Occipital Neuralgia

What occipital neuralgia is

The greater occipital nerve emerges from the upper neck (mainly the C2 nerve root), passes through the muscles at the base of the skull and spreads over the back of the scalp toward the top of the head. The lesser occipital nerve supplies the area behind the ear. When these nerves are compressed or irritated, they fire abnormally, producing brief bursts of intense pain.

Symptoms

• paroxysmal (sudden) shooting, stabbing or electric-shock pain
• starting at the base of the skull and spreading up the back of the head, usually on one side
• episodes lasting seconds to minutes, sometimes repeated
• a dull ache between attacks in some people
• tenderness over the nerve where it exits the skull base
• scalp sensitivity: brushing hair or lying on a pillow can trigger pain
• tingling or numbness in the scalp
• pain behind the eye on the same side
• sensitivity to light in some

Causes and triggers

• tight neck muscles and poor posture
• neck injury, including whiplash
• arthritis of the upper cervical spine
• nerve compression by blood vessels, scar tissue or, rarely, tumors
• diabetes, gout, infection and blood vessel inflammation, rarely
• in many people, no specific cause is found

Triggers include neck movement, keeping the head in one position for long periods, and pressure on the back of the head.

Occipital neuralgia vs other headaches

Migraine can also irritate the occipital nerves, and the conditions often overlap.

Diagnosis

The International Headache Society criteria include:

• paroxysmal pain in the distribution of the occipital nerves
• shooting or stabbing quality, lasting seconds to minutes
• tenderness over the nerve, or pain triggered by pressing on it
• temporary relief with a local anesthetic block of the nerve

A doctor examines the neck, head and nerves. MRI of the head or neck is done if there are unusual features, neurological signs or to look for a cause, such as upper neck arthritis or a structural lesion.

Treatment

Self-care and therapy

• heat packs on the neck
• rest in a comfortable position with a supportive pillow
• gentle massage and stretching of the neck muscles
• physical therapy for posture and neck strength
• workstation adjustments and regular breaks

Medicines

• NSAIDs such as ibuprofen or naproxen for short-term relief, following the label dose
• nerve pain medicines: gabapentin, pregabalin, carbamazepine or low-dose tricyclic antidepressants
• muscle relaxants for muscle spasm in some cases

Procedures

• Occipital nerve block: an injection of local anesthetic, often with a steroid, near the nerve at the back of the head. It can give relief for weeks to months and can be repeated
• Botulinum toxin injections in some cases
• Pulsed radiofrequency of the nerve
• Occipital nerve stimulation or surgical decompression of the nerve for severe, persistent cases that respond to blocks, in specialized centers

Outlook

Most people improve with conservative treatment and nerve blocks. Symptoms can recur, especially with ongoing neck strain, but are usually manageable.

Frequently asked questions

What does occipital neuralgia feel like?

It feels like sudden, sharp, shooting or electric-shock pain starting at the base of the skull and spreading over the back of the head, usually on one side. The scalp may be very tender, and brushing hair or lying on a pillow can trigger pain.

What causes occipital neuralgia?

It is caused by irritation or compression of the occipital nerves, often from tight neck muscles, neck injury such as whiplash, or arthritis in the upper neck. In many people no specific cause is found.

How is occipital neuralgia diagnosed?

A doctor diagnoses it from the pattern of pain and tenderness over the nerve. A nerve block, injecting local anesthetic near the nerve, that relieves the pain supports the diagnosis. MRI is used if there are unusual features or a structural cause is suspected.

How long does occipital neuralgia last?

Individual attacks last seconds to minutes, but episodes can recur over days to months. Many people improve within weeks with heat, therapy and medicines. Nerve blocks can provide relief lasting weeks to months.

Is occipital neuralgia serious?

It is painful but not dangerous. However, sudden severe headaches, headaches with fever or neurological symptoms, or new headaches in older adults need prompt evaluation to rule out serious causes.