Occipital neuralgia is a well-defined type of headache, and its treatment algorithm is still debated across medical specialties. From the analysis of the literature, it appears that surgical decompression of the occipital nerves is the most effective invasive approach to improve the quality of life of patients with occipital neuralgia refractory to medications. The authors describe here a minimally invasive nerve- and muscle-sparing technique to decompress the occipital nerves. The results in terms of reduction of migraine days per month, use of medications, pain evaluation, and decrease in Migraine Headache Index were analyzed by means of a retrospective chart review of 87 patients who underwent nerve- and muscle-sparing surgical decompression of the greater and lesser monolateral or bilateral occipital nerves in their institution and were followed up for at least 12 months. The surgical technique is described in detail. Surgical decompression significantly reduced occipital neuralgia burden (at least 50% improvement) in 91% of patients, with 45% reporting a complete remission of occipital pain. Days with pain per month decreased by 80%, chronic background pain intensity decreased by 81%, and pain intensity during crisis decreased by 76%. Accordingly, drug use dropped by approximately 70%. Only minor complications were reported in four patients. The described technique could contribute to and further support surgical decompression as the first option among the invasive approaches to treat occipital neuralgia. Results corroborate previous findings, adding a less-invasive, nerve- and muscle-sparing approach. Therapeutic, IV.