Occipital Neuralgia Research Articles

Morphological features of the greater occipital nerve and its possible importance for interventional procedures.

Being one of the most prevalent neurological symptoms, headaches are burdensome and costly. Blocks and decompression surgeries of the greater occipital nerve (GON) have been frequently used for migraine, cervicogenic headache, and occipital neuralgia which are classified under headache by International Headache Society. Knowledge of complex anatomy of GON is crucial for its decompression surgery and block. This study was performed to elucidate anatomical features of this nerve in detail. Forty-one cadavers were dissected bilaterally. According to its morphological features, GON was classified into four main types that included 18 subtypes. Moreover, potential compression points of the nerve were defined. The number of branches of the GON up to semispinalis capitis muscle and the number of its branches that were sent to this muscle were recorded. The most common variant was that the GON pierced the aponeurosis of the trapezius muscle, curved around the lower edge of the obliquus capitis inferior muscle, and was loosely attached to the obliquus capitis inferior muscle (Type 2; 61 sides, 74.4%). In the subtypes, the most common form was Type 2-A (44 sides, 53.6%), in which the GON pierced the aponeurosis of each of the trapezius muscle and fibers of semispinalis muscle at one point and there was a single crossing of the GON and occipital artery. Six potential compression points of the GON were detected. The first point was where the nerve crossed the lower border of the obliquus capitis inferior muscle. The second and third points were at its piercing of the semispinalis capitis muscle and the muscle fibers/aponeurosis of the trapezius, respectively. Fourth, fifth, and sixth compression points of GON were located where the GON and occipital artery crossed each other for the first, second, and third times, respectively. On 69 sides, 1-4 branches of the GON up to the semispinalis capitis muscle were observed (median = 1), while 1-4 branches of GON were sent to the semispinalis capitis muscle on 67 sides (median = 1). The novel anatomical findings described in this study may play a significant role in increasing the success rate of invasive interventions related with the GON.

Peripheral Nerve Stimulation for Pain Management: A Review.

Peripheral nerve stimulation has seen a recent upsurge in utilization for various chronic pain conditions, specifically from a neuropathic etiology, where a single peripheral nerve can be pinpointed as a culprit for pain. There is conflicting evidence about the efficacy and long-term outcomes of peripheral nerve stimulation for chronic pain, with most studies being small sized. The focus of this article is to review available evidence for the utilization of peripheral nerve stimulation for chronic pain syndromes as well as upcoming evidence in the immediate postoperative realm. The indications for the use of PNS have expanded from neuropathic pain such as occipital neuralgia and post-amputation pain, to more widespread disease processes such as chronic low back pain. Percutaneous PNS delivered over a 60-day period may provide significant carry-over effects including pain relief, potentially avoiding the need for a permanently implanted system while enabling improved function in patients with chronic pain.

Radiofrequency ablation of the occipital nerves for treatment of neuralgias and headache.

The purpose of this study was to retrospectively assess the efficacy of radiofrequency ablation (RFA) therapy as a treatment for occipital neuralgias and headaches at health clinics in the United States between January 1, 2015 and June 20, 2022. We hypothesize that RFA is a minimally invasive treatment that provides significant pain relief long-term for occipital neuralgias and associated headaches. This retrospective analysis studies data collected from 277 occipital nerve RFA patients who had adequate pre-procedure and post-procedure follow-up for data analysis. Data collected includes the patient's age, biological sex, BMI, headache diagnosis, pre-procedure, and post-procedure pain score using the visual analog scale (VAS), subjective percent improvement in symptom(s), and duration of symptom relief. Statistical analysis used SPSS software, version 26 (IBM), using a paired t-test to assess the significance between pre and post-occipital RFA therapy pain scores. p-values were significant if found to be ≤0.05. The mean pre-procedure pain score before RFA therapy for patients who completed at least 6 months of follow-up was 5.57 (SD = 1.87) and the mean post-procedure pain score after RFA therapy was 2.39 (SD = 2.42). The improvement in pain scores between pre-procedure and post-procedure was statistically significant with a p-value < 0.001. The mean patient-reported percent improvement in pain following RFA therapy was 63.53% (SD = 36.37). The mean duration of pain improvement was 253.9 days after the initiation of therapy (SD = 300.5). When excluding patients who did not have any relief following their RFA procedure, the average pre-procedure pain score was 5.54 (SD = 1.81) and post-procedure pain score was 1.71 (SD = 1.81) with a p-value < 0.001. This study demonstrates the minimally invasive, safe, and effective treatment of RFA in patients with refractory occipital neuralgias and headaches. Additional studies are necessary to illuminate ideal patient characteristics for RFA treatment and the potential for procedural complications and long-term side effects associated with occipital nerve RFA therapy.

Surgical management of pediatric occipital neuralgia: a single-center experience of an uncommon pathology.

Occipital neuralgia (ON) is a rare headache disorder characterized by sharp pain in the distribution of the greater occipital nerve (GON), lesser occipital nerve, or third occipital nerve. ON is commonly associated with traumatic injury, and effective identification and diagnosis can be difficult given the infrequent presentation and similarities to other pediatric headache disorders. While GON decompression has been well described in adults for refractory pain, there is a paucity of data in the pediatric population, with no previously published series on ON. The primary aim of this study was to identify the characteristics of pediatric patients with ON prior to surgical intervention and to describe the natural history of postoperative outcomes after decompression or neurectomy in a pediatric population. A single-center retrospective case series was performed to evaluate factors predisposing children to refractory ON and the surgical efficacy of GON decompression or neurectomy. Six patients (mean age 15.0 ± 2.2 years) were identified for inclusion from October 2021 to October 2022. All patients had refractory ON as diagnosed by a pediatric neurologist. After medical therapy and repeated occipital nerve blocks failed, the patients were referred for GON decompression. Five patients had a history of trauma. Six patients were identified and treated in our cohort, highlighting the infrequency of this pathology. All had at least one occipital nerve block, with 83% receiving varied relief. All underwent bilateral decompression or neurectomy of the GON and experienced relief, reporting improved visual analog scale scores (mean 8.3 ± 0.9 preoperatively to 1.0 ± 2.2 postoperatively, p = 0.0009). The patients were followed for an average of 10 months, and their mean number of medications decreased from 2.7 ± 0.5 preoperatively to 0.8 ± 0.7 postoperatively (p = 0.019). Each patient reported numbness or tingling in the GON distribution postoperatively, which spontaneously resolved over time. Two patients had recurrent pain in a delayed fashion. GON decompression and neurectomy are efficacious treatments of refractory ON in the pediatric population.

Post-Traumatic Headache: A Review of Prevalence, Clinical Features, Risk Factors, and Treatment Strategies.

Post-traumatic headache (PTH) is a common and debilitating consequence of mild traumatic brain injury (mTBI) that can occur over one year after the head impact event. Thus, better understanding of the underlying pathophysiology and risk factors could facilitate early identification and management of PTH. There are several factors that could influence the reporting of PTH prevalence, including the definition of concussion and PTH. The main risk factors for PTHs include a history of migraines or headaches, female gender, younger age, greater severity of the head injury, and co-occurring psychological symptoms, such as anxiety and depression. PTH clinical profiles vary based on onset, duration, and severity: tension-type headache, migraine headaches, cervicogenic headache, occipital neuralgia, and new daily persistent headache. Pharmacological treatments often consist of analgesics and non-steroidal anti-inflammatory drugs, tricyclic antidepressants, or antiepileptic medication. Cognitive behavioral therapy, relaxation techniques, biofeedback, and physical therapy could also be used for PTH treatment. Our work highlighted the need for more rigorous studies to better describe the importance of identifying risk factors and patient-centered treatments and to evaluate the effectiveness of the existing treatment options. Clinicians should consider a multidisciplinary approach to managing PTH, including pharmacotherapy, cognitive behavioral therapy, and lifestyle changes.

The Occipital Nerves Applied Strain Test to Support Occipital Neuralgia Diagnosis.

Occipital neuralgia (ON) is a disabling cephalalgia form with demanding diagnostic workflow. We report the description and reliability analyses of the occipital nerves-applied strain (ONAS) test for occipital neuralgia (ON) early-stage diagnosis in cephalalgia patients. In a retrospective and observational study, we evaluated, among n = 163 consecutive cephalalgia patients, the sensitivity, specificity, and prior probability [positive (PPV) and negative (NPV) predictive values] of the ONAS test against two reference tests (occipital nerve anesthetic block and the painDETECT questionnaire). Multinomial logistic regression (MLR) and χ2 analyses verified the ONAS test outcome's dependence upon independent variables (gender, age, pain site, block test, and painDETECT outcomes). We assessed inter-rater agreement with Cohen's kappa statistic. ONAS test showed sensitivity and specificity of 81 and 18%, respectively, against the painDETECT and of 94 and 46%, respectively, against the block test. PPV was > 70% against both tests, while NPV was 81% against the block test and 26% against the painDETECT. Interrater agreement Cohen's kappa was excellent. Significant association (χ2 analyses) and relationship (MLR) were found only between ONAS test and pain site but not with the other independent predictors. The ONAS test showed satisfactory reliability among cephalalgia patients; thus, it might be considered a valuable early stage tool for ON diagnosis in these patients.

ID: 206943 Real-world Evidence of Pain Relief Following 60-Day Occipital Nerve Stimulation for Head and Neck Pain

The occipital nerves are a common interventional target for head and neck pain related to conditions such as occipital neuralgia and cervicogenic headache. Percutaneous 60-day Peripheral Nerve Stimulation (PNS) treatment has demonstrated efficacy both clinically and in the real-world across a range of nerve targets including the occipital nerves. The present work is a retrospective review of outcomes following 60-day peripheral nerve stimulation treatment targeting the occipital nerves in routine clinical practice.

Can exostoses of the external occipital protuberance and superior nuchal lines cause headache? A report of two cases

Compression of the occipital nerves can cause occipital headache. Several potential compression points have been identified along their course. One of these points is the hitherto undescribed instance of exostoses of anatomic structures of the occipital bone. A 34-year-old man with a prominent external occipital tuberance and superior nuchal lines complained of headache in the area of distribution of the greater occipital nerve with tenderness near the bony protrusion on palpation. A 44-year old woman experienced stabbing pain in the lateral orbital region with pressure on the ossified insertion of the ipsilateral trapezius muscle near the external occipital protuberance. Local nerve block achieved temporary relief of pain. Exostosis of the external occipital protuberance and superior nuchal lines may impinge on the greater and third occipital nerves. The characteristics of the pain in our cases differ in some aspects from those of occipital neuralgia.

ID: 215795 Occipital Nerve Stimulator After Cervical Fusion for Cervicogenic Headaches

A 50-year-old male with severe multilevel cervical degenerative disc disease and disc herniation requiring discectomy and fusion at C3- T1 presented to the clinic due to constant severe headaches for 3 months post-surgery. He had throbbing pain mainly located along the cervical paraspinals and occipitalis. He tried multiple oral pain medications with minimal relief. The patient had also tried multiple occipital nerve blocks with minimal relief. The pain was thought to be originating from the cervical fusion coming specifically from the C2-C3. The third occipital nerve is the superficial medial branch of the C3 dorsal ramus. It supplies part of the semispinalis capitis muscle leading to the occipital neuralgia that he was experiencing. It was thought the patient would be a great candidate for an occipital nerve stimulator. The nerve stimulator leads were placed in a horizontal orientation at the base of the skull across from where the greater occipital nerve emerges.

The importance of manual therapy in occipital neuralgia case study

Occipital neuralgia is defined by the International Classification of Headache Disorders (ICHD-3) as unilateral or bilateralparoxysmal pain in the distribution of the greater, lesser, and third occipital nerves. The aim of this case study is to presentthe importance of manual therapy in occipital neuralgia treatment caused by stereotactic head frame employment.A 58-year-old female patient admitted to the physiotherapy practice for reason of headache, diagnosed as occipitalneuralgia, persist for one and a half year. The patient underwent three manual therapy treatment units, three weeksapart. Relief of pain and an increased ROM of the cervical spine was achieved. In 1-, 2- and 3-months follow-up, therewas no recurrence of pain and no deterioration of the examined functions. The use of manual therapy in the discussedproblem may be an effective form of treatment.

Long term outcomes of occipital nerve stimulation.

Occipital nerve stimulation (ONS) has been investigated as a potential treatment for disabling headaches and has shown promise for disorders such as chronic migraine and cluster headache. Long term outcomes stratified by headache subtype have had limited exploration, and literature on outcomes of this neuromodulatory intervention spanning 2 or more years is scarce. We performed a narrative review on long term outcomes with ONS for treatment of headache disorders. We surveyed the available literature for studies that have outcomes for 24 months or greater to see if there is a habituation in response over time. Review of the literature revealed evidence in treatment of occipital neuralgia, chronic migraine, cluster headache, cervicogenic headache, short lasting unilateral neuralgiform headache attacks (SUNHA) and paroxysmal hemicrania. While the term "response" varied per individual study, a total of 17 studies showed outcomes in ONS with long term sustained responses (as defined per this review) in the majority of patients with specific headache types 177/311 (56%). Only 7 studies in total (3 cluster, 1 occipital neuralgia, 1 cervicogenic headache, 1 SUNHA, 1 paroxysmal hemicrania) provided both short-term and long-term responses up to 24 months to ONS. In cluster headache, the majority of patients (64%) were long term responders (as defined per this review) and only a minority of patients 12/62 (19%) had loss of efficacy (e.g., habituation). There was a high number 313/439 (71%) of adverse events per total number of patients in the studies including lead migration, requirements of revision surgery, allergy to surgical materials, infection and intolerable paresthesias. With the evidence available, the response to ONS was sustained in the majority of patients with cluster headache with low rates of loss of efficacy in this patient population. There was a high percent of adverse events per number of patients in long term follow-up and likely related to the off-label use of leads typically used for spinal cord stimulation. Further longitudinal assessments of outcomes in occipital nerve stimulation with devices labelled for use in peripheral nerve stimulation are needed to evaluate the extent of habituation to treatment in headache.

Postoperative changes in nonspecific low back pain after atlantoaxial stabilization surgery

Objectives: Posterior atlantoaxial stabilization can be technically challenging. Postoperative C2 nerve dysfunction occurs as a complication of this procedure or when a lateral mass is exposed and sacrificed for screw placement. Patients with cervical pathology sometimes complain of low back pain simultaneously. In this study, we aimed to investigate the results of C1-C2 posterior stabilization and C2 nerve root sacrifice on postoperative lumbar complaints. Methods: Twenty-six patients who underwent multicentric posterior C1-C2 stabilization due to atlantoaxial dislocation were retrospectively included in the study. Those that were not sacrificed the C2 nerve root during stabilization were considered group 1 (n = 12), and those that were sacrificed the C2 nerve root were considered group 2 (n = 14). A visual Analogue Scale (VAS) was used for the neck, arm, low back, and leg pain. The EQ-5D Index was used as the overall quality of life scale. Results: Six months postoperatively, both groups showed significant (p &amp;lt; 0.01) improvement in VAS neck, arm, and low back scores between preoperative and postoperative. In addition, there was no significant improvement in the VAS leg and EQ-5D score in either of the groups. While no significant decrease was found in occipital neuralgia in group 1, it showed significant (p &amp;lt; 0.01) improvement in occipital neuralgia in group 2. Conclusions: Although the exact pathophysiology is unknown, cervical stabilization surgery and sacrification of the C2 nerve root in this surgery can, directly and indirectly, improve low back pain.

Endoscope-Assisted Greater Occipital Nerve Decompression for Migraines, Occipital Neuralgia, and New Daily Persistent Headaches.

In the occipital trigger site for migraine, the greater occipital nerve (GON) is thought to be irritated by surrounding structures, including the semispinalis capitis muscle and occipital artery (OA), producing headaches in the back of the neck. Thus, standard decompression involves removal of surrounding tissue and dissection away from the vessel. The authors noticed a consistent pattern between the GON and OA more distally: the OA approaching laterally and diving under the GON, the OA looping back over the GON and intertwining with the medial branch of the GON, and lastly the OA traveling parallel to the GON. The technique described uses a modified endoscopic approach with a counter incision, endoscopic assistance, and radical artery lysis to address distal sites in addition to the standard release. At the counter incision, distal intertwining between vessel and nerve was released. A high-definition endoscope was used to address dynamic compression points more proximally, including hidden areas where the vessel dives under the GON, as well as to facilitate cautery and removal of the vessel. Without the use of an endoscope and counterincision, it is difficult to achieve complete decompression of the nerve distally without injury to the proximal body of the nerve.

Commentary: Minimally Invasive Preganglionic C2 Root Section for Occipital Neuralgia: 2 Case Reports and Operative Video.

*Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA; ‡Neurology Service, Jesse Brown Veterans Administration Medical Center, Chicago, Illinois, USA Correspondence: Konstantin V. Slavin, MD, Department of Neurosurgery, University of Illinois at Chicago, 912 South Wood St., M/C 799, Chicago, IL60612, USA. Email: [email protected]

Diagnosis and treatment of occipital neuralgia: focus on greater occipital nerve entrapment syndrome

Background: Occipital neuralgia is defined as paroxysmal shooting, or stabbing pain in the posterior part of the scalp, in the distribution of the greater and lesser occipital nerves. Occipital neuralgia may present only as an intermittent stabbing pain, but different opinions exist on its cause and diagnostic criteria.Current Concepts: According to the latest version of headache classification, only paroxysmal stabbing pain is included in the diagnostic criteria, and persistent aching pain is excluded. Pain intensity was also limited to severe cases. It has therefore become difficult to classify existing occipital neuralgia, whose main symptom is persistent pain rather than paroxysmal stabbing pain. Occipital neuralgia is classified as either idiopathic or secondary. Secondary occipital neuralgia is caused by structural lesions innervating the trigeminocervical complex (TCC) in the upper spinal cord, the dorsal root of second cervical cord, and the greater occipital nerve (GON).Discussion and Conclusion: Although idiopathic occipital neuralgia has no cause, the entrapment of the GON in the tendinous aponeurotic attachment of the trapezius muscle at the superior nuchal line has recently been proposed as an etiology. Chronic, irritating afferent input of occipital neuralgia caused by entrapment of the GON seems to be associated with sensitization and hypersensitivity of the second-order neurons in the TCC receiving convergent input from trigeminal and occipital structures. TCC sensitization induces referred pain in the facial trigeminal area.

Occipital neuralgia in multiple sclerosis: Successful ultrasound-guided diagnostic occipital nerve block and treatment with cryoablation

Occipital neuralgia in multiple sclerosis: Successful ultrasound-guided diagnostic occipital nerve block and treatment with cryoablation

Migraines, occipital neuralgia, and cluster headaches What are the treatments when nothing else works?

Migraines, occipital neuralgia, and cluster headaches What are the treatments when nothing else works?

Ultrasound-Guided Greater Occipital Nerve Hydrodissection for Treatment of Cervicogenic Headache: A Case Report

We describe an innovative technique of ultrasound-guided greater occipital nerve (GON) hydrodissection for treatment of cervicogenic headache and occipital neuralgia. A 35-year-old female presented to the pain clinic with severe chronic cervicogenic headache impacting her sleep, work and activities of daily living. Conservative management had failed to adequately resolve her pain. Ultrasound-guided suboccipital hydrodissection of the greater occipital nerve was performed with the patient in the prone position. After skin sterilization, the linear ultrasound transducer was oriented in a transverse orientation at the level of the C2-C3 vertebrae. The needle was advanced from medial to lateral “in-plane” under direct ultrasound visualization, until the needle was positioned at the C2 lamina. After confirming the needle tip position, 10 ml of hydrodissection fluid was injected with good visualization of distribution of the solution. The patient described immediate and significant improvement in her symptoms. She reported a sustained decrease in pain scores when followed up in the pain clinic at six and twelve weeks respectively. To the best of our knowledge this is the first application of ultrasound-guided hydrodissection of the GON for cervicogenic headache. It offers a novel, safe and effective technique to aid in the diagnosis and treatment of a common pain condition.

Management of Bilateral Cervical Headache with Right-sided Cooled Radiofrequency Ablation of the Second and Third Cervical Median Branch

This report describes a case of bilateral cervicogenic headache treated with cooled radiofrequency ablation (RFA). The case is considered to review a longstanding cervicogenic headache and the use of cooled RFA of cervical facet joint as a treatment of choice. In this case, a 50-year-old female patient with intermittent dull aching bilateral headache in occipital, temporal, and cervical region for 20 years was diagnosed with bilateral greater occipital neuralgia. She underwent cooled RFA of unilateral right-sided 3rd occipital nerve (cervical 2/3 facet joint) with minimal or no side effects and 100% pain reduction at 24 h of follow-up. After 4 weeks of follow-up, the patient reported a single incident where she experienced pain that settled with medication and had a lower intensity as compared to that which was experienced before the procedure. Cooled RFA of the cervical facet joint in challenging cases can be a line of treatment to alleviate pain with lower side effects and potential for long-term efficacy.

Evidence-Based Patient Selection in Headache Surgery: Impact of Preoperative Radiofrequency Ablation on Surgical Outcomes.

Radiofrequency ablation (RFA) of the greater occipital nerve (GON) is a minimally invasive treatment option commonly used in patients with occipital neuralgia. Patients who undergo occipital surgery for headaches after failed RFA treatment present a unique opportunity to evaluate RFA-treated occipital nerves and determine the impact on headache surgery outcomes. Of 115 patients who underwent headache surgery at the occipital site, 29 had a history of RFA treatment. Migraine Headache Index, Pain Self- Efficacy Questionnaire, and Pain Health Questionnaire-2 outcome scores were recorded preoperatively and at follow-up visits. Intraoperative macroscopic nerve damage and surgical outcomes were compared between RFA-treated and non-RFA-treated patients. RFA-treated patients had a higher rate of macroscopic nerve damage (45%) than non-RFA-treated patients (24%) ( P = 0.03), and they were significantly more likely to require a second operation at the site of primary decompression (27.6% versus 5.8%; P = 0.001) and GON transection (13.8% versus 3.5%; P = 0.04). Outcome scores at the last follow-up visit showed no statistically significant difference between RFA-treated and non-RFA-treated patients ( P = 0.96). RFA-treated patients can ultimately achieve outcomes that are not significantly different from non-RFA-treated patients in occipital headache surgery. However, a higher number of secondary operations at the site of primary decompression and nerve transection are required to treat refractory symptoms. RFA-treated patients should be counseled about an increased risk of same-site surgery and possible GON transection to achieve acceptable outcomes. Therapeutic, III.