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Occipital Neuralgia


Many people with migraines and various headache disorders suffer from pain in the back of the head and neck, or the occipital-cervical region. Trying to sort out what to call this pain can be quite confusing, especially if the cause or the source of the pain is unclear. Pain in the Occipital-Cervical area can originate from any structure in the posterior scalp and neck: muscles, joints, ligaments, connective tissue, blood vessels and of course nerves. If the Occipital Nerves are the cause, then the syndrome is called Occipital Neuralgia.


The Occipital Nerves are two paired nerves (Right and Left) that supply sensation to the posterior scalp, from the crown of the head, down to the top portion of the neck. The Occipital Nerves originate from posterior branches of the C2 nerve root. The nerve courses just beneath the arch of the C1 vertebrae, then in close proximity to vertebral venous structures, the adjacent atlantoaxial ligament and cervical facet joint. It passes through the semispinalis muscle, and then through the region where the trapezius muscle attaches to the occipital bone. From there, branches of the nerve fan out to innervate the posterior scalp. There can be some variation in the course of the Occipital Nerve amongst individuals.


Occipital Neuralgia can be considered a primary headache disorder, or a secondary headache disorder. A primary headache disorder means that while there is a certain type of characteristic pain, no specific anatomical cause is identified. A secondary headache disorder means that the characteristic pain is caused by some known or discovered process.

The International Headache Society defines primary Occipital neuralgia as “a paroxysmal jabbing pain in the distribution of the greater or lesser occipital nerves or of the third occipital nerve, sometimes accompanied by diminished sensation or dysaesthesia in the affected area. It is commonly associated with tenderness over the nerve concerned.” To formally meet criteria for Occipital Neuralgia, the pain must meet the following criteria:

  • Paroxysmal stabbing pain, with or without persistent aching between paroxysms, in the distribution(s) of the greater, lesser and/or third occipital nerves
  • Tenderness over the affected nerve
  • Pain is eased temporarily by local anesthetic block of the nerve

Secondary Occipital Neuralgia– when the dysfunction of the nerve is caused be some known or discovered process – may occur through nerve compression, such as a vascular structure pulsating on the nerve, or a tumor pressing against it. Direct trauma can also cause injury to the Occipital Nerve, such as a blow to the back of the head, or a fall directly on the occipital area. Local inflammation or infection of the surrounding tissues can also cause irritation of the Occipital Nerve. Any of the local structures along the course of the Occipital Nerve can potentially be involved in the pathogenesis of Secondary Occipital Neuralgia. Other causes include osteoarthritis, rheumatoid arthritis, gout, post-herpetic neuralgia, and diabetic neuropathy.

Diagnosing Occipital Neuralgia can be somewhat challenging, especially given all the potential causes of posterior head pain and neck pain. Often, the diagnosis is made clinically by the physician, after taking into account the medical history, the physical examination, and a review of tests and imaging, such as a CT or MRI.


There are many potential ways to treat the pain of Occipital Neuralgia. The first goal is to address any underlying secondary causes of Occipital Neuralgia that may be interfering with improvement. Some of the modalities used are listed here:

  • Occipital Nerve Block
  • Physical Therapy
  • Acupuncture
  • Massage Therapy
  • Chiropractic treatments
  • Anti-inflammatory medications
  • Muscle relaxants
  • Anti-convulsants, such as gabapentin, oxcarbazepine, pregabalin, carbamazepine
  • Anti-depressants, such as amitriptyline, duloxetine
  • Topical salves
  • Other percutaneous blocks, such as Facet Joint Blocks, Medial Branch Nerve Blocks, Transforamenal Epidural Steroid Injections, Radiofrequency Ablation


When Occipital Neuralgia is severe, and does not respond to non-surgical interventions and conservative management. The specific surgical procedure chosen will depend upon the specific secondary cause being considered. Surgical options include:

  • Microvascular decompression – exposing the nerve, identifying blood vessels that might be causing compression, and then gently displacing the vessel away.
  • Occipital Nerve Stimulator – placement of a subcutaneous neuro-stimulator that delivers an electrical impulse directly to the region of the Occipital Nerve. These devices are run off batteries usually placed under the skin on the chest, similar to those used to run Cardiac Pacemakers. The stimulator is connected to the battery via insulated lead wires tunneled under the skin.


While Occipital Neuralgia is not life-threatening, the pain can cause significant disability and decreased function in some individuals. Given the number of potential causes and compounding factors, it is challenging to make any broad statements about prognosis and duration, and this is best addressed with a physician on a case by case basis. The prognosis is improved by seeking prompt attention from a physician with specific expertise in the diagnosis and management of head and neck pain.

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