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Indications and Outcomes for Surgical Treatment of Patients with Chronic Migraine Headaches Caused by Occipital Neuralgia

Ducic, Ivica M.D., Ph.D.; Hartmann, Emily C. M.D.; Larson, Ethan E. M.D.

Plastic and Reconstructive Surgery: May 2009 - Volume 123 - Issue 5 - p 1453-1461
doi: 10.1097/PRS.0b013e3181a0720e
Reconstruction: Head and Neck: Original Articles

Background: Occipital neuralgia is a headache syndrome characterized by paroxysmal headaches localizing to the posterior scalp. The critical diagnostic feature is symptomatic response to local anesthetic blockade of the greater or lesser occipital nerve. Further characterization is debated in the literature regarding the diagnosis and optimal management of this condition. The authors present the largest reported series of surgical neurolysis of the greater occipital nerve in the management of occipital neuralgia.

Methods: A retrospective chart review was conducted to identify 206 consecutive patients undergoing neurolysis of the greater or, less commonly, excision of the greater and/or lesser occipital nerves. A detailed description of the procedure is presented, as is the algorithm for patient selection and timing of surgery. Preoperative and postoperative visual analogue pain scores and migraine headache indices were measured. Success was defined as a reduction in pain of 50 percent or greater.

Results: Of 206 patients, 190 underwent greater occipital nerve neurolysis (171 bilateral). Twelve patients underwent greater and lesser occipital nerve excision, whereas four underwent lesser occipital nerve excision alone. The authors found that 80.5 percent of patients experienced at least 50 percent pain relief and 43.4 percent of patients experienced complete relief of headache. Mean preoperative pain score was 7.9 ± 1.4. Mean postoperative pain was 1.9 ± 1.8. Minimum duration of follow-up was 12 months. There were two minor complications.

Conclusion: Neurolysis of the greater occipital nerve appears to provide safe, durable pain relief in the majority of selected patients with chronic headaches caused by occipital neuralgia.

Washington, D.C.

From the Department of Plastic Surgery, Georgetown University.

Received for publication August 27, 2008; accepted November 11, 2008.

Presented at the IVth Congress of the World Society for Reconstructive Microsurgery, in Athens, Greece, June 24 through 26, 2007.

Disclosure: None of the authors has a financial interest in any of the products mentioned in this article.

Ivica Ducic, M.D., Ph.D.; Department of Plastic Surgery; Georgetown University Hospital; Washington, D.C. 20007;

©2009American Society of Plastic Surgeons