The Surgical Management of an Occipital Spur Contributing to Intractable Posterior Migraines in an Adolescent

Abstract

Background: Occipital spurs are a relatively rare phenomenon in which an exostosis arises from the external occipital protuberance (EOP). In the majority of patients, this anatomic variant is asymptomatic and only noted radiographically. However, some patients may experience symptoms ranging from point tenderness, to skin changes of the overlying scalp, and even to posteriorly based migraines, resulting from the compressive forces exerted on nearby nerves. Here, we describe the successful surgical management of a rare case of intractable posterior migraines occurring in an adolescent patient with an occipital spur. Case: A 16-year-old male presented with a 1-year history of intractable posterior migraines, which rapidly progressed and were unresponsive to medical management. Imaging revealed the patient to have a type III occipital spur, and examination showed a prominent EOP with overlying point tenderness and positive Tinel’s sign over the bilateral greater and third occipital nerves. After a successful nerve block in clinic, the patient underwent surgical excision of the occipital spur with concurrent nerve decompression/avulsion of the bilateral greater occipital nerves and avulsion of the third occipital nerves. Postoperatively, the patient experienced immediate and sustained resolution of his migraines, allowing discontinuation of his medications and a return to normal activities without school absences for 6 months. Conclusion: Although rarely symptomatic, occipital spurs may be associated with occipital migraines due to compression of the neighboring nerves and may benefit from surgical intervention.