Occipital neuralgia and migraine headaches are two conditions that cause similar problems, but are associated with varying symptoms and may respond very differently to certain forms of treatment.
Both occipital neuralgia and migraine headaches can cause debilitating headaches that interrupt one’s normal life. They often lead to an isolated existence, being unable to visit loud, bright public places for fear of exacerbating symptoms. Many individuals are unable to work or are forced to take multiple sick days that lead to poor work performance and, thus, problems with colleagues and employers.
The International Headache Society (IHS) defines occipital neuralgia as:
A paroxysmal jabbing pain in the distribution of the greater or lesser occipital nerves or of the third occipital nerve (nerves running up the back of the neck and head), sometimes accompanied by diminished sensation or dysaesthesia (abnormal sensation) in the affected area. It is commonly associated with tenderness over the nerve concerned.
The corresponding IHS definition of common migraine (now referred to as migraine without aura) is:
Recurrent headache disorder manifesting in attacks lasting 4-72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia (sensitivity to light and sound).
Both Occipital Neuralgia and Migraine Headaches are initially treated with medication in an attempt to reduce symptoms and prevent or alleviate the occurrence of headaches. Although medical therapy can be very effective, for many headache sufferers medication can be less effective over time. If the side effects of the medical therapy outweigh the benefits, the individual may discontinue taking them and is forced to deal with the consequences.
Neurologists and other headache specialists will sometimes have difficulty diagnosing the headache condition as purely occipital neuralgia or migraine, and there may be some overlap in the classification.
Recently, the FDA approved the use of Botox® as a treatment for chronic migraine sufferers who have headaches 15 or more days per month, each lasting four or more hours.
Since 2005, we have been using Botox® at The Institute for Advanced Reconstruction to treat patients (more than 100 to date as of 3/2014) with either occipital neuralgia or migraines, and have often observed very favorable responses to treatment. Many patients are able to reduce or eliminate their need for medical therapy.
Unfortunately, not everyone benefits from Botox®. It is our belief that migraine sufferers represent a very diverse group of patients, and due to the complexity of the condition, we sometimes see patients who do not experience any effect from injection therapy. Conversely, in patients with confirmed occipital neuralgia, we rarely see a patient who does not report some improvement from Botox®.
The reason behind this may be connected to the fact that occipital neuralgia is a condition that is primarily due to “nerve trigger points” as opposed to migraines, in which the underlying problem may be due to a combination of factors.
Accordingly, the IHS specifically describes occipital neuralgia as a condition in which “pain is eased temporarily by local anesthetic block of the nerve.” This supports the notion that the symptoms are primarily due to a “nerve trigger point” problem, as local anesthesia works on nerves to temporarily deaden them.
Many of our occipital neuralgia patients report the onset of the condition following a traumatic event, such as a car accident or fall. A whiplash injury that causes inflammation in the head and neck region may result in the occipital nerves becoming sites of these “trigger points”. Patients with this type of history tend to respond the best to injection therapy, or even to trigger point decompression surgery, discussed below.
Migraine patients are generally more complex, especially adult patients who have had the condition since childhood or female patients who report so-called “menstrual migraines”.* We see more treatment failures with Botox® and trigger point decompression surgery in these patients.
Trigger point decompression surgery involves a minimally invasive approach to the nerves in the head and neck region that cause or contribute to the headache symptoms. The trigger point sites are “relieved” by meticulously removing muscle, fascia (tissue lining) and blood vessels from the areas in which the nerves travel. In doing so, the nerve will no longer be “irritated” and the trigger point will be alleviated. Clinically, this may result in a reduction or elimination of the headache or tenderness in this area. Often, multiple trigger point sites are treated in one surgical procedure, depending on the individual patient’s condition. The techniques utilized in this procedure are based upon well-established methods that have been around for several decades. A simplified version of these methods is used in carpal tunnel surgery, whereby the nerve to the hand is relieved of compression to reverse numbness and weakness in the fingers.
At the Institute for Advanced Reconstruction, we have been performing trigger point decompression surgery for the last 9 years, and have had tremendous success, most notably in patients with occipital neuralgia. Some of our patients have been essentially “cured” of their condition (they no longer need medical therapy and rarely, if ever, have a headache). We have also had success in treating migraine patients with this procedure, although we need to be much more selective in this group because of the factors mentioned earlier.
Trigger point decompression surgery is performed in an outpatient setting and is considered minimally invasive (small incisions in the front and/or back of the head, sometimes with the aid of an endoscope). The surgery is performed under general anesthesia and typically takes anywhere from one to three hours. The recovery time from trigger point decompression surgery is generally 7 to 10 days.
Matthew R. Kaufman, M.D., F.A.C.S., one of the senior surgeons at the Institute for Advanced Reconstruction, is amongst the most experienced trigger point decompression surgeons in the region and nationally.
Please contact us for more information regarding occipital neuralgia treatment or migraine treatment, and to schedule a consultation.
*Around 50% of women with migraines say that their menstrual cycle directly affects the condition. The menstrual cycle, specifically estrogen and progesterone, and the physiological and chemical process of producing them, has a widespread effect on the body. Studies suggest that migraines can be triggered by a drop in estrogen levels such as those which naturally occur in the time just before a woman’s period. Factors such as the release of prostaglandin (a naturally occurring fatty acid that acts in a similar way to a hormone) may also have a role in this process.