Medical Policy

This document addresses surgical and ablative treatments for chronic headaches, such as migraine and tension type headaches, and occipital neuralgia. A variety of procedures are proposed for this purpose and include, for example, identification of nerve trigger points in the forehead and surgically removing muscle tissue from these areas, and closure of a patent foramen ovale. This document does not address nasal or sinus surgery.

Note: Please see the following related documents for additional information:

• SURG.00032 Patent Foramen Ovale Closure Devices
• SURG.00112 Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)
• SURG.00144 Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia

Note: For a high-level overview of this document, please see “Summary for Members and Families” below.

Investigational and Not Medically Necessary:

Surgical treatment for chronic headaches (including but not limited to chronic migraine headache and chronic tension type headache) is considered investigational and not medically necessary. This includes, but is not limited to, the following procedures:

• Resection of musculature, including but not limited to the corrugator supercilii muscle, or any 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; or
• Closure of patent foramen ovale.

Surgical and ablative treatments of occipital neuralgia are considered investigational and not medically necessary. This includes, but is not limited to, the following procedures for treatment of occipital neuralgia:

• Thermal neurolysis (thermal and cryodenervation);
• Neuroplasty;
• Decompression of the occipital nerves;
• Resection or partial resection of muscle or tissue.

This document describes clinical studies and expert recommendations and explains why surgery and nerve blocking treatments for chronic headaches are not considered appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Many people get headaches that keep coming back. Migraines are one type. They can cause pain that lasts for hours or days. People with migraines may also feel sick to their stomach or bothered by bright lights and loud sounds. Most people take medicine to help with these headaches.

Some doctors have tried surgery to treat headaches that do not get better with medicine. In these surgeries, doctors remove small muscles in the forehead or back of the head. They think these muscles might be pressing on nerves and causing pain. Other surgeries involve cutting certain nerves or closing a tiny hole in the heart.

A rare cause of headaches is a condition called occipital neuralgia. This causes sharp pain in the back of the scalp. Doctors have tried different procedures for this too. These include using heat or cold to destroy nerve tissue or surgery to take pressure off the nerves.

What the Studies Show

The research on these surgeries has problems. Most studies are small and do not compare surgery to other treatments. The American Headache Society (AHA) says people should be very careful about headache surgery. They say there is not enough proof that it works well over time.

Three good studies looked at closing the small hole in the heart to stop migraines. None of these studies found that this surgery worked better than medicine alone.

For occipital neuralgia, the studies are even weaker. They are small and do not have comparison groups. This makes it hard to know if the treatments really help.

Is This Clinically Appropriate?

Right now, there is not enough proof that these surgeries work. Because of this, the following procedures are considered to be investigational and not medically necessary:

• Removing or moving muscles in the forehead, around the eyes, or back of the head.
• Cutting nerves in the face or head.
• Closing a hole in the heart (foramen ovale) to treat headaches.
• Using heat, cold, or surgery to treat occipital neuralgia.

The usual treatment for long-lasting headaches is still medicine. Please talk to your doctor if you have questions about your headaches.

(Return to Description/Scope)

Summary

The evidence base for surgical and ablative interventions for chronic headache syndromes and occipital neuralgia is characterized by heterogeneous techniques, inconsistent diagnostic definitions, and limited use of blinded, controlled designs, constraining the ability to determine durable net health benefit. For migraine-related trigger site procedures, randomized controlled trials suggest potential symptom improvement in selected participants; however, interpretation is limited by uncertainty about participant selection, variable and sometimes non-validated outcome definitions, incomplete characterization of concurrent medical therapy, and analytic approaches such as multiple unadjusted comparisons that increase the risk of chance findings (Guyuron, 2005; Guyuron, 2009; Mathew, 2014). Studies of patent foramen ovale closure used more rigorous randomized controlled trials but have not shown statistically significant benefit on the prespecified primary efficacy endpoints, and safety signals including serious adverse events have been reported, limiting confidence in net benefit for headache indications (Dowson, 2008; Mattle, 2016; Tobis, 2017). For occipital neuralgia, published studies of nerve decompression, neurolysis, neurectomy, and radiofrequency-based procedures most commonly relied on uncontrolled observational designs. Although improvements in pain intensity and frequency are frequently reported, the absence of sham-controlled or conservative-care comparators precludes confident attribution of benefit and does not allow comparative effectiveness assessment across modalities (Ducic, 2009; Hoffman, 2018; Son, 2022; Vanelderen, 2010).

Discussion

Evidence quality

Across headache surgery, occipital nerve decompression, and radiofrequency techniques, the evidence base is largely derived from uncontrolled case series conducted in specialized centers. This study design increases susceptibility to referral bias, regression to the mean, placebo effects, and confounding from concurrent treatments that are not consistently described. As a result, findings have limited generalizability to routine community practice. Outcomes are predominantly participant-reported, use heterogenous and sometimes nonvalidated definitions, and are supported by incomplete or variable follow-up. These limitations are particularly consequential for procedures intended to produce irreversible anatomic change, where clinically meaningful benefit must be distinguished from short-term symptomatic fluctuation and where adverse effects may emerge late or be under-ascertained.

Professional Organization Positions

Professional society positions underscore uncertainty about appropriate evidentiary thresholds rather than resolving it.

The American Headache Society (AHA) characterizes surgical approaches as a last-resort option and emphasized the limited long-term evidence and potential for irreversible harms (AHA, 2012).

The American Society of Plastic Surgery (ASPS) supports peripheral nerve or trigger site surgery for selected individuals with refractory chronic migraine based largely on early trial evidence and specialty-specific clinical experience, while still relying on a small and methodologically debated randomized evidence base (ASPS, 2018; Guyuron, 2005).

An American Society of Pain and Neuroscience (ASPN) guideline supports selective consideration of radiofrequency neurotomy for occipital neuralgia after diagnostic blockade and use of formal diagnostic criteria, while explicitly acknowledging heterogeneity in techniques and outcomes and the resulting difficulty synthesizing evidence quantitatively (Lee, 2021).

Collectively, these positions suggest that professional society recommendations are typically contingent on stringent participant selection and diagnostic confirmation, yet are not supported by a robust body of comparative trial evidence.

Trigger Site and Peripheral Nerve Surgery for Migraine and Chronic Headache

Randomized trials evaluating trigger site deactivation and related peripheral nerve procedures contain findings consistent with symptom improvement in subsets of participants, but the internal validity of those findings is limited by study design and measurement issues.

The earliest randomized trial reported high rates of improvement and some headache elimination after surgery, with much lower improvement in controls, but incomplete characterization of placebo injection sites and responses, and limited reporting of concomitant migraine therapies, complicate interpretation (Guyuron, 2005).

A subsequent blinded, sham-controlled trial incorporated surgical exposure without resection in the sham arm. This strengthened inference relative to uncontrolled series, but evaluated numerous outcomes without clear prespecification and without adjustment for multiplicity, leaving uncertainty regarding which statistically significant findings represent reproducible treatment effects (Guyuron, 2009).

Longer-term observational follow-up suggests that improvement may persist in a proportion of operated participants, but these data are difficult to interpret without concurrent control groups and without standardized accounting for additional procedures during follow-up. Five-year follow-up of the initial trial cohort reported sustained improvement in most participants and complete headache elimination in a minority, but excluded those receiving additional trigger site procedures and did not provide comparable long-term control data (Guyuron, 2011).

A subsequent randomized study compared two surgical trigger-site deactivation techniques (nerve avulsion versus decompression), rather than surgery versus continued medical management or sham intervention, and therefore does not inform comparative effectiveness analysis regarding whether surgical treatment improves outcomes beyond non-surgical care (Guyuron, 2015).

A small, randomized study comparing peripheral neurectomy with medical therapy reported statistically significant improvements in pain intensity, headache burden, and disability scores at 6 months in the surgical arm. However, the study enrolled only 26 participants (13 per group), relied exclusively on subjective outcome measures (visual analog score [VAS], migraine headache index [MHI], migraine disability assessment test [MIDAS], pain self-efficacy questionnaire [PSEQ]), and did not describe participant or assessor blinding. In addition, eligibility required a positive response to diagnostic local anesthetic blocks and treatment allocation was influenced by willingness to undergo surgery, introducing substantial selection and expectation bias. The short duration of follow-up further limits conclusions regarding durability of benefit for an irreversible intervention, particularly for outcomes known to be highly placebo- and expectation-sensitive (Bajaj, 2021).

Additional observational studies suggest reduced prescription medication days after surgery among survey responders, including reductions among participants reporting preoperative opioid use, but the lack of a non-surgical comparator and incomplete follow-up limit causal inference and may overestimate benefit if non-responders had poorer outcomes (Ortiz, 2021).

Secondary syntheses reach similar conclusions: a meta-analysis pooling a small number of randomized trials found higher odds of migraine elimination at 1 year in surgical groups but with wide confidence intervals and dependence on the limitations of the underlying trials, while other reviews highlight persistent problems with participant selection, sham control use, and outcome validity (Mathew, 2014; Vincent, 2019).

Patent Foramen Ovale Closure

The randomized evidence evaluating patent foramen ovale closure for migraine is comparatively more mature in design but consistently fails to demonstrate benefit on prespecified primary endpoints.

A double-blind, sham-controlled trial found no difference in complete cessation of migraine at 3 months between closure and sham, while reporting serious adverse events including events deemed related to the device or procedure (Dowson, 2008).

A later randomized trial comparing closure with medical treatment used blinded endpoint evaluation but did not show a statistically significant difference in reduction of migraine days over the primary assessment window, and secondary outcomes were largely non-differentiating (Mattle, 2016).

Another double-blind randomized trial similarly did not show a statistically significant difference on its primary endpoint, even though selected secondary outcomes favored closure, creating an interpretive pattern in which post hoc emphasis on secondary endpoints risks overstating clinical benefit when the trial’s primary hypotheses were not met (Tobis, 2017).

Meta-analyses pooling these trials have produced mixed results across different endpoints, including some pooled reductions in migraine attacks but no consistent evidence of complete migraine resolution, and pooled estimates frequently remain imprecise or sensitive to analytic choices (Elbadawi, 2019; Silalahi, 2024; Zhang, 2022).

Observational analyses suggesting differential effects by migraine subtype are not informative for comparative effectiveness because they generally lack appropriate control groups and are susceptible to selection effects that cannot be resolved without randomized designs (Shi, 2017).

Occipital Neuralgia

For treatment of occipital neuralgia, studies evaluating nerve decompression and neurolysis or neurectomy frequently report substantial improvements in pain frequency, intensity, and medication use, but these findings arise primarily from uncontrolled case series and retrospective cohorts that cannot distinguish procedure effect from natural history, co-interventions, and measurement bias.

Across surgical decompression and ablative approaches (including neurolysis and radiofrequency-based techniques), the published evidence consists primarily of small, retrospective case series reporting that many treated individuals achieve ≥50% pain reduction and reductions in Numeric Rating Scale scores, with relatively low rates of major neurologic complications. However, these findings are derived from uncontrolled designs, heterogeneous diagnostic inclusion (often mixing occipital neuralgia with other chronic headache phenotypes), variable outcome definitions, and selective recruitment from specialized centers. The absence of randomized or well-controlled comparative studies, limited blinding, and substantial risk of selection and reporting bias preclude reliable assessment of treatment effectiveness or durability and limit generalizability to broader clinical populations. Collectively, the evidence is insufficient to establish the net clinical benefit of decompression or ablative surgical interventions for occipital neuralgia or chronic headache syndromes (Austen, 2023; Pietramaggiori, 2023; Son, 2022).

Studies of defined subgroups such as iatrogenic occipital nerve injury similarly report marked improvements on multiple pain measures after mixed operative strategies, but referral and selection effects are likely, and the absence of non-operative comparators prevents estimation of incremental benefit attributable to surgery (Remy, 2024).

Longer follow-up describing reoperation rates adds clinically relevant safety and durability information, and identifies factors such as prior radiofrequency ablation and cervical spine disorders as predictors of reoperation, but does not establish that decompression improves outcomes relative to conservative management or clarify optimal sequencing of interventions (Remy, 2025).

Neurolysis and neurectomy series likewise report high rates of pain relief, including complete relief in substantial minorities, but are limited by lack of controls and often rely on center-specific selection and outcome assessment (Ducic, 2009; Gille, 2004).

In defined postoperative populations such as individuals developing occipital neuralgia after acoustic neuroma resection, mixed procedural approaches alongside conservative management produced pain relief in many participants, but small numbers and heterogeneity of treatments preclude conclusions about which intervention is effective and for whom (Riedy, 2021).

Radiofrequency-based treatments demonstrate a consistent pattern across the available literature: retrospective single-center cohorts of thermal radiofrequency ablation report mean reductions in pain scores and relief lasting several months after select procedures. However, these findings derive from uncontrolled designs with heterogeneous headache phenotypes, variable nerve targets, and nonstandardized outcome definitions, often following positive diagnostic blocks that enrich for responders. Larger datasets increase procedural counts but do not address core threats to validity, including absence of concurrent comparators, inconsistent follow-up intervals, reliance on subjective pain measures, and limited accounting for repeat procedures or co-interventions. Adverse events are reported as uncommon and generally transient, but safety conclusions are constrained by retrospective ascertainment and short, nonuniform surveillance. Collectively, these features preclude reliable estimation of treatment effect size or durability and limit generalizability beyond specialized centers (Abd-Elsayed, 2026; Hoffman, 2018).

Even when comparative designs are introduced, they often compare technical approaches rather than establishing efficacy relative to sham procedures or continued nonsurgical care. For example, a randomized trial comparing proximal versus distal conventional radiofrequency reported superior outcomes with one approach, but this study design does not address whether radiofrequency ablation offers net benefit compared with non-ablative management (AboElfadl, 2025).

Pulsed radiofrequency studies, which evaluate a neuromodulatory rather than neurolytic mechanism, consist primarily of small prospective or retrospective observational series without sham or active comparators. Across these studies, short-term improvements in pain intensity, headache frequency, and medication use are reported, but outcomes are highly expectation-sensitive and difficult to attribute to treatment effect in the absence of blinding or control groups. Additional limitations include short follow-up intervals, reliance on composite or subjective success definitions, and inclusion of heterogeneous headache phenotypes, which together constrain internal validity, limit generalizability, and preclude reliable conclusions regarding comparative effectiveness (Batistaki, 2021; Huang, 2012; Vanelderen, 2010).

Comparative observational work contrasting pulsed radiofrequency with thermal lesion radiofrequency suggests larger and more durable improvements with thermal lesion techniques, but retrospective design and treatment-selection confounding limit causal inference and should be interpreted as hypothesis-generating rather than definitive comparative effectiveness evidence (Yilmaz, 2025).

Integrated Interpretation Across Conditions and Procedures

Taken together, the evidence indicates that reported improvements are common after a range of surgical and ablative interventions, but these signals consistently arise from study designs least able to distinguish treatment effect from bias, expectancy, and natural history. The migraine trigger site surgery literature contains randomized evidence but is constrained by methodological weaknesses and outcome selection issues, while patent foramen ovale closure trials are methodologically stronger, they do not demonstrate benefit on primary efficacy endpoints. For occipital neuralgia, selective guideline support for radiofrequency neurotomy contingent on diagnostic blockade reflects pragmatic clinical practice in the setting of limited evidence rather than confirmation of comparative effectiveness, and emerging observational signals about reoperation risk and prior procedure history highlight the need for controlled research on sequencing and participant selection.

Across conditions, the absence of robust sham-controlled or conservative-care comparators, reliance on subjective outcomes, and limited durability data are particularly consequential given the irreversible nature of many interventions. Emerging observational findings related to reoperation risk and prior procedure history underscore important unanswered questions regarding sequencing and selection, but do not overcome the fundamental evidentiary gaps. Collectively, the available evidence remains insufficient to establish durable net health benefit for surgical or ablative interventions for chronic headache or occipital neuralgia.

According to the International Headache Society (IHS), primary headaches are those that are not associated with any demonstrable organic disease, structural or neurologic abnormality. Two types of primary headache are tension-type headache (also known as ordinary headache, stress headache and idiopathic headache) and migraine. Chronic headache, whether migraine or non-migraine, is defined as occurring on 15 or more days per month for more than 3 months.

Tension-type headaches are very common; estimates of lifetime prevalence range from 30% to 70% of the population. Migraines are present in about 28 million people in the United States. The exact pathology of migraines is unknown, but it is felt that a family history of migraine headaches, medications (for example, birth control pills, vasodilators), fatigue, emotional stress and specific foods or alcohol are probable triggers. Migraines manifest as a recurring attack usually lasting for 4-72 hours and involving pain of moderate to severe intensity, often with nausea, sometimes vomiting, sensitivity to light, sound and other sensory stimuli. Management of headaches has consisted largely of pharmacologic treatment (IHS, 2013).

Migraines are generally treated by two approaches: abortive and preventive. The goal of abortive therapy is to prevent a migraine attack or to stop it once it starts. Medications are prescribed to stop a headache during its prodrome stage or once it has begun and may be taken as needed. Preventive treatment is considered if an individual has more than one migraine per week. The goal is to lessen the frequency and severity of the migraine attacks with daily medication.

It has been proposed that activation of peripheral sensory nerves, including the trigeminal nerve, causes release of peptides, (for example, substance P, calcitonin gene-related peptide, neurokinins), resulting in vasodilatation and migraine headache. Also suggested is that trigger points can be identified, particularly in the region of the forehead, at which peripheral nerve activation occurs.

The American Academy of Neurology (AAN, 2024) does not address surgical treatment of migraines. Currently their goals of long-term migraine treatment, both pharmacologic and nonpharmacologic are as follows:

• Reduce attack frequency, severity, and disability;
• Reduce reliance on poorly tolerated, ineffective, or unwanted acute pharmacotherapies;
• Improve quality of life;
• Avoid acute headache medication escalation;
• Educate and enable individuals to manage their disease to enhance personal control of their migraine;
• Reduce headache-related distress and psychological symptoms.

Occipital neuralgia is classified as a secondary headache by the ICHD. Secondary headaches are usually associated with any disease, structural or neurologic abnormality. In this case, accurate diagnosing is important because treatment of the underlying problem usually eliminates the headache.

Aura: Symptoms such as disturbances in vision, smell or perception that occur prior to a migraine that serve as a warning that the headache may follow.

Etiology: The cause or origin of disease.

Neuroplasty: Surgery to repair or restore nerve tissue.

Neurolysis: The release of a nerve sheath by cutting it longitudinally; operative breaking up of neural adhesions.

Neuralgia: An intense burning or stabbing pain caused by irritation or nerve damage from systemic disease, inflammation, infection, and compression or physical irritation of a nerve.

Nociceptive: Refers to specialized nerve endings that respond to pain or other unpleasant sensations and transmits information about those sensations to the central nervous system.

Occipital: Relating to the back of the head or skull.

Prodrome: The period of time preceding a migraine headache during which a person may feel irritable, out of sorts, moody, unusually sensitive to light or noise, and may notice some fluid retention; this may go on for one or two days or just a few hours before the actual headache begins.

Trigger point: Hyperirritable spots in skeletal muscle that are associated with palpable nodules in taut bands of muscle fibers; the palpable nodules are said to be small contraction knots and a common cause of pain. Compression of a trigger point may elicit local tenderness, referred pain, or motor dysfunction.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:
For the following procedure codes for the headache diagnoses listed, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Peer Reviewed Publications:

1. Abd-Elsayed A, Reilly MJ, Hashimoto N, et al. Radiofrequency ablation of pericranial nerves for treating headaches: 10-year follow-up. Pain Ther. 2026; 15:161-173.
2. AboElfadl GM, Hassanien M, Hamed AA, et al. Comparative efficacy of greater occipital nerve radiofrequency approaches for the treatment of combined migraine and cervicogenic headache: randomized clinical trial. Perioper Care Oper Room Manag. 2025; 41:100571.
3. Austen WG Jr, Remy K, Packowski K, et al. Refractory occipital neuralgia treatment with nerve decompression surgery: a case series. Front Neurol. 2023; 14:1284101.
4. Bajaj J, Doddamani R, Chandra SP, et al. Comparison of peripheral neurectomy vs. medical treatment for migraine: a randomized controlled trial. Neurol India. 2021; 69(Supplement):S110-S115.
5. Batistaki C, Madi AI, Karakosta A, et al. Pulsed radiofrequency of the occipital nerves: results of a standardized protocol on chronic headache management. Anesth Pain Med. 2021; 11(5):e112235.
6. Bearden WH, Anderson RL. Corrugator superciliaris muscle excision for tension and migraine headaches. Ophthal Plast Reconstr Surg. 2005; 21(6):418-422.
7. Dirnberger F, Becker K. Surgical treatment of migraine headaches by corrugator muscle resection. Plast Reconstr Surg. 2004; 114(3):652-657.
8. Dowson A, Mullen MJ, Peatfield R, et al. Migraine Intervention with STARFlex Technology (MIST) trial: a prospective, multicenter, double-blind, sham-controlled trial to evaluate the effectiveness of patent foramen ovale closure with STARFlex septal repair implant to resolve refractory migraine headache. Circulation. 2008; 117(11):1397-1404.
9. Ducic I, Felder JM 3rd, Janis JE. Occipital artery vasculitis not identified as a mechanism of occipital neuralgia-related chronic migraine headaches. Plast Reconstr Surg. 2011; 128(4):908-912.
10. Ducic I, Felder JM 3rd, Khan N, Youn S. Greater occipital nerve excision for occipital neuralgia refractory to nerve decompression. Ann Plast Surg. 2014; 72(2):184-187.
11. 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; 123(5):1453-1461.
12. Elbadawi A, Barssoum K, Abuzaid AS, et al. Meta-analysis of randomized trials on percutaneous patent foramen ovale closure for prevention of migraine. Acta Cardiol. 2019; 74(2):124-129.
13. 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 (Phila Pa 1976). 2004; 29(7):828-832.
14. Guyuron B, Harvey D, Reed D. A prospective randomized outcomes comparison of two temple migraine trigger site deactivation techniques. Plast Reconstr Surg. 2015; 136(1):159-165.
15. Guyuron B, Kriegler JS, Davis J, Amini SB. Comprehensive surgical treatment of migraine headaches. Plast Reconstr Surg. 2005; 115(1):1-9.
16. Guyuron B, Kriegler JS, Davis J, Amini SB. Five year outcome of surgical treatment of migraine headaches. Plast Reconstr Surg. 2011; 127(2):603-608.
17. Guyuron B, Reed D, Kriegler JS, et al. A placebo-controlled surgical trial of the treatment of migraine headaches. Plast Reconstr Surg. 2009; 124(2):461-468.
18. Hoffman LM, Abd-Elsayed A, Burroughs TJ, Sachdeva H. Treatment of occipital neuralgia by thermal radiofrequency ablation. Ochsner J. 2018; 18(3):209-214.
19. Huang JH, Galvagno SM Jr, Hameed M, et al. Occipital nerve pulsed radiofrequency treatment: a multi-center study evaluating predictors of outcome. Pain Med. 2012; 13(4):489-497.
20. Huayllani MT, Janis JE. Migraine surgery and determination of success over time by trigger site: a systematic review of the literature. Plast Reconstr Surg. 2023; 151(1):120e-135e.
21. Lucia Mangialardi M, Baldelli I, Salgarello M, et al. Decompression surgery for frontal migraine headache. Plast Reconstr Surg Glob Open. 2020; 8(10):e3084.
22. Mathew PG. A critical evaluation of migraine trigger site deactivation surgery. Headache. 2014; 54(1):142-152.
23. Mattle HP, Evers S, Hildick-Smith D, et al. Percutaneous closure of patent foramen ovale in migraines with aura, a randomized controlled trial. Eur Heart J. 2016; 37(26):2029-2036.
24. Nagar VR, Birthi P, Grider JS, Asopa A. Systematic review of radiofrequency ablation and pulsed radiofrequency for management of cervicogenic headache. Pain Physician. 2015; 18(2):109-130.
25. Omranifard M, Abdali H, Ardakani MR, et al. A comparison of outcome of medical and surgical treatment of migraine headache: in 1 year follow-up. Adv Biomed Res. 2016; 5:121.
26. Ortiz R, Gfrerer L, Panzenbeck P, et al.Trigger site deactivation surgery for headaches is associated with decreased postoperative medication use. Plast Reconstr Surg Glob Open. 2021; 9(6):e3634.
27. Pietramaggiori G, Scherer S. Minimally invasive nerve- and muscle-sparing surgical decompression for occipital neuralgia. Plast Reconstr Surg. 2023; 151(1):169-177.
28. Pisapia JM, Bhowmick DA, Farber RE, Zager EL. Salvage C2 ganglionectomy after C2 nerve root decompression provides similar pain relief as a single surgical procedure for intractable occipital neuralgia. World Neurosurg. 2012; 77(2):362-369.
29. Remy K, Hazewinkel MHJ, Knoedler L, et al. Aetiologies of iatrogenic occipital nerve injury and outcomes following treatment with nerve decompression surgery. J Plast Reconstr Aesthet Surg. 2024; 95:349-356.
30. Remy K, Hazewinkel MH, Mullen C, et al. Reoperation following primary greater occipital nerve decompression surgery: incidence, risk factors, and outcomes. Plast Reconstr Surg. 2025; 155(1):159-166.
31. Riedy LN, Heiferman DM, Szujewski CC, et al. Occipital neuralgia following acoustic neuroma resection. J Neurol Surg B Skull Base. 2021; 83(Suppl 2):e135-e142.
32. Rigatelli G, Dell’Avvocata F, Ronco F, et al. Primary transcatheter patent foramen ovale closure is effective in improving migraine in patients with high-risk anatomic and functional characteristics for paradoxical embolism. JACC Cardiovasc Interv. 2010; 3(3):282-287.
33. Shi YJ, Lv J, Han XT, Luo GG. Migraine and percutaneous patent foramen ovale closure: a systematic review and meta-analysis. BMC Cardiovasc Disord. 2017; 17(1):203.
34. Silalahi TDA, Hariyanto TI. Efficacy and safety of patent foramen ovale closure for mitigating migraine: a systematic review and meta-analysis of randomized trials and observational studies. Ther Adv Neurol Disord. 2024; 17:17562864241271033.
35. Son B. Decompression of the greater occipital nerve for occipital neuralgia and chronic occipital headache caused by entrapment of the greater occipital nerve. J Neurol Surg A Cent Eur Neurosurg. 2022; 83(5):461-470.
36. Tobis JM, Charles A, Silberstein SD, et al. Percutaneous closure of patent foramen ovale in patients with migraine: the PREMIUM trial. J Am Coll Cardiol. 2017; 70(22):2766-2774.
37. 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; 35(2):148-151.
38. Vincent AJPE, van Hoogstraten WS, Maassen Van Den Brink A, et al. Extracranial trigger site surgery for migraine: a systematic review with meta-analysis on elimination of headache symptoms. Front Neurol. 2019; 10:89.
39. Yilmaz A, Kucukbingoz C. Comparative long-term outcomes of pulsed and lesion radiofrequency of the greater occipital nerve in chronic migraine: a 12-month cohort study. Medicina. 2025; 61(11):1893.
40. Zhang Y, Wang H, Liu L. Patent foramen ovale closure for treating migraine: a meta-analysis. J Interv Cardiol. 2022; 2022: 6456272.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Neurology. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000; 55(6):754-762.
2. American Academy of Neurology. Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology. 2004; 63(12):2215-2224.
3. American Headache Society. American Headache Society urges caution in using any surgical intervention in migraine treatment. 2012. Available at: https://www.brighamandwomensfaulkner.org/assets/Faulkner/headache-center/documents/ahs-migraine-surgery-statement.pdf. Accessed on December 5, 2024.
4. American Society of Plastic Surgeons. Policy statement migraine headache surgery. Approved March 16, 2018. Available at: https://www.plasticsurgery.org/documents/Health-Policy/Positions/ASPS-Statement_Migraine-Headache-Surgery.pdf. Accessed on March 2, 2026.
5. Chen PK, Chen HM, Chen WH, Treatment Guideline Subcommittee of the Taiwan Headache Society. Treatment guidelines for acute and preventive treatment of cluster headache. Acta Neurol Taiwan. 2011; 20(3):213-227.
6. International Headache Society. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders. 3rd Edition. Cephalalgia. 2013; 33(9):629-808.
7. Lee DW, Pritzlaff S, Jung MJ, et al. Latest evidence-based application for radiofrequency neurotomy (LEARN): best practice guidelines from the American Society of Pain and Neuroscience. J Pain Res. 2021; 14:2807-2831.

1. National Headache Foundation. Available at: http://www.headaches.org/. Accessed on January 31, 2026.
2. U.S. National Library of Medicine. Medline Plus: Migraine. Last updated November 20, 2025. Available at: http://www.nlm.nih.gov/medlineplus/migraine.html. Accessed on January 31, 2026.

Aura
Cephalalgia
Headache, Migraine
Migraine
Neuralgia
Neurolysis
Neuroplasty
Occipital
Pulsed Radiofrequency
Radiofrequency Ablation

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.

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