological management of migraine.
Does auriculotemporal PRF treat bruxism?
It may be considered for the associated auriculotemporal pain component. It does not directly treat teeth grinding or replace dental or jaw-function assessment and care.
How long does the benefit last?
It varies and may be insufficient. Assessment over time distinguishes the initial effect of the anaesthetic from the response to radiofrequency.
References and strength of evidence
These references help distinguish established indications from those with preliminary data. They do not describe a single protocol suitable for every target.
- Bendtsen et al., 2019 — EAN guideline on trigeminal neuralgia. Diagnostic assessment and selection of medical and surgical options.
- Ho et al., 2017 — Review of sphenopalatine ganglion block, radiofrequency and stimulation. Different techniques and limitations of the available studies.
- Cohen et al., 2015 — Randomised study of PRF for occipital neuralgia and migraine with occipital tenderness. Findings relate to the selected study population.
- Koning et al. — Auriculotemporal PRF for tinnitus. An uncontrolled retrospective study; it does not establish benefit for every type of tinnitus.
General information by Dr Evangelos Panagiotakos MD. This page does not replace consultation, informed consent or individual instructions. Reviewed: September 2026.