Oxford Health Plans > Medical and Administrative Policies > Occipital Neuralgia and Headache
Title of Policy

Occipital Neuralgia and Headache

The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.

Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Memberís plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.


Policy #: PAIN 018.5 T3

Non-Coverage Statement:

Policy is applicable to:

    Commercial plans

Note: For information regarding implantable neurostimulator systems used in other clinical scenarios, refer to the following policies:
  • Deep Brain Stimulation for Commercial Plans
  • Vagus Nerve Stimulation

Policy and Rationale:

Due to insufficient clinical evidence to support medical efficacy, the following services are not considered to be medically necessary and therefore will not be reimbursed by Oxford:
  • Injection of local anesthetics and/or steroids, used as occipital nerve blocks, for the diagnosis and treatment of occipital neuralgia or headaches including migraine and cervicogenic headaches. There is insufficient evidence that greater occipital nerve blocks can be used as a specific diagnostic test for occipital neuralgia or headaches. The efficacy of local injection therapies for occipital neuralgia or cervicogenic headache and other headaches has not been established in well designed clinical trials.

  • Surgery including but not limited to the following for the treatment of occipital neuralgia or cervicogenic headache.
    • Occipital neurectomy
    • Partial posterior intradural C1-C3 rhizotomy
    • Rhizotomy of C1-C3 spinal dorsal roots
    • Surgical decompression of second cervical nerve root and ganglion
    • Surgical decompression of the greater occipital nerve

    The available evidence is insufficient to conclude that surgery is an effective treatment for occipital neuralgia or cervicogenic headache. The long-term efficacy of surgical procedures for occipital neuralgia or cervicogenic headache has not been established in well designed clinical trials.

  • Occipital neurectomy or surgical nerve decompression for the treatment of headaches. The available evidence is insufficient to conclude that occipital neurectomy or nerve decompression including decompression of the supraorbital, supratrochlear, zygomaticotemporal, or greater occipital nerves is an effective treatment for headaches. The long-term efficacy of these procedures for headaches has not been established in well designed clinical trials.
  • Radiofrequency ablation or denervation for the treatment of occipital neuralgia or cervicogenic headache. The available evidence from published studies is not sufficient to conclude that radiofrequency ablation or denervation is an effective treatment for occipital neuralgia or cervicogenic headache. Well-designed studies are needed to evaluate the potential advantages of radiofrequency ablation for these conditions and to identify which patients would benefit from this procedure.

  • Neurostimulation or electrical stimulation of the occipital nerve for the treatment of occipital neuralgia or cervicogenic headache. The available studies were limited and had significant methodological flaws, making it difficult to draw conclusions regarding the efficacy of electrical stimulation for the treatment of cervicogenic headache or occipital neuralgia. There are no randomized controlled studies in the medical literature comparing occipital neurostimulation to established treatment options or a sham procedure.

Description of Services/Assessment/Background Information:

Cervicogenic headache and occipital neuralgia are conditions whose diagnosis and treatment have been gradually refined over the last several years. This terminology has come to refer to specific types of unilateral headache thought to arise from impingement or entrapment of the occipital nerves and/or the upper spinal vertebrae. Compression and injury of the occipital nerves within the muscles of the neck and compression of the second and third cervical nerve roots are generally felt to be responsible for the symptoms, including unilateral and occasionally bilateral head, neck, and arm pain. The criteria for diagnosis of these entities currently include those of the International Headache Society (IHS) and the Cervicogenic Headache International Study Group.

Various treatments have been advocated for cervicogenic headache and occipital neuralgia. Oral analgesics and anti-inflammatory agents are effective for some patients, but there is a population of patients who do not experience pain relief with these medications. Local injections, epidural steroid injections, radiofrequency ablation of the planum nuchae, electrical stimulation, rhizotomy, ganglionectomy, nerve root decompression, discectomy and spinal fusion have all been investigated in the treatment of cervicogenic headache and occipital neuralgia.

Since medications provide only temporary relief and may cause side effects, surgical treatments such as occipital neurectomy and nerve decompression for migraine and other headaches have been developed as a potential means to permanently prevent or to produce long-term remissions from headaches.

Radiofrequency ablation is performed percutaneously. During the procedure, an electrode that generates heat produced by radio waves is used to create a lesion in a sensory nerve with the intent of inhibiting transmission of pain signal from the sensory nerve to the brain.

Neurostimulation or electrical stimulation is commonly used for control of chronic pain. Electrical stimulation can be delivered in 3 ways: transcutaneously, percutaneously, and using implantable devices.

Clinical Evidence:

Diagnostic Occipital Nerve Blocks
Greater occipital nerve blocks have been advocated as a diagnostic test for cervicogenic headache and occipital neuralgia. However, criteria and standards for diagnostic occipital nerve blocks remain to be defined. There are no well-designed clinical trials that clearly indicate that injection of the greater occipital nerve can be used as a specific diagnostic test for headaches and occipital neuralgia.

The diagnostic value of greater occipital and supra-orbital nerve blockades in patients with cervicogenic headache (n=24), migraine without aura (n=14), and tension-type headache (n=14) was investigated. The pain reduction after greater occipital nerve blockade was significantly more marked in the cervicogenic headache group than in the other categories. Moreover, pain reduction in the forehead was generally only found in the cervicogenic headache patients (77%). Pain reduction was significantly more marked following the greater occipital than the supra-orbital nerve blockade. The volume effect per se was evaluated by saline injection. This procedure did not result in distinct pain reduction. The effect obtained in cervicogenic headache is, accordingly, probably due to the local anaesthesia. The present results support the postulate that different pathogenetic factors probably are responsible for cervicogenic headache, tension-type headache, and migraine without aura (Bovim and Sand 1992). These findings require confirmation in a larger study.

According to the International Headache Society, the diagnostic criteria for cervicogenic headache include the following (International Headache Society, 2005):

  1. Pain, referred from a source in the neck and perceived in one or more regions of the head and/or face, fulfilling criteria C and D
  2. Clinical, laboratory and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck known to be, or generally accepted as, a valid cause of headache
  3. Evidence that the pain can be attributed to the neck disorder or lesion based on at least one of the following:

    1. demonstration of clinical signs that implicate a source of pain in the neck
    2. abolition of headache following diagnostic blockade of a cervical structure or its nerve supply using placebo- or other adequate controls

  4. Pain resolves within 3 months after successful treatment of the causative disorder or lesion.

Therapeutic Occipital Nerve Blocks
Cervicogenic Headache
In a randomized, double-blind, placebo-controlled trial, Naja et al. (2006a) evaluated the effectiveness of nerve stimulator-guided occipital nerve blockade in the treatment of cervicogenic headache. The reduction in analgesic consumption was the primary outcome measure. Fifty adult patients diagnosed with cervicogenic headache were randomly divided into two equal groups of 25 patients each. All patients in both groups received greater and lesser occipital blocks, whereas only 16 patients in each group received facial nerve blockade in association with the occipital blocks. The control group received injections of an equivalent volume of preservative-free normal saline. Pain was assessed using the visual analog scale (VAS) and the Total Pain Index (TPI). Forty-seven patients entered into the final analysis as three patients were lost to follow-up. Anesthetic block was effective in reducing the VAS and the TPI by approximately 50% from baseline values. Analgesic consumption, duration of headache and its frequency, nausea, vomiting, photophobia, phonophobia, decreased appetite, and limitations in functional activities were significantly less in block group compared to control group. The nerve stimulator-guided occipital nerve blockade significantly relieved cervicogenic headache and associated symptoms at two weeks following injection. This study is limited by a small sample size. Another major limitation of the study is the short duration of follow-up. The patients included in the study were followed for 2 weeks, so long-term outcome was not evaluated. The difficulty in blinding when numbness resulted in patients who received anesthetic blockade is another limitation of this study.

In a follow-up trial, the same group evaluated 47 patients with cervicogenic headaches and found that 87% of the patients required more than one occipital nerve injection to achieve 6 months of pain relief (Naja, 2006).

Inan et al. (2001) compared the greater occipital nerve (GON) and C2/C3 nerve blocks in the diagnosis and treatment of cervicogenic headache in 28 patients. In both cases, repeated blocks proved to have a long-lasting effect in the treatment of this disorder, with both GON and C2/C3 blocks being found to be equally effective. This study is limited by a small sample size.

In a prospective case series, injections of depot methylprednisolone into the region of the GON and lesser occipital nerve (LON) produced complete relief of cervicogenic headache in 169 out of 180 patients for a period ranging from 10 to 77 days, the mean duration of relief being 23.5 days. This study is nonrandomized and uncontrolled, limiting the validity of its conclusions. (Anthony, 2000).

In a prospective non-controlled trial, Vincent et al. (1998) studied the effect of GON blocks using 0.5% bupivacaine in 41 patients with cervicogenic headache. The investigators found a significant reduction in head pain at 1 week post injection, as compared with pain during the week before injection. This study is limited by a small sample size and the lack of a comparison group.

Martelletti et al. (1998) compared the results of 9 patients with cervicogenic headaches who received epidural steroid injections and 6 patients with chronic tension headaches who received the same procedure. A decrease in the Numeric Intensity Scale and the Drug Consumption Index were observed in the cervicogenic headache patients.

Weibelt et al. (2010) evaluated the safety and efficacy of occipital nerve blocks (ONBs) used to treat cervicogenic chronic migraine (CCM) and identified variables predictive of a positive treatment response. A positive treatment outcome was defined as a 50% or greater reduction in headache days per month over the 30 days following treatment relative to the 30-day pre-treatment baseline. A total of 150 consecutive patients were treated with unilateral (37) or bilateral (113) ONBs. At the 1-month follow-up visit, 78 (52%) exhibited evidence of a positive treatment response according to the primary outcome variable, and 90 (60%) reported their headache disorder to be "better" (44; 29%) or "much better" (46; 30%). A total of 8 (5%) patients reported adverse events within the ensuing 72 hours, and 3 (2%) experienced adverse events that reversed spontaneously but required emergent evaluation and management. The investigators concluded that for suppression of CCM, ONBs may offer an attractive alternative to orally administered prophylactic therapy. This study lacked a control group and the data used for analyzing the primary outcome variable were partially dependent on patient recall. Both recall bias and placebo effect could have inflated the response rate.

Other Headaches
Ashkenazi et al. (2010) performed a systematic review of peripheral nerve blocks (PNBs) and trigger point injections (TPIs) for headache treatment. The authors found few controlled studies on the efficacy of PNBs for headaches, and virtually none on the use of TPIs for headaches. The most widely examined procedure in this setting was greater occipital nerve block, with the majority of studies being small and non-controlled. The techniques, as well as the type and doses of local anesthetics used for nerve blockade, varied greatly among studies. The specific conditions treated also varied, and included both primary (e.g., migraine, cluster headache) and secondary (e.g., cervicogenic, posttraumatic) headache disorders. According to the authors, results for PNBs were generally positive, but should be taken with reservation given the methodological limitations of the available studies. These limitations included small patient populations, retrospective, non-controlled designs, and heterogeneous groups of patients.. The authors concluded that there is a need to perform more rigorous clinical trials to clarify the role of PNBs and TPIs in the management of various headache disorders, and to aim at standardizing the techniques used for the various procedures in this setting.

In a double-blind placebo-controlled trial, Ambrosini et al. (2005) assessed the preventive effect of an ipsilateral steroid injection in the region of the greater occipital nerve on cluster headache (CH). Sixteen episodic (ECH) and seven chronic (CCH) CH outpatients were included. After a one-week run-in period, patients were allocated by randomization to the placebo or verum acupuncture arms and received on the side of attacks a suboccipital injection of a mixture of long- and rapid-acting betamethasone (n=13; verum-group) or physiological saline (n=10; placebo-group). Acute treatment was allowed at any time, additional preventative therapy if attacks persisted after 1 week. Three investigators performed the injections, while four others, blinded to group allocation, followed the patients. Follow-up visits were after 1 and 4 weeks, where after patients were followed routinely. Eleven verum-group patients (3 CCH) (85%) became attack-free in the first week after the injection compared to none in the placebo-group. Among them eight remained attack-free for 4 weeks. Remission lasted between 4 and 26 months in five patients. According to the investigators, a single suboccipital steroid injection completely suppressed attacks in more than 80% of CH patients. A limitation of this study is small sample size.

Busch et al. (2007) evaluated the clinical outcome in 15 chronic cluster headache patients before and after unilateral nerve blockade of the greater occipital nerve with 5 ml prilocain (1%) on the headache side. Nine of the 15 cluster patients reported some minor improvement in their headache. Six patients did not report any clinical change. Peres et al. (2002) treated 14 cluster headache patients with greater occipital nerve block as transitional therapy (treatment initiated at the same time as preventive therapy). The mean number of headache-free days was 13.1 + 23.6. Four patients (28.5%) had a good response, five (35.7%) a moderate, and five (35.7%) no response. Headache intensity, frequency and duration were significantly decreased comparing the week before with the week after the nerve block. These studies are limited by small sample size and lack of control groups.

Saper et al. (2010) conducted a multicenter, randomized, blinded, controlled feasibility study to obtain preliminary safety and efficacy data on occipital nerve stimulation (ONS) in chronic migraine (CM). Eligible individuals received an occipital nerve block, and responders were randomized to adjustable stimulation (AS), preset stimulation (PS) or medical management (MM) groups. Seventy-five of 110 patients were assigned to a treatment group; complete diary data were available for 66. A responder was defined as a subject who achieved a 50% or greater reduction in number of headache days per month or a three-point or greater reduction in average overall pain intensity compared with baseline. Three-month responder rates were 39% for AS, 6% for PS and 0% for MM. No unanticipated adverse device events occurred. Lead migration occurred in 12 of 51 (24%) patients. The investigators concluded that the results of this feasibility study offer promise and should prompt further controlled studies of ONS in CM.

In a randomized controlled study, Ashkenazi et al. (2008) examined the effect of greater occipital nerve block (GONB) and trigger-point injections (TPIs) on headache in patients with transformed migraine (TM). Thirty- seven patients with TM were randomized to receive GONB and TPIs using lidocaine 2% and bupivacaine 0.5% plus either saline or triamcinolone 40 mg. Twenty minutes after injection, there was a significant decrease in the severity of headache and associated symptoms in both groups, with no significant between-group difference in the majority of outcome measures (the exception was the decrease in phonophobia that was more pronounced in the group that received triamcinolone with the local anesthetics). These findings require confirmation in a larger study.

Saracco et al. (2010) assessed whether adding triamcinolone to local anaesthetics increased the efficacy of greater occipital nerve block (GONB) and trigger point injections (TPIs) for chronic migraine. Thirty-seven patients with chronic migraine were randomized to receive GONB and TPIs using lidocaine 2% and bupivacaine 0.5% plus either saline (group A) or triamcinolone 40 mg (group B). Patients documented headache and severity of associated symptoms for 4 weeks after injection. Changes in symptom severity were compared between the two groups. Twenty minutes after injection, mean headache severity decreased by 3.2 points in group A and by 3.1 points in group B. Mean neck pain severity decreased by 1.5 points in group A and by 1.7 points in group B. Mean duration of being headache-free was 2.7 ± 3.8 days in group A and 1.0 ± 1.1 days in group B. None of the outcome measures differed significantly between the two groups. According to the investigators, adding triamcinolone to local anaesthetic when performing GONB and TPIs was not associated with improved outcome in the sample of patients with chronic migraine. In both groups, the procedure resulted in significant and rapid relief of headache, neck pain, and photophobia. The study is limited by a small sample size and lack of a control therapy.

Afridi et al. (2006) found that 26 of 57 injections in 54 migraineurs yielded a complete or partial response that lasted for the partial response a median of 30 days. For cluster headache 13 of 22 injections yielded a complete or partial response lasting for a median of 21 days for the partial response. Tenderness over the GON was strongly predictive of outcome, although local anesthesia after the injection was not. The presence or absence of medication overuse did not predict outcome. The investigators concluded that GON injection is a useful tool in some patients that provides interim relief while other approaches are explored. The lack of a control group limits the validity of the results of this study.

Naja et al. (2009) also conducted a prospective, randomized, single-blinded comparison between bilateral occipital blockade and conventional expectant therapy in adults suffering from postdural puncture headache (PDPH). Fifty adult patients diagnosed with PDPH were randomly divided into two equal groups of 25 each. All patients in the block group received greater and lesser occipital nerve blocks, whereas the control group received adequate hydration, complete bed rest, and analgesics. Forty-seven patients entered into the final analysis as three patients withdrew from study. Complete pain relief was achieved in 68.4% of block patients after 1 to 2 blocks, with 31.6% ultimately receiving up to 4 blocks. Visual analog scales were significantly lower in the block group, and the block group consumed significantly less analgesics in the follow-up period compared with control group. Block patients had significantly shorter hospital stays and sick leave periods. The investigators concluded that occipital nerve blockade is superior to expectant conservative therapy in the treatment of patients suffering from PDPH. These findings require confirmation in a larger study.

Tobin et al. (2009) conducted a chart review of 108 occipital nerve blocks (ONBs)-to explore the effect of symptomatic medication overuse (SMO) and ONB efficacy. ONB failed in 22% of injections overall. Of the other 78%, the mean decrease in head pain was 83%, and the benefit lasted a mean of 6.6 weeks. Failure rate without symptomatic medication overuse (SMO) was 16% overall, and with SMO was 44% overall. In those who did respond, overall magnitude and duration of response did not differ between those with and those without SMO. Without SMO, ONB failure rate was 0% for postconcussive syndrome, 14% for occipital neuralgia, 11% for non-intractable migraine, and 39% for intractable migraine. With SMO, failure rate increased by 24% in occipital neuralgia, by 36% for all migraine, and by 52% for non-intractable migraine. The investigators concluded that SMO tripled the risk of ONB failure, possibly because medication overuse headache does not respond to ONB. This study lacked a control group.

In an open pilot study, Leinisch-Dahlke et al. (2005) investigated the effect of bilateral block of the greater occipital nerve with 50 mg prilocaine and 4 mg dexamethasone in patients with chronic tension type headache. From 15 patients, only one patient described a headache relief after initial exacerbation of headache for 2 days. Headache intensity was unchanged in 11 patients. In three patients, the headache worsened in the first hours or days after injection. The investigators concluded that a block of the greater occipital nerve is not effective in the treatment of chronic tension type headache.

Other studies have been performed that indicate that greater occipital nerve blocks may be an effective treatment for patients with migraine and postconcussive headaches; however, these studies had small sample sizes and did not have control groups (Young, 2008; Akin, 2008; Caputi, 1997; Hecht, 2004; Ashkenazi, 2005; Saadah and Taylor, 1987).

Surgical Treatment of Occipital Neuralgia or Cervicogenic Headache
A number of different surgical procedures have been studied for the treatment of occipital neuralgia and cervicogenic headache. Bovim et al. (1992) investigated the immediate and long-term results of surgical release of the greater occipital nerve within the trapezius for treatment of patients who had previously had relief of the symptoms of cervicogenic headache with nerve blockade. Of 50 patients responding to a questionnaire sent to 58 patients, 46% reported immediate relief and 36% reported some immediate improvement. However, after a mean follow-up of 14.5 months, only 56% of patients felt that the procedure had been beneficial. The authors recommended further investigation into the efficacy of alternative procedures.

Pikus and Phillips (1996) performed a total of 39 microsurgical decompression procedures of the C2 root and ganglion in 35 patients who met diagnostic criteria for cervicogenic headache. Long-term pain-free outcome (assessed after a mean of 21 months) was achieved by 33% of patients. Another 46% of patients reported adequate relief, while 21% had recurrence of pain at an average of 18 months after surgery. No specific prognostic characteristics were discernible from the analysis performed on the patient population. Study limitations include a small sample size, all patients continuing to use pain medications as needed and variable duration of followup.

Jansen (2000) reported on the results of three different surgical treatments in 102 patients with cervicogenic headache that had been nonresponsive to physical or drug therapy. Thirty-eight patients were treated with C2 ganglionectomy, and 64 patients with demonstrable spinal structural abnormalities were treated with dorsal or ventral spinal decompression and fusion. Complete relief of pain was reported by 80% of the entire group, and 60% to 80% relief was experienced by about 15% of patients. Six percent of patients experienced no relief of pain. Study limitations include a relatively small sample size and lack of specific diagnosis criteria.

In a study conducted by Kapoor et al. (2003), 17 patients with occipital neuralgia underwent dorsal rhizotomy. At a mean follow-up of 20 months, 65% of patients had complete relief of symptoms, 12% had partial relief, and 24% had no relief of symptoms. These findings require confirmation in a larger study.

A retrospective study conducted by Gille et al. (2004) evaluated 10 patients with occipital neuralgia who underwent neurolysis of the occipital nerve and sectioning of the inferior oblique muscle. After a mean follow-up of 37 months, the investigators concluded this new surgical treatment provided good results if patients are well chosen. The small study population limits the validity of the conclusions of this study.

A retrospective chart review was conducted to identify 206 consecutive patients undergoing neurolysis of the greater or, less commonly, excision of the greater and/or lesser occipital nerves. Of 206 patients, 190 underwent greater occipital nerve neurolysis (171 bilateral). Twelve patients underwent greater and lesser occipital nerve excision, whereas four underwent lesser occipital nerve excision alone. The investigators found that 80.5% of patients experienced at least 50% pain relief and 43.4% of patients experienced complete relief of headache. Minimum duration of follow-up was 12 months. (Ducic et al., 2009)

In a retrospective chart review, Acar et al. (2008) evaluated 20 patients who underwent C2 and/or C3 ganglionectomies for intractable occipital pain. All patients reported preoperative pain relief following cervical nerve blocks. The mean follow-up was 42.5 months. Average visual analog scale scores were 9.4 preoperatively and 2.6 immediately after procedure. Ninety-five percent of patients reported short-term pain relief (<3 months). In 13 patients (65%), pain returned after an average of 12 months (C2 ganglionectomy) and 8.4 months (C3 ganglionectomy). Long-term results were excellent, moderate and poor in 20, 40 and 40% of patients, respectively. The investigators concluded that cervical ganglionectomy offers relief to a majority of patients, immediately after procedure, but the effect is short lived. Nerve blocks are helpful in predicting short-term success, but a positive block result does not necessarily predict long-term benefit and therefore cannot justify surgery by itself.

Several small, retrospective studies have reported positive effects of various surgical treatments such as dorsal nerve root section, occipital neurectomy, partial posterior rhizotomy, and nerve release (Hayes, 2003). Some authors have described substantial pain relief after rhizotomy or spinal fusion in patients with cervicogenic headache associated with demonstrable spinal structural abnormalities, such as those due to degenerative changes or motion disorders of the upper spine (Hayes, 2003). However, the available evidence comes primarily from small retrospective case series studies and is insufficient to conclude that surgery is an effective treatment for occipital neuralgia or cervicogenic headache. Surgical procedures such as nerve root decompression or neurectomy may provide effective pain relief for some patients; however, patient selection criteria for these procedures have not been defined, and recurrence is common. (Hayes 2003) The 2008 Hayes Search and Summary on cervical microdecompression surgery for occipital neuralgia concludes that there is insufficient evidence to assess the safety and efficacy of cervical microdecompression surgery for occipital neuralgia (Hayes, 2008a).

Nerve Decompression and Occipital Neurectomy for Headaches
A randomized trial of patients with medication-refractory, but BT-responsive, migraine headaches compared the removal of the glabellar muscles (n=19), removal of the zygomaticotemporal branch of the trigeminal nerve (n=19), or greater occipital neurectomy (n=11) with sham-control patients (n=26) who underwent only exposure at one of the sites. At 1-year follow-up, complete resolution of headaches was found in 57.1% and significant improvement in 83.7% of patients undergoing actual surgery, and significant improvement was found compared with baseline values in all migraine headache measures. In the sham surgery group, 57.7% of patients reported at least 50% reduction in migraine headache. The difference between experimental and control groups was statistically significant (Guyuron et al., 2009). These findings require confirmation in a larger study.

A retrospective analysis was performed on 18 consecutive patients with migraine headaches who had undergone various combinations of surgical decompression of the supraorbital, supratrochlear, and greater occipital nerves and zygomaticotemporal neurectomy. These surgeries were performed by a single surgeon. The number of migraines per month and the pain intensity of migraine headaches decreased significantly. Three patients (17 percent) had complete relief of their migraines, and 50 percent of patients (nine of 18) had at least a 75 percent reduction in the frequency, duration, or intensity of migraines. Thirty-nine percent of patients discontinued all migraine medications. Mean follow-up was 16 months (range, 6 to 41 months) after surgery. One hundred percent of participants stated they would repeat the surgical procedure. According to the investigators, this study confirms prior published results and supports the theory that peripheral nerve compression triggers a migraine cascade. The investigators also stated that a significant amount of patient screening is required for proper patient selection and trigger site identification for surgical success (Poggi et al. 2008). While this study showed a treatment effect, the small sample size, retrospective design, short follow-up, and the different surgical procedures used, limits the generality of the findings to a larger population.

Williams et al. (2010) reported on nine cases of conjunctival injection and tearing (SUNCT) syndrome and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) that failed medical treatment. The patients had an aberrant arterial loop either in contact with or compressing the appropriate trigeminal nerve demonstrated on MRI. All underwent microvascular decompression of the ipsilateral trigeminal nerve for intractable pain. Immediate and complete relief of SUNCT and SUNA symptoms occurred in 6/9 (67%) cases. This was sustained for a follow-up period of 9 to 32 months (mean 22.2). In 3/9 (33%) cases, there was no benefit. Ipsilateral hearing loss was observed in one case. The investigators concluded that medically intractable SUNCT and SUNA patients with a demonstrable aberrant arterial loop impinging on the trigeminal nerve on neuroimaging may benefit from microvascular decompression. The study is limited by a small sample size and lack of a control group.

Radiofrequency Ablation
In a randomized controlled trial of 30 patients with cervicogenic headache, 15 patients received radiofrequency (RF) treatments, and 15 patients underwent local injections of the greater occipital nerve followed by transcutaneous electrical nerve stimulation when necessary. There were no significant differences between the 2 treatment groups at any time during the study. Eight weeks after the initial treatment, 80% of the patients in the RF-group (Group I) and 66,7% of the patients in the local injection group (Group II) reported a successful treatment in terms of a positive global perceived effect and/or an visual analogue scale (VAS) reduction of at least 50% compared to the initial VAS. Sixteen weeks after the initial treatment, the success rate in Group I was 66,7% compared to 55,3% in Group II. After one year, there was no difference of the success rate in Group I (53,3%) compared to Group II (50%). A relatively high percentage of patients (33,3%) in both groups were not followed anymore because of several reasons. The most important reason was the disappointment in the treatment. (Haspeslagh, 2006)

Stovner et al. (2004) conducted a randomized, sham-controlled study of 12 patients with cervicogenic headaches. Six patients underwent radiofrequency neurotomy and six patients received sham treatment. Patients were followed for 2 years. Patients treated with neurotomy were somewhat improved at 3 months, but later follow-up showed no significant differences between the 2 treatment groups.

Vanelderen et al. (2010) reported on the results of a prospective trial with 6 months of follow-up in which pulsed radiofrequency treatment of the greater and/or lesser occipital nerve was used to treat occipital neuralgia in 19 patients. Patients presenting with clinical findings suggestive of occipital neuralgia and a positive test block of the occipital nerves with 2 mL of local anesthetic underwent a pulsed radiofrequency procedure of the culprit nerves. Approximately 52.6% of patients reported a score of 6 (pain improved substantially) or higher on the Likert scale after 6 months. No complications were reported. The investigators concluded that pulsed radiofrequency treatment of the greater and/or lesser occipital nerve is a promising treatment of occipital neuralgia. This study warrants further placebo-controlled trials.

Halim et al. (2010) conducted a retrospective study that included 86 patients who had undergone lateral C1-2 joint pulsed radiofrequency application, for cervicogenic headache in a single pain center from March 2007 to December 2008. The percentage of patients who had ≥50% pain relief at 2 months, 6 months, and 1 year were 50% (43/86), 50% (43/86), and 44.2% (38/86), respectively. Long-term pain relief at 6 months and 1 year were predicted reliably by ≥50% pain relief at 2 months. Apart from 1 patient that complained of increased severity of occipital headache lasting several hours, there were no other reported complications. The lack of a control group limits the validity of the results of this study.

In a clinical audit of 18 chronic cervical pain patients treated with pulsed radiofrequency, satisfactory pain relief of at least 50% was achieved in 72% of the patients at 8 weeks (Van Zundert, 2003). Thirty-three percent of the patients continued with good treatment outcome more than one year after treatment.

Govind et al. (2003) studied 49 patients with occipital headaches who underwent percutaneous radiofrequency neurotomy. Eighty-eight percent of the patients achieved a successful outcome (complete relief of pain for at least 90 days). The median duration of relief in these patients was 297 days. While the results were promising in this study, the lack of a control group leads to difficulties in interpretation of the findings. No details of previous failure of conservative or interventional therapies were given.

Lee et al. (2007) assessed the clinical efficacy of radiofrequency (RF) cervical zygapophyseal joint neurotomy in patients with cervicogenic headache. A total of thirty consecutive patients suffering from chronic cervicogenic headaches for longer than 6 months and showing a pain relief by greater than 50% from diagnostic/prognostic blocks were included in the study. These patients were treated with RF neurotomy of the cervical zygapophyseal joints and were subsequently assessed at 1 week, 1 month, 6 months, and at 12 months following treatment. RF neurotomy of the cervical zygapophyseal joints significantly reduced the headache severity in 22 patients (73.3%) at 12 months after the treatment. The limitations of this study were small sample size and lack of a control group. Study limitations include lack of controls and the small number of patients studied.

The 2008 Hayes Health Technology Brief on radiofrequency ablation for treatment of cervicogenic headache concluded that the evidence for radiofrequency ablation (RFA) for cervicogenic headache is limited and that no definitive conclusions can be drawn regarding its efficacy and safety. The results were promising in case series studies that included definitive diagnostic nerve blocks as part of the selection criteria. However, the randomized controlled trials failed to show a beneficial effect of RFA. (Hayes, 2008b)

Electrical Stimulation
In a systematic review, Jasper and Hayek (2008) evaluated the strength of evidence that occipital nerve stimulation (ONS) is an effective treatment of chronic headache. Ten observational studies, of which 4 were prospective, and a number of case series, case reports, and reviews were identified. No randomized controlled trials (RCT) were identified. All of the studies reported positive outcomes including improved pain relief, reduced frequency, intensity, and duration of headaches with reduced medication consumption. ONS was reportedly successful for 70 to 100% of patients. Reduction of pain in patients with occipital headaches and transformed migraine is significant and rapid; for cluster patients the improvement may be less dramatic and it may take several months of occipital stimulation to achieve relief. No long-term adverse events occurred. Several short-term adverse events occurred including infection, lead displacement, and battery depletion. The body of evidence as a whole is a level of strength of IV, limited.

Johnstone and Sundaraj (2006) evaluated 8 patients with intractable occipital neuralgia. All patients were offered a trial of percutaneous stimulation and if they achieved 50% pain reduction, a permanent lead was implanted. Seven patients proceeded to a permanent stimulator. The visual analogue score was reduced in 5 of the 7 patients after permanent implantation.

In a study conducted by Kapural et al. (2005), 6 patients with treatment refractive chronic headaches were treated with a midline approach for occipital nerve electrical stimulation lead implantation. During the 3-month follow-up, mean visual analog scale scores changed from 8.66 to 2.5, and pain disability index improved from 49.8 to 14.0. The authors concluded that the midline approach has advantages compared with the submastoid approach particularly regarding stability of the system. Although these improvements were statistically significant, this study did not involve any follow-up after the post-treatment assessment to evaluate the durability of benefits.

Slavin et al. (2006) analyzed the records of 14 consecutive patients with intractable occipital neuralgia treated with peripheral neurostimulation. Ten patients proceeded with system internalization after a 50% pain reduction during the trial period. Two patients had their systems explanted because of loss of stimulation effect or significant improvement of pain, and one patient had part of his hardware removed because of infection. The authors concluded that overall, the beneficial effect from chronic stimulation persisted in more than half of the patients for whom the procedure was considered and in 80% of those who significantly improved during the trial and proceeded with internalization. These findings require confirmation in a larger study.

Weiner and Reed (1999) conducted a case series involving 13 patients (17 implant procedures) with intractable occipital neuralgia treated with peripheral neurostimulation. Follow-up ranged from 1.5-6 years. Twelve patients reported good and excellence response with greater than 50% pain control and little or no additional medication. The 13th patient was subsequently explanted following symptom resolution. Weiner and Reed reported that electrical stimulation enabled most patients to manage pain without medications; however, the method for pain measurement was not reported and this study did not assess quality of life.

Amin et al. (2008) evaluated the efficacy of supraorbital nerve stimulation for treatment of intractable supraorbital neuralgia in a case series of 16 patients. The patients underwent a trial of supraorbital nerve stimulation, and efficacy was assessed after 5-7 days. Ten patients consented to undergo permanent implantation of the stimulator. Opioid consumption and headache scores were monitored preoperatively and at timed intervals for 30 weeks. Headache scores decreased, and opioid consumption was reduced in half, and these beneficial accomplishments were maintained up to 30 weeks after implantation.

The 2007 Hayes Technology Brief on electrical stimulation of the occipital nerve for the treatment of occipital neuralgia summarized the available evidence stating that the results of the available studies provide preliminary evidence that subcutaneous electrical stimulation of the greater and lesser occipital nerves offers long-term relief in some patients who have intractable occipital neuralgia. Although the available studies of this technique are small and uncontrolled, most of the patients in these studies had experienced symptoms of occipital neuralgia for more than two years and had failed to respond adequately to other conservative and aggressive treatments. Since occipital neuralgia is a rare disorder, it does not seem feasible to conduct large-scale, randomized controlled trials to evaluate the efficacy of electrical stimulation therapy versus other standard therapies; however, larger studies with longer periods of follow-up are needed to confirm the benefits reported in the available studies. (Hayes, 2007)

The quality of evidence provided by studies for treatment of occipital neuralgia and cervicogenic headache is generally low. Injection therapies, nerve blockades using steroids and anesthetic agents, and surgical procedures such as nerve root decompression or neurectomy may provide effective pain relief for some patients. However, the available studies were limited and had significant methodological flaws, making it difficult to draw conclusions regarding the efficacy of the various treatments. In addition, most treatments do not provide permanent curative results and recurrences occurred in a high proportion of patients.

Additional Search Terms
cranial nerves, methylprednisolone, trigger points

U.S. Food and Drug Administration (FDA):

Local Injection Therapy: Various local anesthetics are approved by the FDA for use in diagnostic and therapeutic nerve blockade. Botulinum toxin-A (BTX-A or BOTOX) is a neurolytic agent that has also been approved by the FDA for treatment of some conditions. However, BTX-A is not specifically approved for treatment of cervicogenic headache or occipital neuralgia; the use of BTX-A for these diagnoses is off-label use. Additional information is available at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/DrugSafetyInformationforHeathcareProfessionals/ucm070366.htm. Accessed November 2010.

Radiofrequency Ablation (RFA): RFA is a procedure and, therefore, is not subject to regulation by the FDA. However, the devices used to perform RFA are regulated by the FDA premarket approval process. There are numerous devices listed in the FDA 510(k) database approved for use in performing RFA. Two product codes are dedicated to these devices, one for radiofrequency lesion generators (GXD) and one for radiofrequency lesion probes (GXI). Additional information is available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm. Accessed November 2010.

Electrical Stimulation: Electrical stimulation of the occipital nerve for the treatment of occipital neuralgia and cervicogenic headache is a procedure and, therefore, not subject to regulation by the FDA; however, the devices used to perform electrical stimulation are regulated via the FDA 510(k) premarket approval process. The Renew™ Quattrode® device received 510(k) approval (K000852) on January 19, 2001, and the Pisces Quad® device was approved (K040568) on March 25, 2004. Additional information is available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm. Accessed November 2010.

Currently no implantable pulse generator, radiofrequency device, or leads are approved by the FDA for peripheral occipital nerve stimulation to treat occipital neuralgia or cervicogenic headaches.

Payment Guidelines:

Applicable CPT Codes

Code Description
62281 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic
63185 Laminectomy with rhizotomy; 1 or 2 segments
63190 Laminectomy with rhizotomy; more than 2 segments
64405 Injection, anesthetic agent; greater occipital nerve
64553 Percutaneous implantation of neurostimulator electrode array; cranial nerve
64568 Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator
64569 Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator
64570 Removal of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator
64626
(Discontinued as of 1/1/2012)
Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, single level
64627
(Discontinued as of 1/1/2012)
Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, each additional level (List separately in addition to code for primary procedure)
64633
(Effective 1/1/2012)
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
64634
(Effective 1/1/2012)
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)
64722 Decompression; unspecified nerve(s) (specify)
64744 Transection or avulsion of; greater occipital nerve
64802 Sympathectomy, cervical
64804 Sympathectomy, cervicothoracic
64999 Unlisted procedure, nervous system

Applicable HCPCS Codes

Code Description
E0720 Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation
L8680 Implantable neurostimulator electrode (with any number of contact points), each
L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension

The foregoing Oxford policy has been adapted from an existing UnitedHealthcare national policy that was researched, developed and approved by the UnitedHealthcare national Medical Technology Assessment Committee. [2011T0080H]

References:

  1. Acar F, Miller J, Golshani KJ, et al. Pain relief after cervical ganglionectomy (C2 and C3) for the treatment of medically intractable occipital neuralgia. Stereotact Funct Neurosurg. 2008;86(2):106-12.
  2. Afridi SK, Shields KG, Bhola R, et al. Greater occipital nerve injection in primary headache syndromes--prolonged effects from a single injection. Pain. 2006 May;122(1-2):126-9.
  3. Akin Takmaz S, Inan N, UÁler S, et al. Greater occipital nerve block in migraine headache: Preliminary results of 10 patients. Agri. 2008 Jan;20(1):47-50.
  4. Ambrosini A, Vandenheede M, Rossi P, et al. Suboccipital injection with a mixture of rapid- and long-acting steroids in cluster headache: a double-blind placebo-controlled study. Pain. 2005 Nov;118(1-2):92-6.
  5. Amin S, Buvanendran A, Park KS, et al. Peripheral nerve stimulator for the treatment of supraorbital neuralgia: a retrospective case series. Cephalalgia. 2008 Apr;28(4):355-9.
  6. Anthony M. Cervicogenic headache: prevalence and response to local steroid therapy. Clin Exp Rheumatol. 2000 Mar-Apr;18(2 Suppl 19):S59-64.
  7. Anthony M. Headache and the greater occipital nerve. Clin Neurol Neurosurg. 1992;94(4):297-301.
  8. Antonaci F, Ghirmai S, Bono G, et al. Cervicogenic headache: evaluation of the original diagnostic criteria. Cephalalgia. 2001 Jun;21(5):573-83.
  9. Ashkenazi A, Blumenfeld A, Napchan U, et al.; Interventional Procedures Special Interest Section of the American. Peripheral nerve blocks and trigger point injections in headache management - a systematic review and suggestions for future research. Headache. 2010 Jun;50(6):943-52.
  10. Ashkenazi A, Matro R, Shaw JW, et al. Greater occipital nerve block using local anaesthetics alone or with triamcinolone for transformed migraine: a randomised comparative study. J Neurol Neurosurg Psychiatry. 2008 Apr;79(4):415-7.
  11. Ashkenazi A, Young WB. The effects of greater occipital nerve block and trigger point injection on brush allodynia and pain in migraine. Headache. 2005 Apr;45(4):350-4.
  12. Bovim G, Sand T. Cervicogenic headache, migraine without aura and tension-type headache. Diagnostic blockade of greater occipital and supra-orbital nerves. Pain. 1992 Oct;51(1):43-8.
  13. Bovim G, Sjaastad O. Cervicogenic headache: responses to nitroglycerin, oxygen, ergotamine and morphine. Headache. 1993;33(5):249-252.
  14. Bovim G, Fredriksen TA, Stolt-Nielsen A, et al. Neurolysis of the greater occipital nerve in cervicogenic headache. A follow up study. Headache. 1992;32(4):175-179.
  15. Busch V, Jakob W, Juergens T, et al. Occipital nerve blockade in chronic cluster headache patients and functional connectivity between trigeminal and occipital nerves. Cephalalgia. 2007 Nov;27(11):1206-14.
  16. Caputi CA, Firetto V. Therapeutic blockade of greater occipital and supraorbital nerves in migraine patients. Headache. 1997 Mar;37(3):174-9.
  17. Ducic I, Hartmann EC, Larson EE. Indications and outcomes for surgical treatment of patients with chronic migraine headaches caused by occipital neuralgia. Plast Reconstr Surg. 2009 May;123(5):1453-61.
  18. ECRI. Hotline Response. Surgical Decompression and Steroid Injection for Cervicogenic Headache. November 2006.
  19. Gawel MJ, Rothbart PJ. Occipital nerve block in the management of headache and cervical pain. Cephalalgia. 1992 Feb;12(1):9-13.
  20. Gille O, Lavignolle B, Vital JM. Surgical treatment of greater occipital neuralgia by neurolysis of the greater occipital nerve and sectioning of the inferior oblique muscle. Spine. 2004 Apr 1;29(7):828-32.
  21. Govind J, King W, Bailey B, Bogduk N. Radiofrequency neurotomy for the treatment of third occipital headache. J Neurol Neurosurg Psychiatry. 2003 Jan;74(1):88-93.
  22. Guyuron B, Reed D, Kriegler JS, et al. A placebo-controlled surgical trial of the treatment of migraine headaches. Plast Reconstr Surg. 2009 Aug;124(2):461-8.
  23. Haspeslagh SR, Van Suijlekom HA, Lame IE, et al. Randomised controlled trial of cervical radiofrequency lesions as a treatment for cervicogenic headache [ISRCTN07444684]. BMC Anesthesiol. 2006 Feb 16;6:1.
  24. Hayes, Inc. Search and Summary. Cervical Microdecompression Surgery (C-2 Microdecompression, Jho Procedure) for Occipital Neuralgia. Lansdale, PA: Hayes, Inc., February 1, 2008a. Archived April 2009.
  25. Hayes, Inc. Health Technology Brief. Electrical Stimulation of the Occipital Nerve for the Treatment of Occipital Neuralgia and Cervicogenic Headache. Lansdale, PA: Hayes, Inc., October 15, 2007. Updated October 2009.
  26. Hayes, Inc. Health Technology Brief. Radiofrequency Ablation for Treatment of Cervicogenic Headache. Lansdale, PA: Hayes, Inc., March 5, 2008b. Updated March 2010.
  27. Hayes, Inc. Hayes Directory. Local Injection Therapy and Neurosurgery for Cervicogenic Headache and Occipital Neuralgia. Lansdale, PA: Hayes, Inc., July 2003. Last update April 1, 2008. Archived November 2008.
  28. Hecht JS. Occipital nerve blocks in postconcussive headaches: a retrospective review and report of ten patients. J Head Trauma Rehabil. 2004 Jan-Feb;19(1):58-71.
  29. Inan N, Ceyhan A, Inan L, et al. C2/C3 nerve blocks and greater occipital nerve block in cervicogenic headache treatment. Funct Neurol. 2001 Jul-Sep;16(3):239-43.
  30. International Headache Society. The International Classification of Headache Disorders, 2nd edition May, 2005. Web site. Available at http://216.25.88.43/upload/CT_Clas/ICHD-IIR1final.pdf. Accessed November 2010.
  31. Jansen J. Surgical treatment of non-responsive cervicogenic headache. Clin Exp Rheumatol. 2000;18(2 Suppl 19):S67-S70.
  32. Jasper JF, Hayek SM. Implanted occipital nerve stimulators. Pain Physician. 2008 Mar-Apr;11(2):187-200.
  33. Johnstone CS, Sundaraf R. Occipital Nerve Stimulation for the Treatment of Occipital Neuralgia - 8 case studies. Pain Med. 2006 Sep-Oct; 7 (5): 467.
  34. Kapoor V, Rothfus WE, Grahovac SZ, et al. Refractory occipital neuralgia: preoperative assessment with CT-guided nerve block prior to dorsal cervical rhizotomy. AJNR Am J Neuroradiol. 2003 Nov-Dec;24(10):2105-10.
  35. Kapural L, Mekhail N, Hayek SM, et al. Occipital nerve electrical stimulation via the midline approach and subcutaneous surgical leads for treatment of severe occipital neuralgia: a pilot study. Anesth Analg. 2005 Jul;101(1):171-4.
  36. Kuhn WF, Kuhn SC, Gilberstadt H. Occipital neuralgias: clinical recognition of a complicated headache. A case series and literature review. J Orofac Pain. 1997;11(2):158-165.
  37. Lee JB, Park JY, Park J, et al. Clinical efficacy of radiofrequency cervical zygapophyseal neurotomy in patients with chronic cervicogenic headache. J Korean Med Sci. 2007 Apr;22(2):326-9.
  38. Leinisch-Dahlke E, Jürgens T, Bogdahn U, et al. Greater occipital nerve block is ineffective in chronic tension type headache. Cephalalgia. 2005 Sep;25(9):704-8.
  39. Martelletti P, Di Sabato F, Granata M, et al. Epidural corticosteroid blockade in cervicogenic headache. Eur Rev Med Pharmacol Sci. 1998 Jan-Feb;2(1):31-6.
  40. Naja Z, Al-Tannir M, El-Rajab M, et al. Nerve stimulator-guided occipital nerve blockade for postdural puncture headache. Pain Pract. 2009 Jan-Feb;9(1):51-8.
  41. Naja ZM, El-Rajab M, Al-Tannir MA, et al. Occipital nerve blockade for cervicogenic headache: a double-blind randomized controlled clinical trial. Pain Pract. 2006a Jun;6(2):89-95.
  42. Naja ZM, El-Rajab M, Al-Tannir MA, et al. Repetitive occipital nerve blockade for cervicogenic headache: expanded case report of 47 adults. Pain Pract. 2006 Dec;6(4):278-84.
  43. Peloso P, Gross A, Haines T, et al. Cervical Overview Group. Medicinal and injection therapies for mechanical neck disorders. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD000319.
  44. Peres MF, Stiles MA, Siow HC, et a. Greater occipital nerve blockade for cluster headache. Cephalalgia. 2002 Sep;22(7):520-2.
  45. Pikus HJ, Phillips JM. Outcome of surgical decompression of the second cervical root for cervicogenic headache. Neurosurgery. 1996;39(1):63-71.
  46. Poggi JT, Grizzell BE, Helmer SD. Confirmation of surgical decompression to relieve migraine headaches. Plastic and Reconstructive Surgery 2008;122(1):115-22.
  47. Saadah HA, Taylor FB. Sustained headache syndrome associated with tender occipital nerve zones. Headache. 1987 Apr;27(4):201-5.
  48. Sand T, Bovim G, Helde G. Intracutaneous sterile water injections do not relieve pain in cervicogenic headache. Acta Neurol Scand. 1992;86(5):526-528.
  49. Saper JR, Dodick DW, Silberstein SD, et al. Occipital nerve stimulation for the treatment of intractable chronic migraine headache: ONSTIM feasibility study. Cephalalgia. 2010 Sep 29.
  50. Saracco MG, Valfrè W, Cavallini M, et al. Greater occipital nerve block in chronic migraine. Neurol Sci. 2010 Jun;31 Suppl 1:S179-80.
  51. Slavin KV, Nersesyan H, Wess C. Peripheral neurostimulation for treatment of intractable occipital neuralgia. Neurosurgery. 2006 Jan;58(1):112-9; discussion 112-9.
  52. Stovner LJ, Kolstad F, Helde G. Radiofrequency denervation of facet joints C2-C6 in cervicogenic headache: a randomized, double-blind, sham-controlled study. Cephalalgia. 2004 Oct;24(10):821-30.
  53. Tobin JA, Flitman SS. Occipital nerve blocks: effect of symptomatic medication: overuse and headache type on failure rate. Headache. 2009 Nov-Dec;49(10):1479-85.
  54. Van Zundert J. Lame IE. De Louw A. et al. Percutaneous pulsed radiofrequency treatment of the cervical dorsal root ganglion in the treatment of chronic cervical pain syndromes: A clinical audit. Neuromodulation. Vol. 6(1)(pp 6-14), 2003.
  55. Vanelderen P, Rouwette T, De Vooght P et al.. Pulsed radiofrequency for the treatment of occipital neuralgia: a prospective study with 6 months of follow-up. Reg Anesth Pain Med. 2010 Mar-Apr;35(2):148-51.
  56. Vincent MB, Luna RA, Scandiuzzi D, et al. Greater occipital nerve blockade in cervicogenic headache. Arq Neuropsiquiatr. 1998 Dec;56(4):720-5.
  57. Weiner RL, Reed KL. Peripheral neurostimulation for control of intractable occipital neuralgia. Neuromodulation. 1999;2(3):217-221.
  58. Weibelt S, Andress-Rothrock D, King W, et al. Suboccipital nerve blocks for suppression of chronic migraine: safety, efficacy, and predictors of outcome. Headache. 2010 Jun;50(6):1041-4.
  59. Williams M, Bazina R, Tan L, et al. Microvascular decompression of the trigeminal nerve in the treatment of SUNCT and SUNA. J Neurol Neurosurg Psychiatry. 2010 Sep;81(9):992-6.
  60. Yi X, Cook AJ, Hamill-Ruth RJ, et al. Cervicogenic headache in patients with presumed migraine: missed diagnosis or misdiagnosis? J Pain. 2005 Oct;6(10):700-3.
  61. Young W, Cook B, Malik S, et al. The first 5 minutes after greater occipital nerve block. Headache. 2008 Jul;48(7):1126-8.

Effective Date: December 1, 2011