Abstract
BACKGROUND: 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. CASE DESCRIPTION: 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. CONCLUSIONS: 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.