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. 2023 Nov 28:14:1284101.
doi: 10.3389/fneur.2023.1284101. eCollection 2023.

Refractory occipital neuralgia treatment with nerve decompression surgery: a case series

William G Austen Jr  1 , Katya Remy  1 , Kathryn Packowski  1 , Merel H Hazewinkel  2 , Lisa Gfrerer  2 , Paul G Mathew  3   4
Affiliations

Refractory occipital neuralgia treatment with nerve decompression surgery: a case series

William G Austen Jr et al. Front Neurol. .

Abstract

Background: The management of refractory occipital neuralgia (ON) can be challenging. Selection criteria for occipital nerve decompression surgery are not well defined in terms of clinical features and best preoperative medical management.

Methods: In total, 15 patients diagnosed with ON by a board-certified, fellowship-trained headache specialist and referred to a plastic surgeon for nerve decompression surgery were prospectively enrolled. All subjects received trials of occipital nerve blocks (NB), at least three preventive medications, and onabotulinum toxin (BTX) prior to surgery before referral to a plastic surgeon. Treatment outcomes included headache frequency (headache days/month), intensity (0-10), duration (h), and response to medication/injectable therapies at 12 months postoperatively.

Results: Preoperatively, median headache days/month was 30 (20-30), intensity 8 (8-10), and duration 24 h (12-24). Patients trialed 10 (±5.8) NB and 11.7 (±9) BTX cycles. Postoperatively, headache frequency was 5 (0-16) days/month (p < 0.01), intensity was 4 (0-6) (p < 0.01), and duration was 10 (0-24) h (p < 0.01). Median patient-reported percent resolution of ON headaches was 80% (70-85%). All patients reported improvement of comorbid headache disorders, most commonly migraine, and a reduction, discontinuation, or increased effectiveness of medications, NB and BTX.

Conclusion: All patients who underwent treatment for refractory ON by a headache specialist and plastic surgeon benefited from nerve decompression surgery in various degrees. The collaborative selection criteria employed in this study may be replicable in clinical practice.

Keywords: headache; migraine; nerve decompression surgery; occipital neuralgia; outcomes; pain.

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Conflict of interest statement

PM was employed by Harvard Vanguard Medical Associates. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Greater occipital nerve (GON) decompression surgery through a 5 cm vertical midline incision in the posterior scalp. (A) Thickened trapezius fascia is shown. The GON is not yet visible as it is stuck within the thickened fascia. (B) Thickened trapezius fascia has been elevated, and the GON has been dissected free.
See this image and copyright information in PMC

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