Surgical Management of Headache Disorders - A Systematic Review of the Literature.

PURPOSE OF REVIEW: This review article critically evaluates the latest advances in the surgical treatment of headache disorders. RECENT FINDINGS: Studies have demonstrated the effectiveness of innovative screening tools, such as doppler ultrasound, pain drawings, magnetic resonance neurography, and nerve blocks to help identify candidates for surgery. Machine learning has emerged as a powerful tool to predict surgical outcomes. In addition, advances in surgical techniques, including minimally invasive incisions, fat injections, and novel strategies to treat injured nerves (neuromas) have demonstrated promising results. Lastly, improved patient-reported outcome measures are evolving to provide a framework for comparison of conservative and invasive treatment outcomes. Despite these developments, challenges persist, particularly related to appropriate patient selection, insurance coverage, delays in diagnosis and surgical treatment, and the absence of standardized measures to assess and compare treatment impact. Collaboration between medical/procedural and surgical specialties is required to overcome these obstacles.

Foramen magnum decompression for Chiari malformation type I - UK surgical practice.

Background: Symptomatic Chiari 1 malformation (CM1) is a common condition in Neurosurgery. Surgery involves hindbrain decompression and restoration of CSF flow through different surgical approaches. No Class 1 evidence exists to suggest the superiority of any of the surgical techniques.Aims: To investigate current surgical practice for symptomatic CM1 patients in the United Kingdom (UK) and determine the willingness to participate in a randomised controlled trial (RCT) comparing different surgical techniques.Methods: An electronic survey was sent to consultant members of the Society of British Neurological Surgeons and the British Chiari-Syringomyelia Group. The questions covered pre-operative and intra-operative management, presence of equipoise/uncertainty in optimal technique and willingness to participate in an RCT.Results: 98 responses were received. 67% operate on adults. 30% on adult and paediatric patients. There is variation in routine pre-operative use of: ICP monitoring (18%), flexion/extension x-rays (16%), venography (20%) and ophthalmology assessment (26%). 18% of neurosurgeons would not offer foramen magnum decompression when the presenting symptom is only refractory cough/sneeze headache. 15% routinely perform bony decompression alone in adults vs 8% in children. In 68% of adult cases, durotomy is performed routinely (46% of them leave the dura open, 54% perform a type of duroplasty) and 16% routinely resect the cerebellar tonsils. Only 17% leave the dura open in children. The most common indicators for durotomy are syringomyelia and intra-operative ultrasound findings. 61% believe there is equipoise/uncertainty in the optimal strategy for decompression and would be willing to participate in an RCT. Comments also mention the heterogeneity of CM1 and that treatment should be tailored to each patient.Conclusion: There is wide variation in pre- and intra-operative management of CM1 patients in the UK and the majority of neurosurgeons would be willing to participate in an RCT comparing bony decompression alone vs dural opening with/without duroplasty.

Decompression of the greater occipital nerve improves outcome in patients with chronic headache and neck pain - a retrospective cohort study.

BACKGROUND: Compression of the greater occipital nerve (GON) may contribute to chronic headache, neck pain, and migraine in a subset of patients. We aimed to evaluate whether GON decompression could reduce pain and improve quality of life in patients with occipital neuralgia and chronic headache and neck pain. METHODS: In this retrospective cohort study, selected patients with neck pain and headache referred to a single neurosurgical center were analyzed. Patients (n = 22) with suspected GON neuralgia based on nerve block or clinical criteria were included. All patients presented with occipital pain spreading frontally and to the neck in various degree. Surgical decompression was performed under local anesthesia. Follow-up was made by an assessor not involved in the treatment of the patients, by telephone 2-5 years after the surgical procedure and an interview protocol was used to collect information. The data from the follow-up protocols were then analyzed and reported. RESULTS: When analyzing the follow-up protocols, decreased headache/migraine was reported in 77% and neck pain was reduced in 55% of the patients. CONCLUSIONS: Decompression of GON(s) may reduce neck pain and headache in selected patients with persistent headache, neck pain, and clinical signs of GON neuralgia. Based on the limitations of the present retrospective study, the results should be considered with caution.

Tracking patients with chronic occipital headache after occipital nerve decompression surgery: A case series.

BACKGROUND: The therapeutic benefit of nerve decompression surgeries for chronic headache/migraine are controversial. AIM: To provide clinical characteristics of headache type and treatment outcome of occipital nerve decompression surgery. METHODS: A retrospective review of clinical records. Inclusion criteria were evidence of chronic occipital headache with and without migrainous features and tenderness of neck muscles, occipital allodynia, and inadequate response to prophylactic drugs. RESULTS: Surgical decompression of the greater and lesser occipital nerves provided complete and extended (3-6 years) relief of new daily persistent headache in case 3 (46 year old female), and of chronic post-traumatic headache in cases 4 and 6 (35 and 30 year old females, respectively), partial relief of chronic headache/migraine in cases 1 and 2 (41 year old female and 36 year old male), and no relief of episodic (cases 3 and 4) or chronic migraine (case 5, 52 year old male), or chronic tension-type headache (case 7, 31 year old male). CONCLUSIONS: As a case series, this study cannot test a hypothesis or determine cause and effect. However, the complete elimination of new daily persistent headache and post-traumatic headache, and the partial elimination of chronic headache/migraine in two patients - all refractory to other treatment approaches - supports and justifies the effort to continue to generate data that can help determine whether decompression nerve surgeries are beneficial in the treatment of certain types of chronic headache.

Occipital Nerve Stimulation for Refractory Pain after Occipitocervical Fusion.

Occipital nerve stimulation (ONS) is electric stimulation of the distal branches of the greater occipital nerve by cylindrical or paddle leads implanted in subcutaneous occipital tissue. This surgical option has emerged as a promising treatment for different types of disabling medical refractory headache and recently also for residual occipital and nuchal pain after previous occipitocervical fusion. The mechanisms of action have not yet been clearly explained: electrical stimulation of the occipital nerve has both peripheral and central effects on the nervous system, which may modulate nociception. ONS is a well-tolerated and safe procedure in comparison with other invasive modalities of treatment. Lead migration/dislodgement is a common complication, but use of new surgical techniques and leads may reduce the rate of this complication.

Ventriculo-peritoneal shunting is a safe and effective treatment for idiopathic intracranial hypertension.

PURPOSE: To determine the outcome of ventriculo-peritoneal shunts as a treatment for idiopathic intracranial hypertension (IIH) Materials and Methods: Retrospective case series of 28 patients with IIH and evidence of raised intracranial pressure (ICP) who underwent shunt insertion. Patients were identified from a prospectively updated operative database. A case-notes review was performed and data on type of shunt, pre- and post-operative symptoms, ophthalmological findings and post-operative complications were recorded. RESULTS: All patients had symptoms of IIH that had failed medical management. Twelve patients had previous lumbo-peritoneal shunts and 2 patients had previous venous sinus stents. All patients had evidence of raised ICP as papilloedema and raised CSF pressure on lumbar puncture. Twenty-seven patients received a ventriculo-peritoneal shunt and 1 patient a ventriculo-atrial shunt. Twenty-six patients received Orbis Sigma Valves and 2 patients Strata valves. At follow-up all patients (100%) had improvement/resolution of papilloedema, 93% had improved visual acuity and 84% had improved headaches. Mean time to last follow-up was 15 (range 4-96) months. Complications occurred in 3 patients (11%): 2 patients required revision of their peritoneal catheters and 1 patient had an anti-siphon device inserted. CONCLUSIONS: Previous literature reported a ventricular shunt revision rate of 22-42% in the management of IIH. We demonstrate ventriculo-peritoneal shunts to be an effective treatment with a revision rate of 11% compared to the previously reported 22-42%.

Idiopathic intracranial hypertension VISION (venous intervention versus shunting in IIH for optic nerve disc swelling) trial: patient perspective questionnaire.

INTRODUCTION: Headaches, visual problems and tinnitus are symptoms of Idiopathic Intracranial Hypertension (IIH) which resolve with reduction of CSF pressure. Impaired cranial venous outflow has been implicated in the pathogenesis and there is evidence of good treatment results in IIH using venous sinus stenting. We are currently initiating a multi-centre randomised controlled trial, the VISION study (Venous Intervention versus Shunting in IIH for Optic Disc Swelling) comparing radiological (venous sinus stenting) to surgical intervention (CSF shunting). As part of the preparations for VISION we made a basic questionnaire available to members of the website IIH UK ( www.iih.org.uk ). METHODS: 10-point questionnaire pertaining to IIH diagnosis, symptoms and management using www.surveymonkey.com . RESULTS: 250 questionnaires were returned. 95.6% of respondents were female, mostly ≤40 years of age. 70% were diagnosed in the last 5 years, but only 35% were diagnosed less than a year after onset of symptoms. 59.4% of patients had not undergone any radiological/surgical intervention, 34.9% had had CSF diversion, 3.6% venous stenting and 2.0% had stent plus shunt. 16.8% indicated their lives were most affected by tinnitus and 18.1% by visual problems, but 49.6% said they were most affected by their headaches. 81% of patients indicated they would be happy to participate in a randomised trial comparing the two treatment options of venous stenting and CSF shunting. CONCLUSION: IIH patients want to be actively involved in their treatment and are favourably disposed towards clinical research. Variation exists in treatment modalities offered. There are individual differences regarding impact of symptoms.

Surgical treatment of pineal cysts in non-hydrocephalic and neurologically intact patients: selection of surgical candidates and clinical outcome.

PURPOSE: Management of patients presenting for various nonspecific complaints without clear neurological abnormalities and with normal ventricular size remains highly controversial. We intended to share our rationale for surgical treatment of patients who show symptoms of transient increase of intracranial pressure owing to the presence of the cyst. MATERIALS AND METHODS: We have retrospectively analyzed 28 cases of patients who presented without Parinaud syndrome nor ventricular enlargement and underwent pineal cyst removal in our centre between 2007 and 2015. We analyzed patients' age, sex, symptoms, preoperative cyst size, perioperative course, treatment outcome and neurologic status at discharge and at follow-up visits 4 and 12 months afterwards. RESULTS: Main complaints included paroxysmal headaches, nausea, vomiting, visual disturbances, syncope and transient depression of consciousness. Mean age of patients was 31 years (17-55); there were 24 females and 4 males. Mean cyst diameter was 17 mm (10-26). Decision about surgical treament was based on signs of transient increases of intracranial pressure. All patients underwent complete cyst excision via midline suboccipital craniotomy and infratentorial supracerebellar route. Short-lasting perioperative neurological signs (notably upgaze palsy) were noted in 22 cases and uniformly resolved within the observation period of 12 months. CONCLUSION: Abnormal neurological findings and ventricular enlargement are not indispensable to justify surgical treatment of pineal cysts. Judicious selection of surgical candidates based predominantly on clinical grounds can lead to excellent operative results.

Headache, Chiari I malformation and foramen magnum decompression.

PURPOSE OF REVIEW: With increasing use of MRI, more patients are being diagnosed with Chiari I malformation (CM1), many of whom are asymptomatic. When symptoms are present, headache is the most frequent presenting feature, although symptoms can be variable. The purpose of this review is to help primary care clinicians better understand the relationship between an individual's presenting symptoms and the presence of radiographic CM1, and to describe the expected outcomes for patients who undergo decompression surgery. RECENT FINDINGS: Recent literature has shown that asymptomatic patients with CM1 tend to have a benign natural history. For symptomatic Chiari malformation, headache is the most common presenting symptom and the majority of patients that present with headache will have symptom improvement after foramen magnum decompression. This improvement is most reliable for patients with classic Chiari-type headache, which are described as occipital or cervical and tussive in nature, but has also been shown in patients with atypical headaches who have undergone surgery. SUMMARY: CM1 is a common radiographic finding and associated symptoms can be variable. The relevance of this finding to a particular patient and need for intervention must be made on an individual basis.

Prospective Analysis of the Greater Occipital Nerve Location in Patients Undergoing Occipital Nerve Decompression.

BACKGROUND: Migraine surgery and onabotulinumtoxinA injections aim to deactivate neurovascular trigger points implicated in chronic headaches. The greater occipital nerve (GON) is a common trigger point. The depth of this nerve has not been previously described. The purpose of this study was to report the intraoperative location, including depth, of the GON in human subjects undergoing migraine surgery. METHODS: We reviewed records of patients who underwent GON decompression by a single surgeon. Intraoperative measurement of the GON location lateral to midline, inferior to the occipital protuberance, and deep to the skin was collected for 2 previously described positions: where GON (a) enters, "point #2," and (b) exits, "point #3," the semispinalis muscle as it travels from deep to superficial (Plast Reconstr Surg. 2010;126:1563-1572; Plast Reconstr Surg. 2004;113:693-697). RESULTS: Thirty-four subjects (60 nerves) were included. The mean depths of the GON were 20 mm (SD, 4) at point no. 3 and 30 mm (SD, 6) at point no. 2. In 26 subjects who underwent bilateral surgery, there was a difference between right and left nerve position lateral to midline at point no. 3 (P = 0.008). Female sex (P = 0.014) and body mass index of 29 kg/m or less (P < 0.001) were associated with a more superficial GON position. CONCLUSIONS: Knowledge of the GON depth (eg, mean of 20 mm where it emerges from the semispinalis muscle) may improve accuracy of procedural treatments for migraines. When performing bilateral interventions, nerve position may differ between sides, particularly with respect to lateral distance from midline. Differences in this study compared with previous anatomic studies may reflect the use of live subjects in a prone position compared with cadaver specimens.

Rhinogenic Contact Point Headache: Surgical Treatment Versus Medical Treatment.

Rhinogenic contact point headache (RCPH) is a headache syndrome secondary to mucosal contact points in the sinonasal cavities, in the absence of inflammatory signs, hyperplastic mucosa, purulent discharge, sinonasal polyps, or masses. It may result from pressure on the nasal mucosa due to anatomic variations among which the septal deviation, septal spur, and concha bullosa, are the most commonly observed. In recent years, RCPH has remained a subject of controversy regarding both its pathogenesis and treatment. This study aimed to investigate the effect of surgical and medical treatment of pain relief in patients with RCPH, evaluating the intensity, duration, and frequency of headaches, and the impact of different treatments on quality of life. Ninety-four patients with headache, no symptoms or signs of acute and chronic sinonasal inflammation and who present with intranasal mucosal contact points positive to the lidocaine test were randomized into 2 equal groups and given medical or surgical treatment. The authors used visual analog scale, number of hours, and days with pain to characterize the headache and Migraine Disability Assessment score (MIDAS) to assess the migraine disability score before and 3 to 6 months after treatment. After treatment the severity, duration, and frequency of the headache decreased significantly (P < 0.001, P < 0.001, and P = 0.031, respectively) as well as the MIDAS in the surgical group compared with medical group. Our results suggest that surgical removal of mucosal contact points is more effective than local medical treatment improving the therapeutic outcomes in patients with contact point headache.

Greater Occipital Nerve Decompression for Occipital Neuralgia.

The aim of the study was to evaluate the effectiveness of greater occipital nerve decompression for the management of occipital neuralgia. Eleven patients of medical refractory occipital neuralgia were enrolled in the study. Local anaesthetic blocks were used for confirming diagnosis. All of them underwent surgical decompression of greater occipital nerve at the level of semispinalis capitis and trapezial tunnel. A pre and postoperative questionnaire was used to compare the severity of pain and number of pain episodes/month. Mean pain episodes reported by patients before surgery were 17.1 ±â€Š5.63 episodes per month. This reduced to 4.1 ±â€Š3.51 episodes per month (P < 0.0036) postsurgery. The mean intensity of pain also reduced from a preoperative 7.18 ±â€Š1.33 to a postoperative of 1.73 ±â€Š1.95 (P < 0.0033). Three patients reported complete elimination of pain after surgery while 6 patients reported significant relief of their symptoms. Only 2 patients failed to notice any significant improvement. The mean follow-up period was 12.45 ±â€Š1.29 months. Surgical decompression of greater occipital nerve is a simple and viable treatment modality for the management of occipital neuralgia.

Greater occipital nerve cryoneurolysis in the management of intractable occipital neuralgia.

OBJECTIVE: To assess technical feasibility of cryoneurolysis of the greater occipital nerve in the management of occipital neuralgia. METHODS: Six patients suffering from unilateral refractory greater occipital neuralgia and who underwent 7 GON cryoneurolysis were assessed between October 2015 and January 2017. All procedures were performed under CT guidance and local anesthesia. A planning CT was performed with contrast enhancement to plan needle target and identify surrounding major vascular structures. A 12G coaxial needle (Inomed) was then inserted and targeted the first bend of the GON under and lateral to the obliquus capitis inferior muscle. A 2.0mm cryoprobe was then inserted in the coaxial and sensitive stimulation at 100Hz was performed. One to three freezing cycles were performed in one session. RESULTS: Technical feasibility was 100% as cryoneurolysis could be performed in all 7 cases with accurate sensitive nerve stimulation prior to freezing cycle. One patient benefited from a second session after failure of the first session. More than 50% pain reduction was achieved at day 7 in all cases, and 5 of 6 cases at one and three months follow-up. CONCLUSION: Cryoneurolysis of the GON in the management of refractory GON neuralgia is feasible. Initial results are promising as 5/7 cases benefited from a 3-month pain alleviation period.

Nerve Blocks in Pediatric and Adolescent Headache Disorders.

PURPOSE OF REVIEW: Peripheral nerve blocks of the scalp, mainly greater occipital nerve blocks, have received a renewed interest amongst pediatric providers as they offer an alternate option to provide both acute and chronic relief from the suffering of children with difficult to treat headaches. This narrative review will provide an in-depth discussion of the published pediatric-specific studies exploring the utility of nerve blocks for pediatric headache disorders. RECENT FINDINGS: A total of seven pediatric publications have been reported to date and reveal excellent therapeutic effectiveness of bilateral greater occipital nerve blocks on primary chronic headaches and post-traumatic headaches. Lidocaine is the preferred anesthetic choice and the value-added of concomitant steroids remains to be elucidated. It is important to ensure complete paresthesia of the blocked nerves to maximize effectiveness. The available studies suggest that peripheral nerve blocks of the scalp are an excellent tool that frontline clinicians can add to their armamentarium in treating pediatric headaches.

Significant improvement of intractable headache after transsphenoidal surgery in patients with pituitary adenomas; preoperative neuroradiological evaluation and intraoperative intrasellar pressure measurement.

OBJECT: Headache is the most common symptom of both primary and metastatic brain tumor, and is generally considered the primary symptom in patients with large pituitary adenomas. However, patients with small pituitary adenomas rarely complain of intractable headache, and neurosurgeons are unsure whether such small adenomas actually contribute to headache. If conventional medical treatments for headache prove ineffective, surgical removal of the adenoma can be considered as an alternative management strategy. METHODS: We conducted a retrospective review of 180 patients who underwent transsphenoidal surgery (TSS) for pituitary adenomas at Kanazawa University Hospital between 2006 and 2014. Patients with acute phase intratumoral hemorrhage were excluded. We identified nine patients with intractable headache as the chief complaint associated with small pituitary adenoma (diameters 15.8 ± 2.6 mm, 11-20 mm), non-functioning in eight, and prolactin-secreting in one. The preoperative neuroradiological studies and headache characteristics were assessed retrospectively, and the intrasellar pressure evaluation was performed during TSS in the last seven patients. RESULTS: All nine patients had complete or substantial resolution of their formerly intractable headache after TSS. Headaches consisted of ocular pain ipsilateral to the adenoma localization within the sella in four cases and bifrontal headache in five. Magnetic resonance imaging of these patients revealed small diaphragmatic foramen, which were so narrow that only the pituitary stalk could pass. Computed tomography scans showed ossification beneath the sellar floor in the sphenoid sinus, presellar type in six cases, and choncal type in three. The adenomas included cysts in seven cases. There was no cavernous sinus invasion. Intrasellar pressure measurements averaged 41.5 ± 8.5 mmHg, range 34-59, significantly higher than in control patients without headache (n = 12), namely 22.2 ± 10.6 mmHg (16-30). CONCLUSION: In this study, the authors demonstrated the validity of TSS in the treatment of intractable headache associated with pituitary adenoma. The presence of ocular pain, especially ipsilateral to the adenoma, integrity of the diaphragm sella, and ossification in the sphenoid sinus, cyst or hemorrhage and the absence of cavernous sinus invasion were the indications for TSS for patients complaining of intractable headache and having pituitary adenomas.

Frontal endoscopic myotomies for chronic headache.

Recent insights into the pathogenesis of migraine headache substantiate a neuronal hyperexcitability and inflammation involving compressed peripheral craniofacial nerves, and these trigger points can be eliminated by surgery. The aim of this study was to describe a modified, innovative, minimally invasive endoscopic technique to perform selective myotomies of corrugator supercilii, depressor supercilii, and procerus muscles, which turned out to be an effective therapy for migraine and tension-type headaches. Forty-three patients (18-75 years) who experienced 15 or more frontal migraine headaches without aura, tension-type headaches, or new daily persistent headaches each month were enrolled in the study between 2011 and 2013. Of 43 patients, 15 were followed for 2 years. Fourteen patients (93.3%) reported a positive response to the surgery: 5 (33.3%) observed complete elimination, 9 (60%) experienced significant improvement (at least 50% reduction in intensity or frequency), and 1 patient (6.6%) did not notice any change in their headaches. A statistically significant difference was found between our protocol compared with currently performed, more invasive technique (odds ratio, 1.9; 95% confidence interval, 1.151-3.13). According to our data, the modified endoscopic procedure leads to better results, compared to previous techniques, together with eliminating the need for general anesthesia, reducing the invasiveness of the procedure and the number of postoperative scars.

The surgical treatment of headache.

Medically refractory headache is an uncommon but difficult-to-treat clinical problem. Patients who fail maximal medical management may be candidates for invasive treatment. In this review, we critically examine the literature on the range of surgical treatments currently available for migraine, trigeminal autonomic cephalalgias, idiopathic intracranial hypertension and Chiari malformation type 1, with particular attention to patient selection, treatment efficacy, and complications.

The neuralgias: diagnosis and management.

The neuralgias are characterized by pain in the distribution of a cranial or cervical nerve. While most often brief, severe, and paroxysmal, continuous neuropathic pain may occur. The most commonly encountered entities include trigeminal, postherpetic, glossopharyngeal, and occipital neuralgia. More unusual cranial neuralgias may occur in periorbital (eg, supraorbital neuralgia) and auricular (eg, nervus intermedius neuralgia) distributions. These disorders may be mimicked by structural and inflammatory/infectious neurologic disease, along with other primary headache disorders (eg, primary stabbing headache). The approach to diagnosis and treatment of this group of headache disorders is reviewed.

Treatment of chronic headache of cervical origin with lipostructure: an observational study.

OBJECTIVE: To test feasibility, safety, and efficacy of local transplant of stromal fraction of adipose tissue in the treatment of chronic headaches of cervical origin. BACKGROUND: Chronic headaches of cervical origin (chronic cervicogenic headache and occipital neuralgia) are characterized by persistent pain due to the involvement of the great occipital nerve, with concurrent myofascial spasm and the consequent nerve entrapment within the trapezoid tunnel. METHODS: Tolerability and effectiveness of treatment of chronic cervicogenic headaches refractory to conventional therapies were evaluated in 24 patients. The visual analog scale of pain and the medication use diary were used in the 3 months preceding treatment; moreover, in order to verify the quality of life, patients are required to fill before surgery the neck pain disability index, the headache disability index, migraine disability assessment scale questionnaire, and the short-form 12 standard v1 questionnaire. Follow-up examination was performed at 3 and 6 months. RESULTS: In 19 cases (79.2%), a good clinical response was recorded. At 6-month follow-up analysis, recurrence of occipital pain was recorded in 7 cases (29.2%); there is a significant reduction in disability and pain scores, and also a significant reduction of need for pharmacologic treatment and a fast return to previous work capacities. CONCLUSIONS: The key point of our therapeutic strategy might be the regenerative role of stromal fraction of adipose tissue transplanted in the area of the occipital nerve entrapment; the results of the present study are encouraging both in terms of reduction of pain scores and in terms of quality of life improvement. The technique is minimally invasive, and no complications were recorded; indeed, the procedure seems to be safe and effective, and thus, a randomized study with larger follow-up and in a large series will be started.

Surgical management of pediatric occipital neuralgia: a single-center experience of an uncommon pathology.

OBJECTIVE: Occipital neuralgia (ON) is a rare headache disorder characterized by sharp pain in the distribution of the greater occipital nerve (GON), lesser occipital nerve, or third occipital nerve. ON is commonly associated with traumatic injury, and effective identification and diagnosis can be difficult given the infrequent presentation and similarities to other pediatric headache disorders. While GON decompression has been well described in adults for refractory pain, there is a paucity of data in the pediatric population, with no previously published series on ON. The primary aim of this study was to identify the characteristics of pediatric patients with ON prior to surgical intervention and to describe the natural history of postoperative outcomes after decompression or neurectomy in a pediatric population. METHODS: A single-center retrospective case series was performed to evaluate factors predisposing children to refractory ON and the surgical efficacy of GON decompression or neurectomy. Six patients (mean age 15.0 ± 2.2 years) were identified for inclusion from October 2021 to October 2022. All patients had refractory ON as diagnosed by a pediatric neurologist. After medical therapy and repeated occipital nerve blocks failed, the patients were referred for GON decompression. Five patients had a history of trauma. RESULTS: Six patients were identified and treated in our cohort, highlighting the infrequency of this pathology. All had at least one occipital nerve block, with 83% receiving varied relief. All underwent bilateral decompression or neurectomy of the GON and experienced relief, reporting improved visual analog scale scores (mean 8.3 ± 0.9 preoperatively to 1.0 ± 2.2 postoperatively, p = 0.0009). The patients were followed for an average of 10 months, and their mean number of medications decreased from 2.7 ± 0.5 preoperatively to 0.8 ± 0.7 postoperatively (p = 0.019). Each patient reported numbness or tingling in the GON distribution postoperatively, which spontaneously resolved over time. Two patients had recurrent pain in a delayed fashion. CONCLUSIONS: GON decompression and neurectomy are efficacious treatments of refractory ON in the pediatric population.