In the occipital trigger site for migraine, the greater occipital nerve (GON) is thought to be irritated by surrounding structures, including the semispinalis capitis muscle and occipital artery (OA), producing headaches in the back of the neck. Thus, standard decompression involves removal of surrounding tissue and dissection away from the vessel. The authors noticed a consistent pattern between the GON and OA more distally: the OA approaching laterally and diving under the GON, the OA looping back over the GON and intertwining with the medial branch of the GON, and lastly the OA traveling parallel to the GON. The technique described uses a modified endoscopic approach with a counter incision, endoscopic assistance, and radical artery lysis to address distal sites in addition to the standard release. At the counter incision, distal intertwining between vessel and nerve was released. A high-definition endoscope was used to address dynamic compression points more proximally, including hidden areas where the vessel dives under the GON, as well as to facilitate cautery and removal of the vessel. Without the use of an endoscope and counterincision, it is difficult to achieve complete decompression of the nerve distally without injury to the proximal body of the nerve.
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