BlueCross and BlueShield of Montana Medical Policy/Codes
Surgical Treatment of Cervicogenic Headache, Cranial Neuralgias or Variant of Migraine
Chapter: Surgery: Procedures
Current Effective Date: December 27, 2013
Original Effective Date: December 27, 2013
Publish Date: September 27, 2013
Description

Cervicogenic and cranial neuralgias are specific types of headaches that may arise from impingement or entrapment of the occipital nerves and/or the upper spinal vertebrae. 

Some medical experts now suggest that compression of this nerve along its path can be a cause of cervicogenic headaches, which can mimic classical migraines.  Cervicogenic headache is similar to migraine headache due to the ipsilateral pain and the typical migraine-like symptoms such as nausea, vomiting, and ocular problems.  Variant of migraine is the term applied to migraine, which exhibits itself in a form other than head pain.

The trigeminocervical nucleus is a region of the upper cervical spinal cord where sensory nerve fibers in the descending tract of the trigeminal nerve (trigeminal nucleus caudalis) are believed to interact with sensory fibers from the upper cervical roots.  This functional convergence of upper cervical and trigeminal sensory pathways allows the bidirectional referral of painful sensations between the neck and trigeminal sensory receptive fields of the face and head.

Microvascular decompression involves microsurgical exposure of the affected nerves, identification of blood vessels that might be compressing the nerves, and gentle displacement of these away from the point of compression.  "Decompression" may reduce sensitivity and allow the nerves to recover and return to a more normal, pain-free condition.  Microvascular surgical decompression may be an option for patients when the pain is chronic, severe and does not respond to conservative treatment.  These patients are thought to be candidates for surgical intervention if they have tenderness over the nerves (greater or lesser occipital, supraorbital/trochelar, zygomatico/auriculo-temporal nerves).  The tenderness is thought to correspond with sensory nerve compression and the anatomical structures surrounding the nerve.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions.  Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Investigational

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.

Rationale

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.

Summary

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.

2011 Update

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.   

Summary

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.

Coding

Disclaimer for coding information on Medical Policies         

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy.  They may not be all-inclusive.           

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers.  Only the written coverage position in a medical policy should be used for such determinations.           

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

339.00–339.89, 346.20–346.23

ICD-10 Codes

G44.89, G44.09, G44.091, G44.099

Procedural Codes: 64716, 64771, 64732, 64734, 64999
References
  1. Bogduk, N. The anatomical basis for cervicogenic headache.  J Manipulative Physiol Ther. (1992) 15:67-70.
  2. Bahman, G., Varghai, A, et al.  Corrugator Supercilii Muscle Resection and Migraine Headaches.  Plastic and Reconstructive Surgery (August 2000):429-34.
  3. Haldeman, S., Dagenais, S.  Cervicogenic headaches: a critical review. Spine J (2001) Jan-Feb;1(1):31-46.
  4. Bahman, G., Tucker, T., et al.  Surgical Treatment of Migraine Headaches.  Plastic and Reconstructive Surgery (June 2002):2183-8.  
  5. Guille, O., Lavignolle, B. et al.  Surgical treatment of greater occipital neuralgia by neurolysis of the greater occipital nerve and sectioning of inferior oblique muscle.  Spine (2004 April) 29(7): 828-32.
  6. Biondi, D, Cervicogenic Headache:  A Review of Diagnostic and Treatment Strategies
  7. Comprehensive Surgical Treatment of Migraine Headaches.  Plast Reconstr Surg.  (2005) 115(1):1-9.
  8. Bahman, G. Kriegler, J. et al.  Comprehensive Surgical Treatment of Migraine Headaches.  Plastic and Reconstructive Surgery (January 2005):1-9.
  9. Vascular compression as a potential cause of occipital neuralgia: a case report.  Cephalalgia (Nov. 2007) 28(1):78-82.
  10. Jansen J., Surgical treatment of cervicogenic headache.  Cephalalgia (2008 Jul) 28 Suppl 1:41-4.
  11. Poggi, J. T., Grizzell, B.E, et al,  Confirmation of Surgical Decompression to Relieve Migraine Headaches.  The American Society of Plastic Surgeons (July 2008):115-22.
  12. Williams, M., Bezina, R. et al.  Microvascular decompression of the trigeminal nerve in the treatment of SUNCT and SUNA.  Journal of Neurol Neurosurg Psychiatry (2010 Sep) 81(9):992-6.
History
September 2013  New 2013 BCBSMT medical policy.
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Surgical Treatment of Cervicogenic Headache, Cranial Neuralgias or Variant of Migraine