Ultrasound-guided needle-knife release for treatment-refractory cervicogenic headache: a case report

Cervicogenic headache (CEH) is a chronic secondary headache syndrome originating from the upper cervical spine. Although conventional treatments such as pharmacological management, nerve blocks, and radiofrequency ablation are effective for many patients, a subset remains refractory to standard therapies. Soft tissue adhesions around the atlas (C1) are a potential but often overlooked pain generator. This report describes the successful management of intractable CEH through use of ultrasound-guided needle-knife release targeting the transverse process of the atlas.

A 32-year-old male presented with a 15-year history of persistent, left-sided pulsatile headache following cervical trauma. The patient had previously undergone extensive treatments, including oral analgesics, C2 nerve blocks, pulsed radiofrequency, and "blind" (nonvisualized) needle-knife therapy, all of which failed to provide sustained relief. Physical examination revealed distinct tenderness at the posterior arch of the atlas. Under high-frequency ultrasound guidance, we identified the transverse process of the atlas and performed precise needle-knife release on the adherent soft tissues attached to the bone surface. This visualized approach allowed for the safe avoidance of critical neurovascular structures such as the vertebral artery. Following a course of six weekly sessions, the patient reported a 90% reduction in pain intensity. At the 6-month follow-up, the therapeutic effect was sustained without recurrence, and the patient's quality of life and daily functioning were significantly improved.

This case highlights that soft tissue pathology around the C1 transverse process can be a critical etiology in refractory CEH. Conventional "blind" needle-knife therapy may fail due to safety concerns limiting the depth of release. Ultrasound-guided needle-knife therapy offers a visualized, safe, and precise minimally invasive alternative for patients unresponsive to traditional C2-targeted therapies, allowing for the effective release of deep soft tissue adhesions.