For those patients and others that are interested in seeing what migraine surgery actually looks like, here are some photos from one of my occipital neuralgia patients during her surgery. This woman had nearly daily headaches that had been not responded to treatment from multiple neurologists and pain management doctors. Following her surgery to date, she is free of all headache pain. All photos are displayed with full consent from the patient.



Case #1

 


This patient is a very pleasant 40-year-old woman who has had 5 1/2 years of severe headaches. She has three children and a husband in graduate school and ad been unable to function to perform her day-to-day activities. She has seen multiple physicians and had multiple failed attempts at relief. She has seen a neurologist, headache specialist, and pain specialist. She has had MRIs and CT scans as well as MRA studies which have not shown anything wrong. She has tried multiple medications with no improvement. Her occipital nerve was clearly compressed and irritated, and once released from compression, she had immediate relief of her headache in the recovery room right after surgery.


Case #2

 

This photo shows the occipital nerve as it is first encountered during surgery.  The nerve can be seen to be constricted by the surrounding muscle, causing irritation that is causing this patient’s migraine headache pain.

Following the release of the nerve,  it can be seen here in this photo as plump and healthy, no longer compressed by the surrounding tissue.  Healthy blood supply can now be seen around the nerve, as it appears more pink than white as the first photo shows.

This photo shows both greater occipital nerves following nerve decompression.  Each nerve has a different course.  The one on the left emerges from more deep muscle, while the more superficial course of the nerve on the right can be seen.  It is not unusual for each nerve to have a different course in the anatomy of the neck.


Case #3

 

This photo shows the pre-operative markings for this patient who is about to undergo migraine surgery for occipital neuralgia. IMPORTANTLY, THIS PATIENT CHOSE TO SHAVE HER ENTIRE HEAD, AND THIS IS NOT NECESSARY FOR THE OPERATION.  The X at the top represents the occipital protuberance, and the midline marking shows the plane in which the incision will be made. The dots represent where the greater occipital nerve and third occipital nerve can be found, but the Xs toward the bottom of the photo are over the points where this patient felt a “Tinel” sign, or sensitivity to tapping on the third occipital nerve. The smaller, lower lines on each side and the dot in the middle of that line represent the incisions for the approach to the lesser occipital nerves, and the point at which we expect that nerve to be found, respectively. While it is not necessary to shave this region the head, this patient did so on her own the day before surgery.


The photo shows the third occipital nerve (TON) in the lower portion of the incision. The greater occipital nerve is seen above it just as it was identified, constricted by the surrounding muscle and connective tissue. This migraine surgery incision is in the midline of the back of the patient’s head and upper neck.


In this photo taken during migraine surgery for this same woman with a long history of occipital neuralgia, the greater occipital nerve can be seen now free of the surrounding constrictive structures, coursing from the deep tissue (splenius capitis muscle toward the middle of the photo) up toward the upper right hand corner of the frame, where it enters the looser subcutaneous space. The third occipital nerve, seen with a rubber loop around it, has also been freed but is associated with neuromatous tissue and was therefore subsequently cut. This woman found complete relief from her headaches immediately following this operation.


In this photo, the lesser occipital nerve has been dissected from the surrounding tissue. This nerve emerges from the posterior border of the sternocleidomastoid muscle. For reference, the top of this patient’s head is toward the right of the photo and the back of the ear can be seen toward the bottom of the photo.


Case #4

 

In this photo, a lymph node is found in the upper course of the greater occipital nerve, putting pressure on the nerve itself.  This is another type of structure that can cause nerve compression and these lymph nodes are removed during nerve decompression surgery so that the occipital nerve can course more freely without excessive irritation and compression from surrounding structures.

Case #5

 

This patient suffered from complex and severely painful migraines for more than 15 years. She was unable to be productive as a computer programmer, and the severe pain from her headaches affected her professional and social life severely. She has been treated by multiple headache specialists (including neurologists and pain doctors) for many years without headache resolution.

During her occipital nerve decompression, very interesting findings were noted. On the left, more painful side, this patient had a very thick muscle band, called the trapezius fascia, that was over 1cm thick and pushing right on her occipital nerve trunk. Recent research out of Harvard[1] has shown that patients with severe headaches often have much thicker trapezius fascia than normal. This patient demonstrates how release of this thick tissue removes the compressive irritation that produces migraine pain, as her discomfort was significantly improved immediately after surgery.

[1] Gfrerer, Lisa M.D., Ph.D.; Hansdorfer, Marek A. M.D.; Ortiz, Ricardo M.D.; Chartier, Christian; Nealon, Kassandra P. B.Sc.; Austen, William G. Jr. M.D. Muscle Fascia Changes in Patients with Occipital Neuralgia, Headache, or Migraine, Plastic and Reconstructive Surgery: January 2021 – Volume 147 – Issue 1 – p 176-180 doi: 10.1097/PRS.0000000000007484

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