Medical Policy: 07.01.66 

Original Effective Date: November 2014 

Reviewed: August 2017 

Revised: August 2017 

 

Benefit Application:

Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

 

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

 

Description:

Occipital neuralgia and cervicogenic headache are conditions whose diagnosis and treatment have been debated in the medical literature due to lack of expert consensus regarding their etiology and treatment. The terminology refers to specific types of headache thought to arise from impingement or entrapment of the occipital nerves and/or the upper spinal vertebrae. Compression and injury of the occipital nerves within the muscles of the neck and compression of the second and third cervical spinal nerve roots are generally felt to be responsible for the symptoms, including unilateral and occasionally bilateral head, neck and arm pain.

 

The clinical features of cervicogenic headache may mimic those associated with primary headache disorders (e.g. tension-type headaches, migraine, or hemicrania continua), making it difficult to distinguish among headache types.  The International Headache Society (IHS), created a headache classification system, the IHS criteria is regarded as the gold standard for diagnosis of all types of headaches. Headache and facial pain is classified into primary, secondary and other etiologies (painful cranial neuropathies, other facial pains and other headaches). Primary headaches are without obvious causative factors and include migraine, tension and cluster headaches. Secondary headaches include headaches attributed to injury or disorders to the head and neck (i.e. cervicogenic headache) and cranial neuralgias (i.e. occipital neuralgia).

 

Numerous treatments for headaches (e.g. migraine, cluster headaches, tension type headaches and cervicogenic headache), occipital neuralgia and atypical facial pain have been proposed, with varying levels success. The consensus on standard treatment does not exist, because of the variability in patient selection and clinical outcomes. Pharmacological treatment with oral analgesics, anti-inflammatory medications, tricyclic antidepressants, and anticonvulsant medications have been used alone or in combination with other treatment modalities. Other treatment modalities suggested are: the use of cervical collar during the acute phase; physical therapy with stretching and strengthening exercises; postural training; relaxation exercises; transcutaneous nerve stimulation (TENS); and manual therapy including spinal manipulation and spinal mobilization. Pharmacological and alternative treatment modalities are not effective for some individuals, and therefore, other treatment methods have been proposed, such as local injections of anesthetics and/or steroids, epidural steroid injections and ablative treatments to include but not limited to pulsed radiofrequency ablation; radiofrequency ablation (RFA), radiofrequency denervation, radiofrequency neurotomy, radiofrequency rhyzotomy; chemical neurolysis (chemodenervation); and cyrodenervation (cyroablation), to attempt to denervate the occipital and/or upper cervical nerve(s) for pain relief.    

 

Headaches

  • Chronic Migraine: Migraine is a common disabling primary headache disorder. Chronic migraine headache is defined as greater than or equal to 15 days per month lasting 4 hours a day or longer in an adult patient.
  • Chronic tension type headache: Frequent episodic tension type headache, with daily or very frequent episodes of headache, typically bilateral, pressing to tightening in quality and of mild to moderate intensity, lasting hours, to days or unremitting. The pain does not worsen with routine physical activity, but may be associated with mild nausea, photophobia or phonophobia.    
  • Chronic cluster headache: Chronic cluster headaches is one of the trigeminal autonomic cephalagias (TACs), a group of primary headache disorders characterized by unilateral trigeminal distribution pain that occurs in association with ipsilateral cranial autonomic features. Cluster headache is characterized by attacks of severe unilateral, orbital, supraorbital or temporal pain. In the episodic form, attacks occur daily, usually one to eight times a day for several weeks, followed by a period of remission. The chronic form of cluster headaches occur for more than 1 year without remissions, or with remission periods lasting less than 1 month.
  • Cervicogenic headache: The clinical features of cervicogenic headache may mimic those associated with primary headache disorders (e.g. tension-type headache, migraine, or hemicranias continua), making it difficult to distinguish among headache types. Cervicogenic headaches is characterized by continuous, unilateral head pain radiating from the occipital areas to the front area, with associated neck pain and ipsilateral shoulder or arm pain. The headache is moderate in intensity with non-throbbing character. It is described as dull, boring, dragging pain that can fluctuate in intensity. The duration of the headache may range from a few hours to several days, and in some cases several weeks. The pain can be exacerbated by neck movements and is usually caused by neck trauma.       
    • The anatomic point for cervicogenic headache is the trigeminocervical nucleus in the upper cervical spinal cord, where sensory nerve fibers in the descending tract of the trigeminal nerve are believed to interact with sensory fibers from the upper cervical roots. This functional intersection of upper cervical and trigeminal sensory pathways is through to allow bidirectional transmission of pain signals between the neck and the trigeminal sensory receptor fields of the face and head.
    • Cervicogenic headache is typically caused by a disorder of the cervical spine and its component bony, disc and/or soft tissue elements, usually but not invariably accompanied by neck pain.

 

The first three cervical spine nerves and their rami are the primary peripheral nerve structures that can refer to pain to the head:

  • The C1 spinal nerve (suboccipital nerve) supplies the atlanto-occipital joint. Pathology or injury affecting this joint is a potential source for pain that is referred to the occipital region of the head.
  • The C2 spinal nerve and its dorsal root ganglion have a close proximity to the lateral capsule of the atlanto-axial (C1-2) zygapoplyseal joint and supply the atlanto-axial and C2-3 zygapophyseal joints. Trauma to, or pathologic changes around, these joints can be a source of referred head pain.
  • The third occipital nerve (dorsal ramus C3) has a close anatomic proximity to, and supplies, the C2-3 zygapophyseal joint. Pan from the C2-3 zygapophyseal joint is referred to the occipital, frontotemporal and periorbital regions of the head (third occipital headache).

 

Occipital Neuralgia

Occipital neuralgia can be a cause of a headache in the occipital region which can be intermittent or continuous. The pain of occipital neuralgia has a sudden onset.  It is described as severe, stabbing, electric, shock-like, sharp or shooting. It originates in the nuchal region and immediately spreads towards the vertex. The bouts of pain may start spontaneously or be provoked by a specific maneuver such as brushing the hair, exposure to cold or moving the neck. Other causes can include myofacial tightening, trauma of C2 nerve root (whiplash injury), prior skull or suboccipital surgery, other types of nerve entrapment, idiopathic causes, sustained muscle contraction, and spondylosis of cervical facet joints.

 

On examination, pressure, palpation, or percussion over the occipital nerve trunks may reveal local tenderness, trigger painful paroxysms (increase of symptoms), or elicit paresthesia along the distribution of the affected nerve. Percussion of the nerve often reproduces the distribution of pain. Also, cervical range of motion may be restricted and local posterior neck muscle spasms may be found.

 

Occipital neuralgia is sometimes accompanied by diminished sensation or dysesthesia (abnormal sensation) in the affected area. The remainder of the neurological examination is typically normal. An abnormal neurological examination is an alert for potential alternative or underlying causes of the symptoms.

 

Diagnostic local anesthetic nerve blocks may be required for a definitive diagnosis to be obtained. The relief of pain after a diagnostic local anesthetic block of the greater and lesser occipital nerves is generally confirmatory of the diagnosis of occipital neuralgia.

 

Persistent Idiopathic Facial Pain (PIFP)/Atypical Facial Pain

Persistent idiopathic facial pain (also known as atypical facial pain), is characterized by persistent facial and/or oral pain with varying presentations but recurring daily for more than 2 hours per day over more than 3 months, in the absence of neurologic deficit.

 

Persistent idiopathic facial pain (PIFP)/atypical facial pain is most often depicted as dull, nagging or aching. It can have sharp exacerbations, and it is aggravated by stress. Pain may be described as either deep or superficial. With time, it may spread to a wider area of the craniocervical region. PIFP may be comorbid with other pain conditions such as chronic widespread pain. In addition, it presents with high levels of psychiatric comorbidity and psychosocial disability.

 

For persistent idiopathic facial pain, tricyclic antidepressants (e.g. amitriptyline) are the preferred treatment. When tricyclic medications are contraindicated or poorly tolerated, gabapentin or pregabalin are preferred alternative choices. 

 

Ablative Treatments

Ablative procedures including but not limited to pulsed radiofrequency ablation; radiofrequency ablation (RFA), radiofrequency denervation, radiofrequency neurotomy, radiofrequency rhizotmy; cryodenervation (cryoablation), and chemical neurolysis (chemodenervation) may be performed in attempt to denervate the occipital nerve (greater or lesser), upper cervical nerve (e.g. second cervical nerve also known as C2), supraorbital, supratrochlear or sphenopalatine ganglion. The proposed goal of denervation is to “shut off” the pain signals that are sent to the brain from the joints and nerves. An additional purported objective is to reduce the likelihood of, or to delay, any recurrence that may occur by selectively destroying pain fibers without causing excessive sensory loss, motor dysfunction or other complications. 

 

Ablative treatments for occipital neuralgia, chronic headaches (including but not limited to cervicogenic headache, migraines, cluster headaches, tension headaches) and persistent idiopathic facial pain (PIFP)/atypical facial pain have been proposed for pain relief.

 

Pulsed Radiofrequency Ablation

Pulsed radiofrequency (PRF) ablation has been proposed as a possibly safer alternative to non-pulsed or continuous radiofrequency ablation (RFA) in the treatment of a variety pain syndromes. Pulsed radiofrequency uses short bursts of radiofrequency current (heat is dissipated during the silent period), rather than the continuous current, which allows the needle to remain relatively cool so that the tissue cools slightly between each burst, reducing the risk of destroying nearby tissue. Pulsed radiofrequency causes the transmission across small unmyelinated nerve fibers to be disrupted, but not permanently damaged. This is because the temperature will not exceed 42 degrees Celsius, versus 80 degrees Celsius reached in non-pulsed or continuous radiofrequency ablation (RFA).

 

The available evidence from published studies is not sufficient to conclude that pulsed radiofrequency ablation is an effective treatment for occipital neuralgia, chronic headaches (including but not limited to cervicogenic headache, migraines, cluster headaches, tension headaches) and persistent idiopathic facial pain (PIFP)/atypical facial pain. Well-designed studies are needed to evaluate the potential advantages of pulsed radiofrequency ablation for these conditions and to identify which patients would benefit from this procedure. The evidence is insufficient to determine the effects of this technology on net health outcomes.

 

Radiofrequency Ablation (RFA)

A variety of terms may be used to describe percutaneous radiofrequency denervation including radiofrequency ablation (RFA), radiofrequency neuroablation, radiofrequency lesioning, radiofrequency neurotomy, radiofrequency rhizotomy and radiofrequency articular rhizolysis.

 

Radiofrequency ablation (RFA) is performed under local anesthetic with fluoroscopic guidance. A percutaneously introduced electrode applies heat (80 to 85 degrees Celsius) as a continuous flow (non-pulsed) from radio waves to selectively destroy sensory afferent nerve fibers thereby interrupting pain signals from a specific site. The destruction of the nerve may be permanent or temporary. In cases where the pain returns, the procedure may need to be repeated. Radiofrequency ablation (RFA) has been proposed for the treatment of pain associated with occipital neuralgia and chronic headaches (including but not limited to cervicogenic headache, migraines, cluster headaches, tension headaches).

 

Based on review of the peer reviewed medical literature that includes small randomized and small non-randomized studies and systemic reviews, the available evidence is limited and conflicting. Based on systematic reviews of radiofrequency ablation for the treatment of occipital neuralgia and chronic headaches (including but not limited to cervicogenic headaches, migraines, cluster headaches, tension headaches), the randomized studies did not provide strong evidence that radiofrequency ablation was effective, where a few of the non-randomized studies suggested this technique was effective. In summary, there is some evidence that radiofrequency techniques may offer a potential benefit, but this benefit has not been confirmed in adequate randomized controlled trials with sufficient sample size. Additional randomized controlled clinical trials with longer follow up and larger patient populations to include identifying which patients would benefit from radiofrequency ablation are needed. The evidence is insufficient to determine the safety and long term efficacy to support the use radiofrequency ablation for the treatment of occipital neuralgia, chronic headaches (including but not limited to cervicogenic headache, migraines, cluster headache and tension headaches) and persistent idiopathic facial pain (PIFP)/atypical facial pain.

 

Cryodenervation (Cryoablation)

Cryodenervation involves inserting a slim, laminated, double walled cryodenervation probe under local anesthesia. The cryodenervation probe has been cooled to -70 degrees Celsius by carbon dioxide, thereby freezing the pain causing nerves. However, there is lack of published data to support the safety and efficacy of this technique.  

 

Chemical Neurolysis (Chemodenervation)

Chemical neurolysis is also referred to as chemical ablation, chemodenervation or chemical denervation, involves an injection of neurolytic agent(s) such as phenol, alcohol, glycerol or hypertonic saline to denervate a nerve. The chemical ablating agent is injected into the nerve to cause the temporary degeneration of the nerve’s fibers in order to interrupt the transmission of nerve signals, usually for pain relief. However, there is lack of published data to support the safety and efficacy of this technique.

 

Summary

Based on review of the peer reviewed medical literature, the available evidence is  insufficient to conclude that ablative treatments including but not limited to pulsed radiofrequency ablation; radiofrequency ablation (RFA), radiofrequency denervation, radiofrequency neurotomy, radiofrequency rhizotmy; cryodenervation (cyroablation); and chemical neurolysis (chemodenervation) are effective treatments for occipital neuralgia, chronic headaches (including but not limited to cervicogenic headache, migraines, cluster headaches, tension headaches) and persistent idiopathic facial pain (PIFP)/atypical facial pain. Additional randomized controlled clinical trials with larger patient populations and longer follow up are needed. The evidence is insufficient to determine the effects of these ablative treatments on net health outcomes.

 

Practice Guidelines and Position Statements

International Headache Society (IHS)

In 2013, the International Headache Society issued the International Classification of Headache Disorders, 3rd Edition:

 

Chronic Migraine
  • Is a common disabling primary headache disorder
  • Headache occurring on 15 or more days per month for more than 3 months, which has the features of migraine headache on at least 8 days per month.

The IHS considers the diagnostic criteria for chronic migraine as follows:
Headache (tension-type like and/or migraine like) on ≥ 15 days per month for > 3 months and fulfilling the below criteria:

  • Occurring in a patient who has had at least five attacks fulfilling criteria below for migraine without aura or migraine with aura
  • On ≥ 8 days per month for > 3 months, fulfilling any of the following:
    • Characteristics below for migraine with aura
    • Symptoms or characteristics for migraine without aura below
    • Believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative

The IHS considers the diagnostic criteria for migraine with aura as follows:

At least five attacks fulfilling the criteria below:

  • Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
  • Headache has at least two of the following four characteristics:
    • Unilateral location
    • Pulsating quality
    • Moderate or severe pain intensity
    • Aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)
  • During headache at least one of the following:
    • Nausea and/or vomiting
    • Photophobia and phonophobia

The IHS considers the diagnostic criteria for migraine without aura as follows:

At least two attacking fulfilling the criteria below:

  • One or more of the following fully reversible aura symptoms:
    • Visual
    • Sensory
    • Speech and/or language
    • Motor
    • Brainstem
    • Retinal
  • At least two of the following four characteristics:
    • At least one aura following symptom spreads gradually over ≥ 5 minutes, and/or two or more symptoms occur in succession
    • Each individual aura symptom lasts 5-60 minutes
    • At least one aura symptoms is unilateral
    • The aura is accompanied or followed within 60 minutes, by headache 

 

Chronic Tension Headache
  • New daily persistent headache
  • Considered a primary headache disorder

The IHS considers the diagnostic criteria for chronic tension headache as follows:

Headache occurring on ≥ 15 days per month on average for > 3 months (≥ 180 days per year), fulfilling the following criteria below:

  • Lasting hours to days, or unremitting
  • At least two of the following four characteristics
    • Bilateral location
    • Pressing or tightening (non-pulsating) quality
    • Mild to moderate intensity
    • Not aggravated by routine physical activity such as walking or climbing stairs
  • Both of the following:
    • No more than one photophobia, phonophobia or mild nausea
    • Neither moderate or severe nausea nor vomiting

 

Chronic Cluster Headache
  • Is one of the trigeminal autonomic cephalalgias (TACs)
  • Considered under primary headache disorders, but may be secondary to another disorder
  • Trigeminal autonomic cephalalgias (TACs) share the clinical features of headache, which is usually lateralized, and often prominent cranial parasympathetic autonomic features, which are again lateralized and ipsilateral to the headache.

The IHS considers the diagnostic criteria for chronic cluster headache as follows:

  • Attacks fulfilling criteria for cluster headache and the criterion below
    • Occurring without remission period, or with remissions lasting < 1 month, for at least a year.

Cluster headache criteria, at least five attacks fulling the criteria below:

  • Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes (when untreated)
  • Either or both of the following:
    • At least one of the following symptoms or signs, ipsilateral to the headache:
      • Conjunctival injection and/or lacrimation
      • Nasal congestion and/or rhinorrhea
      • Eyelid edema
      • Forehead and facial swelling
      • Forehead and facial flushing
      • Sensation of fullness in the ear
      • Miosis and/or ptosis
    • A sense of restlessness or agitation
  • Attacks have a frequency between one every other day and eight per day for more than half of the time when the disorder is active.

 

Cervicogenic Headache
  • Secondary headache usually associated with cervical myofascial pain sources.
  • Headache caused by a disorder of the cervical spine and its component bony, disc and/or soft tissue elements, usually but not invariably accompanied by neck pain.  

The IHS considers the diagnostic criteria for cervicogenic headache as follows:

  • Clinical laboratory and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck, known to be able to cause headache
  • Evidence of causation demonstrated by at least two of the following: 
    • Headache has developed in temporal relation to the onset of the cervical disorder or appearance of the lesion
    • Headache has significantly improved or resolved in parallel with improvement in or resolution of the cervical disorder or lesion
    • Cervical range of motion is reduced and headache is made significantly worse by provocative maneuvers
    • Headache is abolished following diagnostic blockade of the cervical structure or its nerve supply. 

 

Occipital Neuralgia
  • Pain in the head and neck is mediated by afferent fibers in the trigeminal nerve, nervus intermedius, glossopharyngeal and vagus nerves and the upper cervical roots via the occipital nerves. Stimulation of these nerves by compression, distortion, exposure to cold or other forms of irritation or by a lesion in central pathways may rise to stabbing or constant pain felt in the area innervated.
  • Classified under painful cranial neuropathies and other facial pains  

The IHS considers the diagnostic criteria for occipital neuralgia as follows:

Unilateral or bilateral pain fulfilling the following criteria below:

  • Pain is located in the distribution of the greater, lesser and/or third occipital nerves
  • Pain has two of the following three characteristics:
    • Recurring in paroxysmal attacks lasting from a few seconds to minutes
    • Severe intensity
    • Shooting, stabbing or sharp in quality
  • Pain is associated with both of the following:
    • Dysaesthesia and/or allodynia apparent during innocuous stimulation of the scalp and/or hair
    • Either or both of the following:
      • Tenderness over the affected nerve branches
      • Trigger pointes at the emergence of the greater occipital nerve or in the area of distribution of C2
    • Pain is eased temporarily by local anesthetic block of the affected nerve

 

Persistent Idiopathic Facial Pain (PIFP)
  • Also known as atypical facial pain
  • Persistent facial and/or oral pain, with varying presentations but recurring daily for more than 2 hours per day over more than 3 months, in the absence of clinical neurological deficit.
  • Classified under painful cranial neuropathies and other facial pains

The IHS considers the diagnostic criteria for persistent idiopathic facial pain (PIFP) as follows:

Facial and/or oral pain fulfilling the following criteria below:

  • Recurring daily for > 2 hours per day for > 3 months
  • Pain has both of the following characteristics:
    • Poorly localized, and not following the distribution of a peripheral nerve
    • Dull, aching or nagging quality
  • Clinical neurological examination is normal
  • A dental cause has been excluded by appropriate investigations

 

American Society of Anesthesiologists Task Force and American Society of Regional Anesthesia and Pain Medicine

In 2010, the American Society of Anesthesiologists Task Force and American Society of Regional Anesthesia and Pain Medicine issued a practice guidelines for chronic pain management which included the following:

 

Ablative techniques include chemical denervation, cryoneurolysis or cryoablation, thermal intradiscal procedures (i.e. intervertebral disc annuloplasty (IDET), transdiscal bioaculopathy), and radiofrequency ablation.  

 

Recommendations for Ablative Techniques:

  • Chemical denervation: (e.g. alcohol, phenol or high concentration local anesthetic) should not be used in the routine care of patients with chronic non-cancer pain.
  • Cryoablation: may be used in the care of selected patients (e.g. post-thoracotomy pain syndrome, low back pain (medial branch), and peripheral nerve pain) 

 

Regulatory Status

Radiofrequency ablation (RFA) is a procedure and, therefore, is not subject to regulation by the FDA. However, the devices used to perform RFA are regulated by the FDA premarket approval process. There are numerous devices listed in the FDA 510(k) premarket approval process.

 

Prior Approval:

Prior approval is required.

 

Policy:

  • See also Medical Policy 07.01.41 Pulsed Radiofrequency
  • See also Medical Policy 07.01.58 Facet Joint Denervation
  • See also Medical Policy 07.01.51 Occipital Nerve Stimulation
  • See also Medical Policy 02.01.52 Application of Anesthesia to Sphenopalatine Ganglion for Headaches 

 

Ablative treatments, including but not limited to the following, for the treatment of occipital neuralgia and/or chronic headaches, cervicogenic headaches, migraines, cluster headaches, tension headaches and persistent idiopathic facial pain (PIFP)/atypical facial pain are considered investigational:

  • Radiofrequency ablation (RFA); Radiofrequency denervation; Radiofrequency neurotomy; Radiofrequency rhizotomy
  • Cryodenervation (cryoablation)
  • Chemical neurolysis (chemodenervation)
  • Pulsed radiofrequency ablation

 

Based on review of the peer reviewed medical literature, the available evidence is  insufficient to conclude that ablative treatments i.e. pulsed radiofrequency ablation; radiofrequency ablation (RFA), radiofrequency denervation, radiofrequency neurotomy, radiofrequency rhizotmy; cryodenervation (cyroablation); and chemical neurolysis (chemodenervation) are effective treatments for occipital neuralgia, chronic headaches (including but not limited to cervicogenic headache, migraines, cluster headaches, tension headaches) and persistent idiopathic facial pain (PIFP)/atypical facial pain. Additional randomized controlled clinical trials with longer follow up and larger patient populations to include identifying which patients would benefit from these ablative techniques are needed. The evidence is insufficient to determine the effects of these ablative techniques on net health outcomes.

 

Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.

  • 64600 Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch
  • 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guideance (fluoroscopy or CT); cervical or thoracic, single facet joint
  • 64640 Destruction by neurolytic agent other peripheral nerve or branch

 

Selected References:

  • American Headache Society American Headache Society Urges Caution in Using any Surgical Intervention in Migraine Treatment. Issued April 13, 2012.
  • International Headache Society (IHS) The International Classification of Headache Disorders (ICHD).
  • American Association of Neurological Surgeons (AANS) Patient Information Occipital Neuralgia. Updated February 2013.
  • National Institute of Neurological Disorders and Stroke Occipital Neuralgia.
  • Practice Guidelines for Chronic Pain Management: An Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 2010, V 112, no 4.
  • The American Academy of Pain Medicine Occipital Nerve Radiofrequency Ablation for Occipital Neuralgia and Headaches: Use in Special Patient Populations (Case Study).
  • The American Academy of Pain Medicine Incidence of Third Occipital Neuralgia Following Radiofrequency Denervation of the C2-3 Facet Joint.
  • National Guideline Clearing House Neck and Upper Back (Acute and Chronic), Work Loss Data Institute; 2011.
  • David M. Biondi, D.O., Cervicogenic Headache: A Review of Diagnostic and Treatment Strategies, JAOA supplement 2, Vol 105, No 4 April 2005
  • Vibhu Kapoor, et.al., Refractory Occipital Neuralgia: Preoperative Assessment with CT-Guided Nerve Block Prior to Dorsal Cervical Rhizotomy. American Journal of Neuroradiolgoy
  • J Govind, et.al., Radiofrequency Neurotomy for the Treatment of Third Occipital Headache, J Neural Neurosug Psychiatry 2003; 74:88-93. Journal of Neurology, Neurosurgery & Psychiatry
  • PubMed. Response of Cervicogenic Headaches and Occipital Neuralgia to Radiofrequency Ablation of the C2 Dorsal Root Ganglion and/or Third Occipital Nerve. Headache 2014 Mar;54(3):500-10.
  • Tiffany Vu and Akhil Chhatre, Case Report Cooled Radiofrequency Ablation for Bilateral Greater Occipital Neuralgia. Case Reports in Neurological Medicine Volume 2014, Article ID 257373. Case Reports in Neurological Medicine
  • UpToDate. Occipital Neuralgia. Ivan Garza, M.D., Topic last updated January 29, 2014.
  • UpToDate. Cervicogenic Headache. David M. Biondi, M.D., Zahid H. Bajwa, M.D.. Topic last updated May 2, 2016.
  • UpToDate. Tension Type Headache in Adults: Acute Treatment. Frederick R. Taylor, M.D.. Topic last updated July 6, 2016.
  • UpToDate. Cluster Headache: Treatment and Prognosis. Arne May, M.D.. Topic last updated March 15, 2017.
  • UpToDate. Overview of Chronic Daily Headache. Ivan Garza, M.D., Todd J. Schwedt, M.D., MSCI. Topic last updated October 26, 2016.
  • UpToDate. Chronic Migraine. Ivan Garza, M.D., Todd J. Schwedt, M.D., MSCI. Topic last updated May 12, 2015.
  • Clinical Trials
  • Institute for Clinical Systems Improvement (ICSI) Healthcare Guideline Diagnosis and Treatment of Headache. Updated January 2013.
  • Slavin Konstantin, Nersesyan Hrachya, et.al. Current Algorithm for the Surgical Treatment of Facial Pain, Head and Face Medicine July 2007
  • American Society of Anesthesiologists and American Society of Regional Anesthesia and Pain Medicine, Practice Guideline for Chronic Pain Management, Anesthesiology 2010 Vol 112. No 4
  • Medscape. Radiofrequency Treatment in Chronic Pain, Expert Rev Neurother 2010;10(3):469-474.
  • American Academy of Neurology and American Headache Society, Evidence Based Guideline Update: NSAIDs and Other Complementary Treatments for Episodic Migraine Prevention in Adults. Neurology 2012;78:1346-1363  This guideline has been retired and is no longer valid or supported by AAN
  • UpToDate. Overview of Craniofacial Pain, Zahid H. Bajwa M.D., Charles C. Ho, M.D., Sajid A. Khan M.D., Ivan Garza, M.D., Topic last updated July 21, 2015.
  • Cohen S, Peterlin LB, Fulton L, et. al. Randomized, double-blind, comparative-effectiveness study comparing pulsed radiofrequency to steroid injections for occipital neuralgia or migraine with occipital nerve tenderness. Pain 2015 December; 156(12):2585-2594
  • UpToDate. Acute Treatment of Migraine in Adults. Zahid H Bajwa M.D., Jonathan H. Smith, M.D., Topic last updated June 1, 2016.
  • UpToDate. New Daily Persistent Headache. Ivan Garza M.D., Todd J. Schwedt M.D., MSCI, Topic last updated May 23, 2016.
  • Nagar VR, Birthi P, Grider JS, et. al. Systematic review of radiofrequency ablation and pulsed radiofrequency for management of cervicogenic headache. Pain Physician 2015 Mar-Apr 18(2):109-30. PMID 25794199
  • British Association for the Study of Headache (BASH). Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-Type Headache, Cluster Headache, Medication-Overuse Headache.
  • Govind J, King W, Bailey B, Bogduk N. Radiofrequency neurotomy for the treatment of third occipital headache. J Neurol Neurosurg Psychiatry. 2003 Jan;74(1):88-93.
  • Halim W, Chua NH, Vissers KC. Long-term pain relief in patients with cervicogenic headaches after pulsed radiofrequency application into the lateral atlantoaxial (C1—2) joint using an anterolateral approach. Pain Pract. 2010 Jul-Aug;10(4):267-71
  • Haspeslagh SR, Can Suijlekom HA, Lame IE. et. al. Randomized controlled trial  of cervical radiofrequency lesions as a treatment for cervicogenic headache. BMC Anesthesiol 2006 Feb 16;6:1. PMID 16483374
  • Huang JH, Galvagno SM Jr, Hammed M, et. al. Occipital nerve pulsed radiofrequency treatment: a multi-center study evaluating predictors of outcome. Pain Med. 2012 Apr;13(4):489-98. PMID 22390409
  • Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Diagnosis and Treatment of Headache.
  • Lee JB, Park JY, Park J, et. al. Clinical efficacy of radiofrequency cervical zygapophyseal neurotomy in patients with chronic cervicogenic headache. Korean Med Sci 2007 Apr;22(2):326-9. PMID 17449944
  • Manolitsis N, Elahi F. Pulsed radiofrequency for occipital neuralgia. Pain Physician 2014 Nov-Dec;17(6):E709-17. PMID 25415786
  • Nagar VR, Birthi P, Grider JS, et. al. Systematic review of radiofrequency ablation and pulsed radiofrequency for management of cervicogenic headache. Pain Physician 2015 Mar-Apr;18(2):109-30. PMID 25794199
  • National Clinical Guideline Center (NICE). Headaches in over 12s: diagnosis and management. Clinical Guideline (CG 150) Published 2012, Last updated November 2015.
  • Stovner LJ, Kolstad F, Helde G. Radiofrequency denervation of facet joints C-2-C6 in cervicogenic headache: a randomized, double blind, sham-controlled study. Cephalgia. 2004 Oct;24(10):821-30. PMID 15377312
  • Vanelderen P, Rouwette T, De Vooght P, et. al. Pulsed radiofrequency for the treatment of occipital neuralgia: a prospective study with 6 months of follow-up. Reg Anesth Pain Med 2010 Mar-Apr;35(2):148-51. PMID 20301822
  • Zhang J, Shi DS, Wang R. Pulsed radiofrequency of the second cervical ganglion (C2) for the treatment of cervicogenic headache. J Headache Pain 2011 Oct;12(5):569-71. PMID 21611808     
  • UpToDate. Preventative Treatment of Migraines in Adults. Zahid H. Bajwa M.D. Jonathan H. Smith M.D. Topic last updated May 31, 2017.  
  • UpToDate. Tension Type Headaches in Adults: Preventative Treatment. Frederick R. Taylor M.D., Topic last updated June 16, 2016.

 

Policy History:

  • August2017 - Annual Review, Policy Revised
  • October 2016 - Annual Review, Policy Revised
  • October 2015 - Annual Review, Policy Revised
  • November 2014 - New Policy

Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

 

*CPT® is a registered trademark of the American Medical Association.