Background In many patients suffering from primary
headaches, the available pharmacological and behavioural treatments are not satisfactory. This is a review of (minimally) invasive interventions targeting pericranial nerves that could be effective in refractory patients. Methods The interventions we will cover have in common pericranial nerves as targets, but are distinct according to their rationale, modality and invasiveness. They range from
nerve blocks/infiltrations to the percutaneous implantation of neurostimulators and
surgical decompression procedures. We have critically analysed the published data (PubMed) on their effectiveness and tolerability. Results and conclusions There is clear evidence for a preventative effect of suboccipital
injections of local anaesthetics and/or
steroids in
cluster headache, while evidence for such an effect is weak in
migraine. Percutaneous occipital nerve stimulation (ONS) provides significant long-term relief in more than half of
drug-resistant
chronic cluster headache patients, but no
sham-controlled trial has tested this. The evidence that ONS has lasting beneficial effects in chronic
migraine is at best equivocal. Suboccipital infiltrations are quasi-devoid of side effects, while ONS is endowed with numerous, though reversible, adverse events. Claims that
surgical decompression of multiple pericranial nerves is effective in
migraine are not substantiated by large, rigorous, randomized and
sham-controlled trials.