Occipital Neuralgia

Occipital Neuralgia related chronic migraine / headache can be characterized by the following findings:

  • Constant aching, burning, and/or shooting occipital pain, often radiating to vertex, fronto-temporal or periorbital areas (retro-orbital behind the eye pain when severe)
  • Unilateral or bilateral
  • Often difficulties lying on the back of the head “Pillow sign”
  • No specific age range or sex dominance
  • Involves the greater, dorsal, and/or lesser occipital nerves (C2/C3 nerve branches)
  • Tender occipital nerves on pressure
  • Some can feel pain/pressure behind the eye, especially when pressure applied over occipital nerves
  • Often positive/temporary response to nerve blocks
  • May present alone or with other headache or migraine forms.

Chronic Post-operative (following Acoustic neuroma removal or craniotomy) pain/ occipital neuralgia/ chronic migraine / headache.

Each or in combination can follow previous cranial surgery, as is most commonly seen after an acoustic neuroma surgery. Any of the aforementioned symptoms under occipital neuralgia headings can be present.

Migraine headache itself can be defined as an episodic headache lasting 4-72 hours with (any two of): unilateral, throbbing, moderate to severe, worsened by movement and (any one of): nausea/vomiting, photophobia, phonophobia. It becomes chronic if headache of any kind lasts > 15 days per month, for at least 3 months. It may present with signs of occipital and/or fronto-temporal neuralgia as well. Some people have an aura before the actual migraine begins. An aura is a group of symptoms, including vision disturbances, which act as a warning sign that a headache is coming.

The causes of migraines can be very complex and many patients spend years searching for relief. Often patients will tell us that few providers were willing to listen to them, and even fewer tried to help them solve the cause of their migraines. For many patients who have tried other treatments without success, surgical treatment might be the best option to treat their migraines/occipital neuralgia/chronic headaches.

You should also know:

What is actually done during occipital peripheral nerve surgery?

Under general anesthesia, incision in made in the back of the head and deepened through anatomical layers. I created the approach so that no head shaving is required. Once the occipital nerves are identified, release of compression/trigger points over each nerve is performed (decompression or neurolysis). If nerve excision is required, the nerve is dissected proximally, transected and the proximal end is implanted into a nearby muscle. Although a combination of these procedures might be required, the exact type of surgery is individualized and based on each patient’s specific presentation. Nerve decompression is usually done in most of patients with the intent of preserving sensation. Scalp numbness usually follows nerve excision. When excising a damaged nerve from previous surgery, like for patients after acoustic neuroma surgery, implantation of its proximal stump into muscle is carefully done to minimize its chance that it develops a painful neuroma. Still, one can not exclude the possibility that even after damaged nerve/neuroma excision, patient’s pain may persist, continuing to negatively affect quality of life. The duration and severity of chronic pain that persisted before current nerve surgery can certainly leave negative psychological effect on some patients, contributing to continued or progressive pain. This is why it is not possible to predict how each individual will respond to nerve excision, and thus not possible to guarantee the outcome. Luckily this does not happen often, so most patients have great relief after removal of damaged nerve/neuroma.

Does this surgery interfere with movements of arms/legs? Does it involve brain or spine?

Occipital nerves are sensory nerves, providing sensation to the back of the head. Therefore, there no reason that any movement dysfunction of the face, arms or legs would follow.

Surgery is done on peripheral nerves, no brain or spine is exposed or manipulated at any point during surgery.

Surgery: Inpatient or outpatient, its duration, recovery, outcome?

Most, if not all of the above treatments are done on an outpatient basis, unless your pre-existing medical condition would warrant admission. It takes in average 1 – 1.5 hours to perform the surgery. There are no special dressings since incision is hidden in the occipital hair. Sutures are removed about three weeks after surgery.

Ambulation is permitted right after the surgery. Activities are limited to light for the first 1-2 weeks.

Recovery varies but it usually takes about one-two weeks and can certainly vary depending on several variables (type of professional work done, age, co-morbidities, etc). Similarly, some patients have immediate headache relief, most take about 2-3 weeks, while others may take about 3 months to fully observe benefits of surgery.