Blue Cross and Blue Shield of Montana (BCBSMT) considers surgical treatment* for cervicogenic headaches, cranial neuralgias (eg., occipital neuralgia), or variant of migraine experimental, investigational, and unproven.
*Surgical treatment (microvascular decompression) may include but is not limited to:
- Resection of musculature (including but not limited to the corrugator supercilii , trapezius, or semispinalis capitis muscles), or
- Resection of soft tissue from the forehead, periorbital, occipital or other facial or scalp areas, or manipulation or repositioning of any muscle or other soft tissue within these areas, or
- Resection of any portion of the trigeminal nerve or its branches.
Guille et al. (2004) evaluated a new surgical treatment for greater occipital neuralgia consisting of neurolysis of the greater occipital nerve and section of the inferior oblique muscle. All of the patients had pain exacerbated by flexing of the cervical spine. Mean follow-up was 34 months. The results of the treatment were assessed based on: degree of pain on a visual analog scale (VAS) before surgery, at three months, and at last follow-up; and the degree of patient satisfaction at follow-up. Anatomic anomalies (i.e., hypertrophy of the venous plexus around C2, nerve penetration of the inferior oblique muscle, and degenerative C1-C2 osteoarthritis) were found in three patients. The mean VAS score was 80/100 before surgery and 20/100 at last follow-up. The majority of the patients were satisfied or very satisfied with the operation. Patients reported a decrease in analgesic consumption.
Bogduk (2004) reported that, although liberation of the greater occipital nerve initially results in pain reduction in 80% of patients, the relief is not long-term, with a median duration of only three to six months. Excision of the greater occipital nerve provides relief in approximately 70% of patients but has a mean duration of only 244 days. Dorsal rhizotomy at C1–3 or C1–4 has provided some patients with complete relief for one to four years; however, there is recurrence in some patients.
The available evidence published in the peer-reviewed literature is inadequate to conclude that surgical decompression is an effective treatment for cranial neuralgias, cervicogenic headache or variant of migraine. The limited scientific data suggest that some patients may obtain a short-term benefit; however, the long-term benefit to the patient remains unknown. Early diagnosis and management by way of a comprehensive, multidisciplinary pain treatment program can significantly decrease the prolonged course of costly treatment and disability that is associated with this challenging pain disorder.
A search of peer reviewed literature was conducted through October 2011. Williams et al (2010) reported on nine cases of unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) syndrome and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) that were unsatisfactory to medical management. All underwent microvascular decompression of the ipsilateral trigeminal nerve for intractable pain. Immediate and complete relief of SUNCT and SUNA symptoms occurred in six of nine (67%) cases. This was sustained for a follow-up period of 9-32 months (mean 22.2). In three of nine (33%) cases, there was no benefit. Ipsilateral hearing loss was observed in one case. Authors note this demonstrated that these patients may benefit from microvascular decompression.
Different surgical procedures continue to be investigated for the treatment of occipital neuralgia and cervicogenic headache. However, the studies are small and remain to be validated by prospective randomized controlled studies with larger study groups required. Therefore, the experimental, investigational, and unproven coverage position of this medical policy remains unchanged.
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