OCCIPITAL NEURALGIA AND HEADACHE - Health Plan of Nevada

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Jansen (2000) reported on the results of three different surgical treatments in 102 patients with cervicogenic headache that had been nonresponsive to physical or drug therapy. Thirty-eight patients were treated with C2 ganglionectomy, and 64 patients with demonstrable spinal structural abnormalities were treated with dorsal or ventral spinal decompression and fusion. Complete relief of pain was reported by 80% of the entire group, and 60% to 80% relief was experienced by about 15% of patients. Six percent of patients experienced no relief of pain. In a study conducted by Kapoor et al. (2003), 17 patients with occipital neuralgia underwent dorsal rhizotomy. At a mean follow-up of 20 months, 65% of patients had complete relief of symptoms, 12% had partial relief, and 24% had no relief of symptoms. A retrospective study conducted by Gille et al. (2004) evaluated 10 patients with occipital neuralgia who underwent neurolysis of the occipital nerve and sectioning of the inferior oblique muscle. After a mean follow-up of 37 months, the investigators concluded this new surgical treatment provided good results if patients are well chosen. 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) 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 (
microdecompression surgery for occipital neuralgia concludes that there is insufficient evidence to assess the safety and efficacy of cervical microdecompression surgery for occipital neuralgia (Hayes, 2008a). Nerve Decompression and Occipital Neurectomy for Headaches A randomized trial of patients with medication-refractory, but BT-responsive, migraine headaches compared the removal of the glabellar muscles (n=19), removal of the zygomaticotemporal branch of the trigeminal nerve (n=19), or greater occipital neurectomy (n=11) with sham-control patients (n=26) who underwent only exposure at one of the sites. At 1-year follow-up, complete resolution of headaches was found in 57.1% and significant improvement in 83.7% of patients undergoing actual surgery, and significant improvement was found compared with baseline values in all migraine headache measures. In the sham surgery group, 57.7% of patients reported at least 50% reduction in migraine headache. The difference between experimental and control groups was statistically significant (Guyuron et al., 2009). These findings require confirmation in a larger study. 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 Occipital Neuralgia & Headache Page 11 of 21
Page 1 and 2: OCCIPITAL NEURALGIA AND HEADACHE Pr
Page 3 and 4: • Prognostic - to predict the out
Page 5 and 6: CLINICAL EVIDENCE Diagnostic Occipi
Page 7 and 8: Other Headaches Ashkenazi et al. (2
Page 9: up to 4 blocks. Visual analog scale
Page 13 and 14: Lee et al. (2007) assessed the clin
Page 15 and 16: diagnoses is off-label use. Additio
Page 17 and 18: Anthony M. Headache and the greater
Page 19 and 20: Kapural L, Mekhail N, Hayek SM, et
Page 21: PROTOCOL HISTORY/REVISION INFORMATI

OCCIPITAL NEURALGIA AND HEADACHE - Health Plan of Nevada

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