The occipital region is the area in the back of the scalp/head. It is one of the most commonly treated areas for patients seeking surgical relief from chronic headaches. In my humble opinion, many people are often told they suffer from migraines, when they really have neuralgia (i.e. pain caused by mechanical compression or irritation of a nerve). The offending structure(s) causing this compression/irritation may be a spastic muscle, an enlarged or aberrant blood vessel, and/or tight connective tissue. When the pain emanates from and/or occurs in the occipital region of the head, it is called ‘occipital neuralgia’ or ON for short. In the case of people who have pain in the back of the head, the question for the surgeon is, which “neur” (i.e. nerve) is causing the “algia” (i.e. pain).
There are three primary surgical targets in the occipital region: the greater occipital nerve, the lesser occipital nerve, and the third occipital (AKA least occipital) nerve. Symptoms may be unilateral or bilateral and can be characterized as sharp, electrical-like, stabbing, pressure-like or pounding. However, it is important to keep in mind that pain is inherently a subjective phenomenon and people may experience their discomfort in many ways, not just those listed above. ON sufferers may experience a significant tightness in the nuchal (i.e. neck) musculature with their flares, but this tightness may not always be present. Often, but not always, patients have a history of a whiplash-type injury to the head/neck. So how do we decide who is a surgical candidate?
In order to decide who may actually have ON, we look at the patient’s history, perform a comprehensive physical exam, but focus primarily on the possibility of nerve compression/irritation causing these symptoms and also perform a specific set of diagnostic nerve blocks tailored to each patient. If the appropriate criteria are met, the patient is considered a candidate for surgical intervention. A surgical plan is then carefully constructed for that person. It is important to keep in mind that each person’s symptom complex will be different and therefore each person will require addressing different nerves. There is no such thing as “the headache surgery” – it is a distinct set of procedures, each focusing on a specific nerve(s) that are utilized in varying combinations for each person.