This systematic review and meta-analysis evaluates the efficacy of surgical interventions for intractable or refractory migraines. The study included eleven studies, focusing on clinical trials and observational studies that involved various surgical procedures such as nerve decompression, occipital nerve stimulation (ONS), septorhinoplasty, and functional endoscopic sinus surgery. The meta-analysis of four studies involving 95 patients showed a significant reduction in mean migraine intensity scores with ONS (−2.27, 95% CI: −3.92 to −0.63, P = 0.021). Three studies with 85 patients reported an average MIDAS score reduction of −52.3, though this was not statistically significant (95% CI: −136.85 to 32.19, P = 0.116). Two additional studies confirmed these reductions in MIDAS scores. Nerve decompression surgery showed a substantial decrease in average migraine intensity, with a median MIDAS score drop from 57 to 20. Two studies indicated success rates of 40% and 82% in achieving a 50% reduction in the migraine MHI through nerve decompression. Septorhinoplasty and sinus surgery were also found to effectively reduce migraine intensity scores. The findings suggest that surgical interventions, particularly nerve decompression and ONS, show promise as effective treatments for intractable migraines, but more robust and comprehensive research is needed to refine and solidify their efficacy.This systematic review and meta-analysis evaluates the efficacy of surgical interventions for intractable or refractory migraines. The study included eleven studies, focusing on clinical trials and observational studies that involved various surgical procedures such as nerve decompression, occipital nerve stimulation (ONS), septorhinoplasty, and functional endoscopic sinus surgery. The meta-analysis of four studies involving 95 patients showed a significant reduction in mean migraine intensity scores with ONS (−2.27, 95% CI: −3.92 to −0.63, P = 0.021). Three studies with 85 patients reported an average MIDAS score reduction of −52.3, though this was not statistically significant (95% CI: −136.85 to 32.19, P = 0.116). Two additional studies confirmed these reductions in MIDAS scores. Nerve decompression surgery showed a substantial decrease in average migraine intensity, with a median MIDAS score drop from 57 to 20. Two studies indicated success rates of 40% and 82% in achieving a 50% reduction in the migraine MHI through nerve decompression. Septorhinoplasty and sinus surgery were also found to effectively reduce migraine intensity scores. The findings suggest that surgical interventions, particularly nerve decompression and ONS, show promise as effective treatments for intractable migraines, but more robust and comprehensive research is needed to refine and solidify their efficacy.