Lymph node compression of the lesser occipital nerve: A cause of migraine

Literature Review: Pericranial Nerve Blocks for Chronic Migraines

Purpose of Review

Headaches, especially migraines, are one of the most pervasive neurological disorders affecting up to 15.9% of the population. Current methods of migraine treatment include lifestyle changes, pharmacologic, and minimally invasive techniques such as peripheral nerve stimulation (PNS) and pericranial nerve blocks (PNB).

Recent Findings

PNBs are used to treat and prevent migraines and involves injection of local anesthetics with or without corticosteroids. PNBs include the greater occipital, supraorbital, supratrochlear, lesser occipital, auriculotemporal, sphenopalantine ganglion, and cervical root nerve blocks. Of the PNBs, the most extensively studied is the greater occipital nerve block (GONB) which has been shown to be an efficacious treatment for migraines, trigeminal neuralgia, hemi-crania continua, and post-lumbar puncture, post-concussive, cluster, and cervicogenic headaches but not medication overuse and chronic tension type headaches.

Summary

In this review, we aim to summarize the recent literature on PNBs and their efficacy in the treatment of migraines including a brief discussion of peripheral nerve stimulation.

Increasing Collaboration between Headache Medicine and Plastic Surgery in the Surgical Management of Chronic Headache

INTRODUCTION

Chronic headache is one of the most disabling conditions afflicting humankind. The management of chronic headaches has, to date, been only partially successful. The goal of this paper is to highlight the importance of collaboration between surgeons and headache physicians in treating this condition.

METHODS

We present a narrative review of migraine pathophysiology, its medical and surgical treatment options, and the important role of collaboration between headache physicians and surgeons.

RESULTS

Migraine headaches can be treated with both medication-based regimens and surgery. Novel medications such monoclonal antibodies directed at the CGRP molecule or its receptor have recently been FDA approved as an effective treatment modality in chronic migraines. However, these medications are associated with a high cost, and there is a paucity in data regarding effectiveness compared to other treatment modalities. The pathophysiology of headache likely exists along a spectrum with peripheral - extracranial and meningeal - factors at one end and central - brain - factors at the other, with anatomic and physiologic connections between both ends. Recent evidence has clearly shown that surgical decompression of extracranial nerves improves headache outcomes. However, appropriate patient selection and preoperative diagnosis are of paramount importance to achieve excellent outcomes.

CONCLUSIONS

Surgeons and headache physicians who are interested in providing treatment for patients with chronic headache should strive to form a close collaboration with each other in order to provide the optimal plan for migraine/headache patients.

Intramuscular Lipoma-Induced Occipital Neuralgia on the Lesser Occipital Nerve

Occipital neuralgia (ON) is commonly characterized by a neuralgiform headache accompanied by a paroxysmal burning sensation in the dermatome area of the greater, lesser, or third occipital nerve. The authors report a rare case of ON caused by an intramuscular lipoma originating from the lesser occipital nerve.A 52-year-old man presented with sharp pain in the left postauricular area with a 3 × 2-cm palpable mass. Computed tomography revealed a mass suspiciously resembling an intramuscular lipoma within splenius muscle. In the operation field, a protruding mass causing stretching of the lesser occipital nerve was found. After complete resection, the neuralgiform headache symptom had resolved and the intramuscular lipoma was confirmed through histopathology.Previous studies on the causes of ON have reported that variation in normal anatomic structures results in nerve compression. Occipital neuralgia, however, caused by intramuscular lipomas in splenius muscles have not been previously reported, and the dramatic resolution following surgery makes it an interesting case worth reporting.

Targeting pericranial nerve branches to treat migraine: Current approaches and perspectives

BACKGROUND

Migraine is a highly prevalent neurological disorders and a major individual and societal burden. Migraine is not curable at the present time, but it is amenable to acute symptomatic and preventive pharmacotherapies.

SUMMARY

Since the latter are frequently unsatisfactory, other treatment strategies have been used or are being explored. In particular, interventions targeting pericranial nerves are now part of the migraine armamentarium. We will critically review some of them, such as invasive and noninvasive neurostimulation, therapeutic blocks and surgical decompressions.

CONCLUSIONS

Although current knowledge on migraine pathophysiology suggests a central nervous system dysfunction, there is some evidence that interventions targeting peripheral nerves are able to modulate neuronal circuits involved in pain control and that they could be useful in some selected patients. Larger, well-designed and comparative trials are needed to appraise the respective advantages, disadvantages and indications of most interventions discussed here.

The lesser occipital nerve visualized by high-resolution sonography—normal and initial suspect findings

Background

The lesser occipital nerve (LON) supplies the lateral part of the occiput and is—together with the greater occipital nerve (GON)—involved in headache pathogenesis. While the GON was described in high-resolution ultrasound (HRUS), the same does not apply to the LON. We aimed at characterizing the LON in HRUS, and present cases of suspect findings in the course of the LON identified by HRUS.

Methods

The LON was examined bilaterally in eight anatomical specimens with HRUS ( n = 16). HRUS-guided ink marking and consecutive dissection was performed. Further, measurements of the LON diameter were performed in 10 healthy volunteers ( n = 20), and patient charts were reviewed to identify patients who were considered to have possible pathology of the LON.

Results

The LON was identified correctly in all cadavers on both sides and all volunteers except for one side ( n = 19). The average diameter was 1.08 ± 0.30 mm. Four patients with pain within the LON territory and presumed peripheral origin of headache (defined as resolution of headache after diagnostic HRUS-guided selective blockade) were identified, and three of these showed interference of the LON with lymph nodes or an accessory muscle belly.

Discussion

We confirm the possibility of visualization of the LON using HRUS. HRUS may be a helpful adjunct tool in the assessment of patients with atypical headache.