PONOS • INTERVENTIONAL PROCEDURES
Occipital nerve radiofrequency
The procedure, from diagnostic block to follow-up.
A targeted treatment for selected patients with occipital neuropathic pain, migraine with an occipital trigger or somatic tinnitus associated with the third occipital nerve. The first step is to assess the target.
The role of the diagnostic blockWhat happens during treatment
When is the procedure considered?
Radiofrequency is considered after specialist assessment when there is a plausible target and appropriate treatments have not provided sufficient relief or are not tolerated. The location of pain alone is not enough to determine treatment.
Occipital neuralgia
Pain in the distribution of the occipital nerves, with neuropathic features and consistent clinical findings. The response to an anaesthetic block contributes to patient selection.
Read about occipital neuralgiaMigraine with an occipital neuropathic trigger
When an occipital neuropathic component appears to contribute to attacks, targeted nerve treatment may be considered following a meaningful response to a diagnostic block.
The procedure complements neurological assessment and migraine treatments; it is not automatically appropriate for every migraine.
Somatic tinnitus and the third occipital nerve
In selected cases with a suspected neuropathic contribution from the third occipital nerve, RF may be discussed after a selective anaesthetic block significantly improves tinnitus.
Read the specific criteriaWhich nerve is treated?
Greater and lesser occipital nerves
These are different targets, selected according to the distribution of pain and clinical assessment. The greater occipital nerve arises predominantly from C2; the lesser occipital nerve belongs to the cervical plexus, with C2–C3 contributions.
Treatment may be unilateral or bilateral: not every patient needs all nerves to be treated.
Third occipital nerve (TON)
This is a branch of the C3 spinal nerve, related to the C2–C3 joint and the lower occipital region. It requires a dedicated assessment and diagnostic block.
A greater occipital nerve block is not equivalent to a selective third occipital nerve block. C2–C3 joint pain and TON neuropathy also need to be distinguished.
The diagnostic block: a response-based decision
A diagnostic block involves a targeted injection of local anaesthetic near the suspected nerve. In the PONOS pathway, the ultrasound-guided block is interpreted alongside examination and differential diagnosis.
Define the symptom to measure
Before the block, record pain, scalp sensitivity, limitations and, when present, tinnitus intensity and impact. A headache diary is also considered for migraine.
Record the degree and duration of relief
Following the instructions provided, the patient records changes over the subsequent hours and during activities that usually trigger symptoms. A clinically meaningful response with timing consistent with the anaesthetic is important.
Decide whether to proceed
Significant improvement supports the proposed target, but does not by itself prove neuropathy or guarantee RF effectiveness. An uncertain or negative result calls for reassessment; a further block may sometimes be appropriate.
Somatic tinnitus associated with the third occipital nerve
The procedure may be considered within specialist care when somatic tinnitus is suspected to be related to a neuropathic component involving the third occipital nerve, following ENT and audiological assessment.
- The clinical findings should be consistent with a cervical somatic contribution.
- The selective anaesthetic block must significantly improve tinnitus itself. Relief of neck pain alone is insufficient to attribute the auditory symptom to that nerve.
- The response is documented and discussed alongside expected benefits, alternatives and risks.
Evidence on cervical RF for tinnitus includes clinical case reports and does not establish a standard treatment for TON neuropathy associated with tinnitus. One published case described a response following a C2–C3 medial branch block and RF: this finding cannot be generalised to every tinnitus presentation or every occipital nerve.
How to prepare
Reports and medication
- Bring your reports, medication list and results of previous blocks.
- Report anticoagulants, antiplatelet medication, allergies, infections, pregnancy and implanted devices.
- Do not stop medication yourself: any changes are agreed with your treating clinicians.
Instructions for the day
You will receive instructions on eating, any fasting requirements, an accompanying adult and your journey home, depending on the anaesthesia and procedural setting.
Report fever, skin lesions near the treatment area or recent changes in your health before the appointment.
What happens during occipital radiofrequency treatment?
Confirm the target and consent
The diagnosis, side, nerve target, block response and goals are reviewed. The clinician explains the technique, alternatives and specific risks.
Positioning and image guidance
The procedure takes place in an equipped clinical setting, with sterile preparation and local anaesthesia. Ultrasound and, when indicated for the cervical target, radiological guidance help position the electrode near the nerve.
Checks and RF application
Position and parameters are checked; sensory and motor stimulation tests may be used according to the target. Dr Panagiotakos uses a combined protocol incorporating ablative radiofrequency and neuromodulation. Their application is tailored to the nerve, treatment site and clinical findings.
Observation and discharge
After clinical review, you receive instructions for the following hours and contact details for any problems. Observation time and the return to activities are individualised.
Two approaches, a targeted choice
Distal approach: occipital ridge
Treatment can be performed along the course of the nerves at the occipital ridge. The site is identified according to the symptomatic territory and nerve target.
Proximal approach: upper cervical region
Another site used in Dr Panagiotakos’s practice is where the nerves emerge above the cervical joints. Landmarks and anatomical relationships are specific to each nerve: there is no single point applicable to all occipital nerves.
The approach depends on clinical assessment, the anaesthetic block response and visualisation of the target. Treating an occipital nerve proximally does not automatically mean performing facet joint denervation.
The combined PONOS procedure: ablation and neuromodulation
Dr Panagiotakos uses a combined approach incorporating thermal radiofrequency ablation and pulsed radiofrequency for neuromodulation. These components have different biological effects; their use is tailored to each target, without an identical protocol for every patient.
Pulsed radiofrequency (PRF)
PRF uses pulses with controlled temperature, generally limited to around 42 °C, aiming for neuromodulation without intentionally creating a thermal lesion.
It may be considered for occipital neuropathic pain and selected migraine with an occipital component. Studies do not demonstrate uniform benefit for every patient.
Thermal radiofrequency
This produces a controlled thermal lesion. It may be considered for specific targets and clinical presentations following diagnostic selection and assessment of sensory risks.
TON denervation for C2–C3 joint pain should not be confused with greater occipital nerve treatment. Changes in sensation and neuropathic pain after treatment need explicit discussion.
Learn about the differences between pulsed and thermal radiofrequency.
Recovery and follow-up
Local soreness, unusual sensations or a temporary increase in pain may occur. Immediate relief may reflect the local anaesthetic: the RF response is assessed over time according to the agreed plan.
Occipital pain
Record intensity, episode frequency, sensitivity to touch and activities you can resume.
Migraine
Continue your diary: headache days, intensity, rescue medication and limitations. Preventive treatments should only be changed with your treating clinician.
Tinnitus
Assess perceived intensity and the impact on sleep and daily life separately. Pain relief does not necessarily mean tinnitus improvement.
Benefit may last for a variable period or be insufficient. Repeat treatment is not automatic: it requires reassessment of previous benefit, diagnosis and alternatives.
Risks and symptoms to report
Risks include local pain, bleeding, infection, medication reactions, altered sensation, neuritis and nerve injury, including persistent injury. A specific risk of post-procedural neuropathic pain has been described after thermal RF of the third occipital nerve; balance disturbances may also occur.
Contact the centre for markedly increasing pain, fever, redness or discharge at the treatment site, or new persistent sensory symptoms. New weakness, difficulty walking or other sudden neurological symptoms require urgent assessment.
Assessment before choosing the procedure
The pathway starts by identifying the nerve involved and interpreting the diagnostic block response. Bring records of previous treatments and your symptom diary.
Request an assessmentCall PONOSQuestions about the procedure
Does a positive anaesthetic block guarantee success?
No. It supports the choice of target, but the response to radiofrequency may differ and is not guaranteed.
Is the procedure appropriate for every migraine?
No. It is considered in selected cases with a consistent occipital neuropathic component and a meaningful block response, as part of neurological care.
For tinnitus, is neck pain relief enough?
No. When the target symptom is somatic tinnitus associated with the third occipital nerve, significant tinnitus improvement after the selective block must also be documented. Evidence for RF in this indication remains limited.
Are all occipital nerves treated?
No. The nerve, side and technique are selected through assessment and the diagnostic block. A greater occipital nerve block does not replace a third occipital nerve block.
When can I resume normal activities?
This depends on the procedure, any sedation and your individual response. You will receive specific discharge instructions, including advice about driving and returning to work.
Evidence and further reading
Levels of evidence differ between indications: studies of PRF for headache do not establish RF effectiveness for tinnitus.
This page describes the procedural pathway and does not replace medical assessment or the centre’s individual instructions.