Occipital Neuralgia Research Articles

Severe Bilateral Glossopharyngeal Neuralgia Managed With Nerve Blocks Following Plasmodium falciparum Malaria Infection Treated With Mefloquine

BACKGROUND: The Internal Classification of Headache Disorders diagnosis for glossopharyngeal neuralgia (GN) includes recurrent paroxysmal severely painful attacks in the glossopharyngeal nerve distribution. Precipitating factors may be swallowing or talking, and diagnosis is made by exclusion. Conservative management includes medications, such as carbamazepine. For refractory cases, interventional nerve blocks may be required. CASE REPORT: A 38-year-old woman experienced severe bilateral GN and occipital neuralgia with atypical migraines after treatment with mefloquine for severe Plasmodium falciparum malaria. Symptoms included the inability to perform activities of daily living (ADLs) due to severe “electric sharp stabbing pain.” Following ineffective conservative management, she was successfully treated with a series of nerve blocks every 3 months. Over time, with repeated interventions, she acquired a significantly lower baseline of pain enabling her to participate in ADLs. CONCLUSIONS: This case report highlights nerve blocks as a viable treatment option for refractory bilateral GN following treatment with mefloquine. KEY WORDS: Glossopharyngeal neuralgia, malaria, plasmodium, falciparum, mefloquine, regional nerve blocks, stellate ganglion nerve block,glossopharyngeal nerve block

Temporary Peripheral Nerve Stimulation for the Treatment of Greater Occipital Neuralgia

BACKGROUND: Greater occipital neuralgia (GON), a cause of chronic headaches, can be debilitating and vastly affect one’s quality of life. Recent strides in comprehending the pathophysiology of GON and the ongoing evolution of approaches to the condition’s treatment have led to the pursuit of more effective interventions. Among these, temporary peripheral nerve stimulation (PNS) devices have surfaced as an avenue for management, presenting a minimally invasive yet highly efficient alternative in treating other chronic pain conditions. This study discusses a case of GON successfully managed with temporary (60-day) PNS. CASE REPORT: A 35-year-old man presented with a nearly 8-month history of intractable headaches without any inciting event along the left greater occipital nerve distribution. The patient underwent a series of 2 diagnostic GON blocks and experienced 90% pain relief. A 60-day PNS device was implanted to treat the patient’s left-side GON, and during the 6-month period, the patient received 75% pain with no complications. CONCLUSIONS: Temporary PNS is a promising treatment for painful mononeuropathies. Most PNS devices are implanted permanently to provide benefits, but this new development allows temporary stimulation devices to manage chronic pain. This case demonstrates another potential therapeutic option for pain management providers to alleviate pain in patients suffering from GON. KEY WORDS: Peripheral nerve stimulation, occipital neuralgia, chronic headache, neuromodulation, pain medicine

Reoperation Following Primary Greater Occipital Nerve Decompression Surgery: Incidence, Risk Factors and Outcomes.

Although nerve decompression surgery is an effective treatment for refractory occipital neuralgia (ON), a proportion of patients experience recurrence of pain and undergo reoperation. This study analyzes the incidence, risk factors, and outcomes of reoperation following primary greater occipital nerve (GON) decompression. 215 patients who underwent 399 primary GON decompressions were prospectively enrolled. Data included patient demographics, past medical and surgical history, reoperation rates, intraoperative findings, surgical technique, and postoperative outcomes in terms of pain frequency (days/month), duration (hours/day), intensity (scale 0-10), and migraine headache index (MHI). Bivariate analyses, univariable and multivariable logistic regression analysis was performed. 27 (6.8%) GON decompressions required reoperation with neurectomy at a median follow-up time of 15.5 months (9.8-40.5). Cervical spine disorders on imaging that did not warrant surgical intervention (OR, 4.88; 95% 1.61-14.79; p<0.01) and radiofrequency ablation (RFA) (OR, 4.20; 95% CI, 1.45-15.2; p<0.05) were significantly associated with higher rates of reoperation. At 12 months postoperatively, patients who underwent reoperation achieved similar mean reductions in pain frequency, duration, intensity and MHI, as compared to patients who underwent only primary decompression (p>0.05). Patients with ON who have a history of cervical spine disorders or RFA should be counseled that primary decompression has a higher risk of reoperation, but outcomes are ultimately comparable.

Occipital nerve stimulation in pediatric patients with refractory occipital neuralgia.

Occipital neuralgia (ON) is a disabling problem within the pediatric population. Many of these patients fail medical therapies and continue to suffer without further surgical management. Occipital nerve stimulation (ONS) is used to treat ON in the adult population leading to a 72-89% reduction in pain; however, there are limited studies regarding its use in the pediatric population. In this study, we examined the outcomes of ONS in pediatric patients with medically refractory ON. We performed a chart review of pediatric patients at our institution who have undergone ONS for the same indications. We identified 3 patients at our institution who underwent ONS trial and/or permanent implantation for ON. One patient had complete pain relief after the trial and declined permanent implantation. The other patient had fewer attacks compared to his pre-trial baseline and controlled them by adjusting his permanent implant stimulation settings. The last patient had near complete relief of her symptoms and no longer required any pain medication. Our study highlights the paucity of studies evaluating the utility of ONS in the pediatric ON population. Limited data from both the literature and our institution's experience reveal that pediatric patients may benefit from trial and/or permanent implantation of ONS for medically refractory ON pain.

Ultrasound-guided third occipital nerve (TON) blocks

Peripheral nerve blocks, including occipital nerve blocks (ONBs), have received increased attention and support as pain management tools during the previous few decades. Researchers have documented usefulness of ONBs particularly for acute headache management in the outpatient setting. The blocks also play a role in other healthcare settings, such as in the emergency department. The potential role of ONBs for the management of acute headache episodes in primary and emergency care settings is not yet fully practiced. In this paper, we will review block techniques of third occipital nerve (TON): indication, medication selection, complications and measures that can help improve safety in this procedure of headache management. Key word: Analgesia, Regional; Headache; Occipital Nerve Block; Occipital Neuralgia; Third Occipital Nerve; Ultrasound-Guide. Citation: Hidayati HB, Puspamaniar VA, Sugondo AT, Firdausa FS. Ultrasound-guided third occipital nerve (TON) blocks. Anaesth. pain intensive care 2024;28(1):166−170; DOI: 10.35975/apic.v28i1.2390 Received: October 13, 2023; Reviewed: October 18, 2023; Accepted: January 02, 2024

Ultrasound-Guided Occipital Nerve Block in the Management of Refractory Headache and Its Outcomes: A Prospective Study

Abstract Purpose Headache severely impacts health and lifestyle, causing distress and leading to accommodative changes in affected individuals. Treatment options available for refractory headache range from a conservative approach to advanced forms. The purpose of our study was to evaluate the effectiveness of ultrasound-guided occipital nerve block (ONB) in the management of refractory headaches using visual analog scale (VAS) score and Barrow Neurological Institute Pain Intensity Score (BNIPIS). Methods A study sample of 30 eligible patients with refractory headaches including occipital neuralgia, migraine, tension headache, cluster headache, and vascular headaches aged between 18 and 65 years were included in our study. VAS and BNIPIS were noted for each patient before and after the procedure. ONB was given around the target nerve under aseptic precaution. Two milliliters of 0.5% bupivacaine was used as an injection solution for all patients. Results The mean VAS score in acute pain at pre-treatment and post-treatment after 24 hours and 3 months was found as 7.53, 1.53, and 3.20, whereas in chronic pain the score was 8.13, 3.07, and 5.87, respectively. Pre-treatment pain levels in acute and chronic subjects in BNIPIS IV and V category shifted to category I and II after 24 hours (postinjection) that later were recorded II and III, respectively, after 3 months. Conclusion Standard treatment guidelines are given by the international headache association for the management of headaches. The use of ONB is well advocated and practiced for a long time. In our study, we found that the use of greater occipital nerve block reduced pain levels affecting VAS and BNIPIS, which was more effective in acute cases than in chronic cases.

Lower cranial neuropathy as a presentation of cerebral venous sinus thrombosis secondary to antiphospholipid syndrome: A case report

Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke especially among young adults. The clinical presentation of CVST is diverse, which makes the diagnosis to be challenging. Lower cranial neuropathy is a rare presentation of CVST, with few cases in literature. We are describing a case of 39-year-old male patient, presented with left occipital neuralgia, with left lower cranial neuropathies due to left transverse and sigmoid sinus thrombosis; secondary to antiphospholipid syndrome, with good response to anticoagulation.

The triangular area between the greater, lesser, and third occipital nerves and its possible clinical significance.

Occipital Neuralgia (ON) is defined as a unilateral or bilateral pain in the posterior area of the scalp occurring in the distribution area or areas of the greater occipital nerve (GON), lesser occipital nerve (LON), and/or third occipital nerve (TON). In the present study, the purpose was to show the possible importance of the triangular area (TA) in nerve block applied in ON by measuring the TA between GON, TON, and LON. A total of 24 cadavers (14 males, 10 females) were used in the present study. The suboccipital region was dissected, revealing the points where the GON and TON pierced the trapezius muscle and superficial area, and the point where the LON left the sternocleidomastoid muscle from its posterior edge and was photographed. The area of the triangle between the superficial points of these three nerves and the center of gravity of the triangle (CGT) were determined by using the Image J Software and the results were analyzed statistically. The mean TA values were 952.82 ± 313.36 mm2 and 667.55 ± 273.82 mm2, respectively in male and female cadavers. Although no statistically significant differences were detected between the sides (p > 0.05), a statistically significant difference was detected between the genders (p < 0.05). The mean CGT value was located approximately 5cm below and 3-3.5cm laterally from the external occipital protuberance in both genders and sides. In ON that has more than one occipital nerve involvement, all occipital nerves can be blocked by targeting TA with a single occipital nerve block, and thus, the side effects that may arise from additional blocks can be reduced. The fact that there was a statistically significant difference according to the genders in the TA suggests that different block amounts can be applied according to gender.

Peripheral Nervous System Pain Modulation.

The percutaneous technique of electrode insertion in the vicinity of the greater occipital nerves to treat occipital neuralgia was first described in the 1990s by Weiner and Reed. This subsequently stimulated awareness of peripheral nerve stimulation (PNS). The more recent advent emergence of a minimally invasive percutaneous approach by way of using ultrasound has further increased the interest in PNS as a viable alternative to more invasive techniques. PNS has become more popular recently and is increasingly used to treat various pain conditions. Its foundation is fundamentally based on the gate control theory, although the precise mechanism underlying its analgesic effect is still indefinite. Studies have demonstrated the peripheral and central analgesic mechanisms of PNS by modulating the inflammatory pathways, the autonomic nervous system, the endogenous pain inhibition pathways, and the involvement of the cortical and subcortical areas. Peripheral nerve stimulation exhibits its neuromodulatory effect both peripherally and centrally. Further understanding of the modulation of PNS mechanisms can help guide stimulation approaches and parameters to optimize the use of PNS. his chapter aims to review the background and mechanisms of PNS modulation. PNS is becoming one of the most diverse therapies in neuromodulation due to rapid evolution and expansion. It is an attractive option for clinicians due to the simplicity and versatility of procedures that can be combined with other neuromodulation treatments or used alone. It has a distinct role in the modulation of functional conditions.

Comparison of the Effect of Continuous Radiofrequency and Pulsed Radiofrequency Treatment on Third Occipital Neuralgia

Background: Third occipital neuralgia (TON) is an uncommon headache caused by C2-3 zygapophyseal joint osteoarthritis. Both continuous and pulsed radiofrequency have been used to treat TON. However, no studies have compared the effects of continuous radiofrequency (CRF) and pulsed radiofrequency (PRF) on TON. This study aimed to determine the most effective treatment for TON. Methods: A total of 61 patients were enrolled. CRF was performed at 80°C for 90 sec at three target lesions. During PRF, 42°C for 120 sec was applied to the target lesions. Numeric rating scale score (NRS) was assessed in all patients before treatment and at 2 weeks, 3, and 6 months after treatment. Successful treatment was defined as an NRS pain reduction of at least 50% at 6 months, as compared with the pretreatment score. Results: The mean post treatment pain scores at 2 weeks, 3, and 6 months were significantly lower in both groups. At 2 weeks and 6 months post-procedure, the CRF group showed significantly more pain reduction than the PRF group. The prevalence of pain reduction by at least 50% was lower in the PRF group than in the CRF group. The proportion of patients with &gt; 50% reduction in the NRS was 71% in the CRF versus 50% in the PRF group at the final follow-up. Conclusion: CRF was associated with earlier and longer pain reduction than PRF in patients with TON. Therefore, CRF should be recommended for patients with TON as much as possible.

A Case Report of Occipital Neuralgia Treated with Acupuncture in the Occipital Nerve Area

This case report presents the effectiveness of Korean medicine in the treatment of occipital neuralgia. The patient with occipital neuralgia was treated with acupuncture. Acupuncture treatment was administered to the occipital nerve area, which is commonly used in occipital nerve blocks by western medicine doctors. The severity of the symptoms was assessed daily using the Numerical Rating Scale (NRS) score of pain. The patient received outpatient treatment a total of 7 times, and only received acupuncture treatment each time. According to the patient, his symptoms decreased by about 90% two days after acupuncture treatment, and the frequency and duration of the symptoms also decreased. Seven days after all acupuncture treatments, the severity of pain was reduced from NRS 6 to NRS 0. The findings of this case report suggest that treatment with Korean medicine can be an effective option for treating occipital neuralgia. Acupuncture can be a good treatment method for occipital neuralgia, along with western drug treatment and occipital nerve block.

Tourette’s Syndrome cervical dystonia induced occipital neuralgia remedied by peripheral nerve stimulation: A case report

BackgroundDystonia is uncommon in Tourette’s syndrome, and occipital neuralgia secondary to Tourette's dystonia is more rare, affecting quality of life. Occipital peripheral nerve stimulation (PNS) is an excellent alternative by being adjustable and minimally invasive. Our case demonstrates occipital PNS as an effective option for refractory Tourette’s dystonia.Case PresentationA thirty-four-year-old male with poorly controlled Tourette’s cervical dystonia presented with severe occipital neuralgia. Various medications were prescribed including propranolol and amitriptyline, and bilateral third-occipital nerve rhizotomies and occipital nerve blocks were trialed. Distal nerve blocks at the occipital protuberance were most effective. Therefore, an occipital PNS trial was done, and a PNS was implanted with no complications. Upon follow-up, the patient reported drastic pain reduction.ConclusionOur case illustrates neuromodulation benefits for a rare presentation of refractory occipital neuralgia secondary to Tourette’s-related dystonia. Occipital PNS should be considered for refractory cases because it is safe, easy to implant, and effective.

Review of craniofacial pain syndromes involving the greater occipital nerve: relevant anatomy, clinical findings, and interventional management.

Craniofacial pain syndromes exhibit a high prevalence in the general population, with a subset of patients developing chronic pain that significantly impacts their quality of life and results in substantial disabilities. Anatomical and functional assessments of the greater occipital nerve (GON) have unveiled its implication in numerous craniofacial pain syndromes, notably through the trigeminal-cervical convergence complex. The pathophysiological involvement of the greater occipital nerve in craniofacial pain syndromes, coupled with its accessibility, designates it as the primary target for various interventional procedures in managing craniofacial pain syndromes. This educational review aims to describe multiple craniofacial pain syndromes, elucidate the role of GON in their pathophysiology, detail the relevant anatomy of the greater occipital nerve (including specific intervention sites), highlight the role of imaging in diagnosing craniofacial pain syndromes, and discuss various interventional procedures such as nerve infiltration, ablation, neuromodulation techniques, and surgeries. Imaging is essential in managing these patients, whether for diagnostic or therapeutic purposes. The utilization of image guidance has demonstrated an enhancement in reproducibility, as well as technical and clinical outcomes of interventional procedures. Studies have shown that interventional management of craniofacial pain is effective in treating occipital neuralgia, cervicogenic headaches, cluster headaches, trigeminal neuralgia, and chronic migraines, with a reported efficacy of 60-90% over a duration of 1-9months. Repeated infiltrations, neuromodulation, or ablation may prove effective in selected cases. Therefore, reassessment of treatment response and efficacy during follow-up is imperative to guide further management and explore alternative treatment options. Optimal utilization of imaging, interventional techniques, and a multidisciplinary team, including radiologists, will ensure maximum benefit for these patients.

A surgical decision aid for occipital neuralgia with literature review and single center case series

BackgroundOccipital neuralgia (ON) is a debilitating headache disorder. Due to the rarity of this disorder and lack of high-level evidence, a clear framework for choosing the optimal surgical approach for medically refractory ON incorporating shared decision making with patients does not exist. MethodsA literature review of studies reporting pain outcomes of patients who underwent surgical treatment for ON was performed, as well as a retrospective chart review of patients who underwent surgery for ON within our institution. ResultsThirty-two articles met the inclusion criteria. A majority of the articles were retrospective case series (22/32). The mean number of patients across the studies was 34 (standard deviation (SD) 39). Among the 13 studies that reported change in pain score on 10-point scales, a study of 20 patients who had undergone C2 and/or C3 ganglionectomies reported the greatest reduction in pain intensity after surgery. The studies evaluating percutaneous ablative methods including radiofrequency ablation and cryoablation showed the smallest reduction in pain scores overall. At our institution from 2014 to 2023, 11 patients received surgical treatment for ON with a mean follow-up of 187 days (SD 426). ConclusionBased on these results, the first decision aid for selecting a surgical approach to medically refractory ON is presented. The algorithm prioritizes nerve sparing followed by non-nerve sparing techniques with the incorporation of patient preference. Shared decision making is critical in the treatment of ON given the lack of clear scientific evidence regarding the superiority of a particular surgical method.

Comprehensive Criteria for Differential Diagnosis and a Surgical Management Algorithm for Occipital Neuralgia and Migraine Headaches

The differential diagnoses and nuances of the surgical management of occipital migraine and occipital neuralgia have not been clearly discussed in the available literature. This study aims to highlight additional diagnostic features and offers an algorithm for the surgical treatment of occipital migraine and occipital neuralgia based on the vast experience of the senior author spanning over 23 years. A retrospective cohort study was conducted to review the number and distribution of patients who underwent surgical treatment for occipital migraine headaches and neuralgia and the signs and symptoms observed. Among the 660 patients who underwent surgical treatment for headaches within the territory of the greater occipital nerves, 86 patients underwent isolated deactivation of the greater occipital site (site IV) or combined greater and lesser occipital sites (site IV and site VI surgical). Within the isolated occipital headache group, 43 patients met the criteria for migraine headaches and 43 for occipital neuralgia. Our additional observation on the differences between the occipital neuralgia and migraine groups included that occipital neuralgia is more commonly unilateral, less commonly familial, and more commonly associated with a whiplash-type injury. In addition, the patient with occipital neuralgia can consistently identify the distinct point of pain using the index finger. An ultrasound Doppler signal can also be detected at the pain site and a pulse is often palpable in the site identified by the patient. Occipital neuralgia is also commonly continuous and unrelenting, with occasional spikes of shooting pain, and is less likely to respond to botulinum toxin-A injection. Patients with occipital neuralgia often have a single-site headache while patients with migraine headaches often suffer from headaches in multiple sites. Additional clinical criteria are offered for the differential diagnosis of occipital migraine headaches and occipital neuralgia based on the vast experience of the senior author and the developed surgical management algorithm.

Occipital neuralgia early diagnosis by external eliciting of the occipital nerves: A reliability study

Occipital neuralgia early diagnosis by external eliciting of the occipital nerves: A reliability study

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

BackgroundThe 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.MethodsIn 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.ResultsPreoperatively, 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 &amp;lt; 0.01), intensity was 4 (0–6) (p &amp;lt; 0.01), and duration was 10 (0–24) h (p &amp;lt; 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.ConclusionAll 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.

Treatment delay from onset of occipital neuralgia symptoms to treatment with nerve decompression surgery: a prospective cohort study.

The aims of this study were to (1) evaluate the time between onset of occipital neuralgia symptoms and nerve decompression surgery, (2) perform a cost comparison analysis between surgical and nonsurgical treatment of occipital neuralgia, and (3) report postoperative results of nerve decompression for occipital neuralgia. Subjects (n = 1112) who underwent screening for nerve decompression surgery were evaluated for occipital neuralgia. Of those, 367 patients (33%) met the inclusion criteria. Timing of occipital neuralgia symptom onset and pain characteristics were prospectively collected. Cost associated with the nonsurgical treatment of occipital neuralgia was calculated for the period between onset of symptoms and surgery. A total of 226 patients (73%) underwent occipital nerve decompression. The average time between onset of occipital neuralgia and surgery was 19 years (7.1-32). Postoperatively, the median number of pain days per month decreased by 17 (0-26, 57%) (P < .001), the median pain intensity decreased by 4 (2-8, 44%) (P < .001), and median pain duration in hours was reduced by 12 (2-23, 50%) (P < .001). The annual mean cost of nonsurgical occipital neuralgia treatment was $28 728.82 ($16 419.42-$41 198.41) per patient. The mean cost during the 19-year time frame before surgery was $545 847.75($311 968.90-$782 769.82). This study demonstrates that patients suffer from occipital neuralgia for an average of 19 years before undergoing surgery. Nerve decompression reduces symptom severity significantly and should be considered earlier in the treatment course of occipital neuralgia that is refractory to conservative treatment to prevent patient morbidity and decrease direct and indirect health care costs.

The original nerve of a greater occipital nerve schwannoma causing occipital neuralgia identified with magnetic resonance neurography

Schwannomas are benign tumors arising from Schwann cells in the peripheral nerve and rarely develop at suboccipital area. We report a case of a greater occipital nerve schwannoma causing occipital neuralgia. The original nerve of the schwannoma was identified with Magnetic Resonance (MR) neurography. A sixty-something male patient was admitted for a suboccipital mass. Physical examination revealed an about 4 cm beaded masses subcutaneously at suboccipital area. MR imaging showed that the lesions were not suppressed on 3 dimensional T2 weighting with fat suppression. Three dimensional fusion images (3 dimensional T2 weighting with fat suppression and 3-dimensional computed tomography) clearly revealed the original nerve of the lesions. The patient underwent a complete excision on the tumor. Histopathological examination diagnosed it as a schwannoma. The MR neurography findings contributed to preoperatively diagnose the tumors as a greater occipital nerve schwannoma.

Vascularized Denervated Muscle Targets for Headache Surgery-Presentation and Surgical Management.

Patients with substantial trauma to their occipital nerves and those with recurrent or persistent chronic headaches after occipital nerve decompression surgery require transection of their greater occipital and/or lesser occipital nerves to control debilitating pain. Current techniques, such as burying the transected nerve stump in nearby muscle, do not prevent neuroma formation, and more advanced techniques, such as targeted muscle reinnervation and regenerative peripheral nerve interface, have demonstrated only short-term anecdotal success in the context of headache surgery. Vascularized denervated muscle targets (VDMTs) are a novel technique to address the proximal nerve stump after nerve transection that has shown promise to improve chronic nerve pain and prevent neuroma formation. However, VDMTs have not been described in the context of headache surgery. Here authors describe the etiology, workup, and surgical management of 2 patients with recurrent occipital neuralgia who developed vexing neuromas after previous surgery and were successfully treated with VDMTs, remaining pain-free at 3-year follow-up.