Occipital neuralgia is a pain in the region of the occipital nerve distribution, often manifesting as intractable headaches that plague a large number of patients. Most of the literature reports the anatomical cause of this disease, i.e., compression or entrapment of the main trunk and/or branches of the occipital nerve. Microscopic decompression of the occipital nerve under local anesthesia can be used to address the anatomic cause of occipital neuralgia. Intraoperatively, localized compression or entrapment of the nerve by blood vessels from various causes or local scar formation on the nerve can be seen on the scalp. This compression does not directly cause a headache attack; when the concentration of intravascular neurotransmitters and changes in the vessel wall and hemodynamics occur, they cause irritation to the abnormally contacted nerve and cause a headache attack. In addition, local injury to the greater occipital nerve, adhesions and compression of enlarged lymph nodes can also cause occipital neuralgia due to compression of the greater occipital nerve. Therefore, releasing the compression during the course of the occipital nerve is the key to treat occipital neuralgia. The occipital neuralgia can be completely cured by dissecting and releasing the occipital nerve under microscope, fully freeing it so that its trunk and branches can be fully decompressed, removing the adhesions and enlarged lymph nodes and the blood vessels entangled with them, and if necessary, removing part of the muscle to reduce the compression on the occipital nerve.