INTRODUCTION: Nerve decompression surgery for occipital neuralgia (ON) of the lesser occipital nerve (LON) is oftentimes performed in combination with treatment of the greater and third occipital nerves (GON and TON). The traditional surgical approach requires multiple separate incisions. This study describes combined GON/LON approach through a single vertical midline incision and reports on the postoperative outcomes. METHODS: Among 1713 patients who were screened for nerve decompression surgery between 2011 and 2023, those who underwent combined GON/LON decompression for treatment of ON were identified retrospectively. Patients who underwent LON decompression through the vertical midline incision were compared to those who underwent LON decompression through a separate incision. Outcomes included postoperative complications, LON reoperation, pain frequency (days/month), intensity (scale 0-10), duration (hours), and Migraine Head Index (MHI) at final follow-up. RESULTS: A total of 124 patients underwent 184 combined GON/LON surgeries. LON decompression was performed through a midline incision in 91 (73.4%) patients and through a separate incision in 33 (26.6%). LON reoperation rates for pain recurrence were higher in the separate incision group as compared to the midline incision group (15.2% versus 4.4%, p<0.05). At a median follow-up of 17.9 months after the last intervention, reductions in pain frequency, intensity, duration and MHI were comparable between both techniques (p>0.05). Postoperative complications were not significantly different between both groups (p>0.05). CONCLUSION: During combined GON/LON surgery, approaching the LON through the midline incision is feasible and allows for safe and effective LON decompression or neurectomy, with lower reoperation rates for recurrent pain.