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Background: Patients who undergo occipital nerve decompression for treatment of migraine headaches due to occipital neuralgia have already exhausted medical options for treatment. When surgical decompression fails, it is unknown how best to help these patients. We examine our experience performing greater occipital nerve excision for pain relief in this select, refractory group of patients.
Methods: A retrospective chart review supplemented by a follow-up survey was performed on all patients under the care of the senior author who had undergone greater occipital nerve excision after failing occipital nerve decompression. Headache severity was measured by the migraine headache index (MHI) and disability by the migraine disability assessment (MIDAS). Success rate was considered the percentage of patients who experienced a 50% or greater reduction in migraine headache index at final follow-up.
Results: 71 of 108 patients responded to the follow-up survey and were included in the study. Average followup was 33 months. The success rate of surgery was 70.4%. 41% of patients showed a 90% or greater decrease in MHI. MHI changed, on average, from 146 to 49, for an average reduction of 63% (p<0.001). MIDAS scores decreased by an average of 49% (p<0.001). Multivariate analysis revealed that a diagnosis of cervicogenic headache was associated with failure of surgery. The most common negative side effect was bothersome numbness or hypersensitivity in the denervated area, occurring in up to 31% of patients.
Conclusion: Excision of the greater occipital nerve is a valid option for pain relief in patients with occipital headaches refractory to both medical treatment and surgical decompression. Potential risks include failure in patients with cervicogenic headache and hypersensitivity of the denervated area. In order to provide the best outcome to these patients that have failed all previous medical and surgical treatments, a multidisciplinary team approach remains critical.

Table 1: Headache Surgery - Primary Outcomes

	Pre-Op	Post-Op	Change	Change (%)	P
Migraine Headache Index (MHI)	146.13	49.38	-96.75	-63%	<0.001
Migraine Disability Assessment (MIDAS)	169.44	81.89	-87.55	-49%	<0.001

Table 2: Success Rates for Occipital Excision After Decompression

Outcome	N	%
>50% Reduction in MHI	50	70.4%
>90% Reduction in MHI	29	41%