Decreased need for botulinum toxin and nerve blocks after headache surgery

Patients with head and neck neuralgias typically exhaust conservative treatment options, including expensive botulinum toxin (BTX) and local anesthetic injections (peripheral nerve blocks; NB) before undergoing headache surgery. However, the impact of surgery on reducing injectable use and thereby treatment cost remains unclear.

This multicenter study included patients with complete pre- and postoperative injectable data who underwent headache surgery at two academic centers between 2021 and 2026.

Eighty-four patients were included. Preoperatively, 74% (n = 62) received BTX with limited efficacy: 30% reported no relief, 46% some relief (<50%), 21% significant relief (>50%), and 3% complete relief. Relief duration was <3 months in 86%. NBs were administered to 87% (n = 73), with 35% reporting significant or complete pain relief. Among the responders, 54% experienced relief in <1 week. Paired comparison (n = 55) demonstrated that NBs provided significantly more relief than BTX (p = 0.035). NBs administered by treating surgeons significantly outperformed those from outside providers (p < 0.001). Postoperatively, BTX use decreased from 74% to 36% (p < 0.001), and NB use from 87% to 27% (p < 0.001). The projected annualized cost reduction was $365,808 in this cohort.

Injectable treatments provide limited symptom relief for neuralgias of the head and neck. NBs were associated with greater patient-reported symptom relief compared to BTX, underscoring their role as an effective diagnostic tool. Additionally, targeted NBs provided significantly more pain relief than injections administered through universal injection protocols. Headache surgery significantly reduces injectable use, thereby reducing associated healthcare costs.