occipital neuralgia and cervicogenic, cluster and migraine headaches

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
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