A recent case I had the opportunity to evaluate was of a young woman following a head injury and increased neck pain and headaches following her treatment. She had just completed a series of treatments with GyroStim in Colorado Springs and her neck pain and headaches had significantly increased. On clinical examination her facet joints were swollen and very painful to touch. She had stability issues present even though her neck muscles were very tight. Her headaches had significantly increased and her overall function had declined to a point of living at home, unable to look after her young son.
Her story is all too familiar. Sometimes treatments fail to address our patient’s problems. Sometimes if the incorrect treatment is picked for the problem a patient’s condition can be worsened. Failure to diagnose and treat a problem quickly can make it much more difficult to recover months and even years later. This brings me to the reason of this post, migraine surgery. Medical management, facet injections, narcotics, supplements, rest or exercise, did not improve this client’s symptoms and she opted for surgery to free up the greater occipital nerve (GON), and cut the lesser occipital nerve (LON) and 3rdupper cervical nerve, burying them into the surrounding muscles. Her surgery was conducted by Ziv Peled MD in San Francisco. Our client found this surgical option by searching and finding a video related to the term ‘migraine surgery’.
Surgical interventions to release an entrapped GON, or cut other upper cervical nerves, have been around for decades.
There is a re-branding occurring even though the pain that these nerves are causing is not always typical migraine symptoms. These nerves do have interconnections with our dura and trigeminal ganglia/nucleus, and it is thought that mechanical issues affecting the upper cervical nerves such as the GON and LON can be associated with migraines.
Plastic surgeons are performing less invasive surgical procedures following a series of upper cervical nerve blocks to assess for locations of nerve entrapment. A common finding is a nerve entrapment to the GON at the semispinalis capitis SSCa muscle as this nerve pierces through the upper portion of this muscle prior to exiting under a sling of the upper trapezius.
Other areas of entrapment are related to the occipital artery as well as at the inferior oblique muscle of the C1-2 articulation as the nerve wraps around this muscle. Dry needling can be very effective by targeting the medial inferior oblique upper cervical muscle and the semispinalis capitis muscle around the GON.
Freeing the GON nerve in the SSCa and packing fat around the nerve is what was done surgically in our patient example. Smaller nerves were resected and buried into the surrounding muscles to prevent regrowth.
Greater Occipital Nerve GON Blocks and Migraines
Prior to considering nerve entrapment surgery of the GON specific nerve blocks should be considered. These are also done to determine if surgery would be beneficial. Here is a study that looked at changes in allodynia or increased skin sensitivity and headache pain following an injection to the GON with lidocaine and bupivacaine in patients with migraines. Sadly no control group of saline was used.
Overall there is variability in success rates and GON blocks. They range from 60-80% in reduction in pain and headache. Most do not show a complete reduction in headache pain.
Success rate of Migraine Surgery
Overall the success rate is quite high in reducing overall headache pain. This was seen in multiple studies, including a great study that looked at a 5 year follow up and had a larger sample group of 69 patients with a control group of 25.
“Sixty-one (88 percent) of 69 patients have experienced a positive response to the surgery after 5 years. Twenty (29 percent) reported complete elimination of migraine headache, 41 (59 percent) noticed a significant decrease, and eight (12 percent) experienced no significant change.”
Five-Year Outcome of Surgical Treatment of Migraine Headaches
Another study looked at social media data of patients that had undergone migraine surgical procedures and their numbers were surprisingly similar to the clinical studies outcomes.
What is causing what?
We know there are connections between the brain and the cervical spinal nerves. We are discovering the complexity and interconnections more each decade. How does this help us treat someone’s headache?
Answering the question ‘WHY’
Why are the nerves entrapped? Answering this question early can change our entire focus on how to assess and treat this type of problem. Doing this would also make migraine surgery much less likely.
If Botox and trigger point injections are helping. If manual interventions help reduce the headache but they return. This suggests an underlying mechanical problem.
When screening the upper neck to see if there is involvement and a potential association with headache pain a top test to perform is the assessment of the atlas as it moves on the axis. This test is highly sensitive but not very specific. Meaning, it is positive in a lot of neck-associated conditions. Repeat testing can be used to check if prior treatments have been targeting the neck effectively. Is treatment working?