occipital neuralgia and cervicogenic, cluster and migraine headaches

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authors reported that all patients were generally pain free during the 1- to 3-month period when the patients wore cervical collars restricting movement, but only 5 out of 32 patients remained pain free 3 years after surgery. The mean duration of improvement was 14.8 months (range, 1 to 58 months) (Jansen and Sjaastad, 2007). In another study, Jansen (2008) summarized the results of cervical disc removal in 60 patients with long lasting severe unilateral (n = 32) or bilateral (n = 28) cervicogenic headache unresponsive to other treatment options. Sixty-three per cent of the unilateral and 64% of the bilateral cases had long lasting pain freedom or improvement. After secondary deterioration (in 37% of patients with unilateral and in 36% with bilateral CEH) and further treatments, the final mean improvement was 73% and 66%, respectively. The mean observation time was short (19.8 to 25.5 months). These conclusions are limited by the small sample size in the reported studies. 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. 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 investigators found that 80.5% of patients experienced at least 50% pain relief and 43.4% of patients experienced complete relief of headache. Minimum duration of follow-up was 12 months. (Ducic et al., 2009). Interpretation of these findings is limited due to the retrospective design of the study. In a retrospective chart review, Acar et al. (2008) evaluated 20 patients who underwent C2 and/or C3 ganglionectomies for intractable occipital pain. All patients reported preoperative pain relief following cervical nerve blocks. The mean follow-up was 42.5 months. Average visual analog scale scores were 9.4 preoperatively and 2.6 immediately after procedure. Ninety-five percent of patients reported shortterm pain relief (
A retrospective analysis was performed on 18 consecutive patients with migraine headaches who had undergone various combinations of surgical decompression of the supraorbital, supratrochlear, and greater occipital nerves and zygomaticotemporal neurectomy. These surgeries were performed by a single surgeon. The number of migraines per month and the pain intensity of migraine headaches decreased significantly. Three patients (17 percent) had complete relief of their migraines, and 50 percent of patients (nine of 18) had at least a 75 percent reduction in the frequency, duration, or intensity of migraines. Thirty-nine percent of patients discontinued all migraine medications. Mean follow-up was 16 months (range, 6 to 41 months) after surgery. One hundred percent of participants stated they would repeat the surgical procedure. According to the investigators, this study confirms prior published results and supports the theory that peripheral nerve compression triggers a migraine cascade. The investigators also stated that a significant amount of patient screening is required for proper patient selection and trigger site identification for surgical success (Poggi et al. 2008). While this study showed a treatment effect, the small sample size, retrospective design, short follow-up, and the different surgical procedures used, limits the generality of the findings to a larger population. Williams et al. (2010) reported on nine cases of conjunctival injection and tearing (SUNCT) syndrome and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) that failed medical treatment. The patients had an aberrant arterial loop either in contact with or compressing the appropriate trigeminal nerve demonstrated on MRI. All underwent microvascular decompression of the ipsilateral trigeminal nerve for intractable pain. Immediate and complete relief of SUNCT and SUNA symptoms occurred in 6/9 (67%) cases. This was sustained for a follow-up period of 9 to 32 months (mean 22.2). In 3/9 (33%) cases, there was no benefit. Ipsilateral hearing loss was observed in one case. The investigators concluded that medically intractable SUNCT and SUNA patients with a demonstrable aberrant arterial loop impinging on the trigeminal nerve on neuroimaging may benefit from microvascular decompression. The study is limited by a small sample size and lack of a control group. Radiofrequency Ablation In a randomized controlled trial of 30 patients with cervicogenic headache, 15 patients received radiofrequency (RF) treatments, and 15 patients underwent local injections of the greater occipital nerve followed by transcutaneous electrical nerve stimulation when necessary. There were no significant differences between the 2 treatment groups at any time during the study. Eight weeks after the initial treatment, 80% of the patients in the RF-group (Group I) and 66,7% of the patients in the local injection group (Group II) reported a successful treatment in terms of a positive global perceived effect and/or an visual analogue scale (VAS) reduction of at least 50% compared to the initial VAS. Sixteen weeks after the initial treatment, the success rate in Group I was 66,7% compared to 55,3% in Group II. After one year, there was no difference of the success rate in Group I (53,3%) compared to Group II (50%). A relatively high percentage of patients (33,3%) in both groups were not followed anymore because of several reasons. The most important reason was the disappointment in the treatment. (Haspeslagh, 2006) In a randomized, double-blind trial, Lord et al. (1996) compared percutaneous radio-frequency neurotomy in which multiple lesions were made with a control treatment using an identical procedure except that the radio-frequency current was not turned on. The trial included 24 patients who had pain in one or more cervical zygapophyseal joints. The source of the pain had been identified with the use of double-blind, placebo-controlled local anesthesia. Twelve patients received each treatment. The Occipital Neuralgia & Headache Page 11 of 24
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