What is Occipital Neuralgia

Introduction

Occipital neuralgia is a headache felt at the back of the head and surrounding areas caused by inflammation or injury of the occipital nerve, which runs through the scalp. The headache is typically intense and sudden, feels like electric shock pain, with shooting and throbbing sensations, and may last seconds to minutes.¹

Causes

1. Nerve Compression/Irritation: Pressure on occipital nerves, often from muscle tension or trauma.
2. Muscle Tension/Spasms: Stress, poor posture, or injuries tighten muscles, aggravating nerves.
3. Trauma/Injury: Head, neck, or back trauma can damage nerves, triggering neuralgia.
4. Cervical Spine Disorders: Conditions like disc disease or arthritis can compress nerves.
5. Inflammation: Infections, autoimmune diseases, or inflammatory conditions may inflame nerves.
6. Tumors/Growths: Rarely, benign or malignant growths compress nerves, causing pain.
7. Genetic Predisposition: Inherited factors may increase susceptibility to neuralgia.
8. Systemic Disorders: Diseases like diabetes or multiple sclerosis can affect nerve function.
9. Psychological Factors: Stress, anxiety, or depression can worsen neuralgia symptoms.

What is the occipital nerve?

To understand occipital neuralgia, firstly it is important to understand what the occipital nerve is.  Nerves are like tiny wires that carry messages between different parts of the body and the brain. The occipital nerve is responsible for letting your brain know what is happening at the back of your head and upper neck. It helps you feel sensations  like touch and pain in your scalp. When there is something wrong with this nerve, it can lead to a condition called occipital neuralgia, causing headaches and discomfort in the head and neck.^2,3

 There are three major parts of the occipital nerve: 

• The greater occipital nerve (GON)
• The lesser (or tiny) occipital nerve (LON)
• The third (or least) occipital nerve (TON).⁴

In over 90% of occipital neuralgia cases, the primary nerve implicated is the GON.¹ This headache disorder is mainly caused by occipital nerve compression, which can occur spontaneously or be triggered by various factors. These include injuries, pinched nerves, tense neck muscles, disc disease, infections, and inflammation.^2,3

Risk factors

While occipital neuralgia can affect people of any age, background, or gender, numerous factors enhance the likelihood of developing it. Those who have had previous neck/head traumas or injuries are more likely to acquire occipital neuralgia. People with chronic neck tension, neck tumours, cervical disc diseases, blood vessel inflammation, osteoarthritis of the upper cervical spine, nerve entrapment, infection, gout, and diabetes are also at risk for this disorder. Although these factors may be linked to an increased risk of occipital neuralgia, many cases may have unknown origins (idiopathic).⁵ 

Symptoms

There are many types of headaches,however, the presence of specific symptoms can help distinguish occipital neuralgia from other types of headahces.  The following features are specific to occipital neuralgia: 

• When and how does the pain occur? It is paroxysmal (sudden/acute pain, which usually happens repeatedly and spontaneously)

• Where is the headache located? The back of the head and upper neck and spreads to the vertex (highest point of the head) and behind the ears. It is more common on one side of the head (prone to the left side) but can also occur  on both sides.

• How does the pain feel? Continuous aching, stabbing, intermittent electric shock pain, burning, throbbing, sharp/shooting. 

• How long does it last? Second to minutes, sometimes hours. Some people experience exacerbated pain, starting with lower-intensity pain and occasionally progressing in severity.

• How long will I experience this? Occipital neuralgia is usually chronic. It can be continuous (no remission), remitting (pain-free periods of more than a month), or undefined (pain not lasting more than three months since its onset).

• What factors trigger the pain?: Abnormal neck movements or postures, and spasms of the neck muscles such as the trapezius and sternocleidomastoid can trigger bouts of occipital neuralgia.. 

• Does the pain radiate? It usually originates from the base of the head to the top and sometimes radiates to the front of the head and eyes. 

• Are there any associated symptoms? Some patients experience allodynia (extreme sensitivity to a touch that typically does  not cause pain), dysesthesia  (abnormal or unpleasant touch sensations), and tenderness to palpation on specific areas.⁵

How is occipital neuralgia diagnosed?

To diagnose this disease, doctors will review your medical history, including any symptoms you experienced and any past or current medical conditions. They will also do physical and neurological examinations. If the medical history and physical examination are unclear, diagnostic imaging such as Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) scans may be requested. 

In several guidelines, a nerve block is required to confirm the diagnosis. Local anaesthetic and steroid medication are injected into the area around the nerve. The relief of the nerve block can help to confirm the diagnosis of occipital neuralgia.³

Treatment 

The treatment of occipital neuralgia focuses on managing pain during symptomatic periods. It is also important to identify and manage factors that may exacerbate the condition. 

Non-surgical treatments

• Adequate rest and posture correction canreduce neuralgic pain and muscle tension.
• Warm compress: the heating pads  can provide pain relief when applied to the appropriate location. 
• Physical therapy and massage
• Nerve block: injecting medications and steroids into the nerve to produce a numbing effect.
• Botulinum toxin injections will decrease nerve inflammation.
• Over-the-counter drugs: analgesic and anti-inflammatory drugs, such as ibuprofen and naproxen, can help alleviate  the pain. 
• Medication (by prescription): anti-inflammatory drugs, anticonvulsants, muscle relaxants, and opioids^7,8

Surgical treatments

• Surgical decompression

In this procedure, the surgeon makes an incision in the back of the neck to expose the greater occipital nerves and release them from the surrounding tissue and muscles that may be compressing them.¹

• Neurolysis of the occipital nerve

One of the most significant causes of occipital neuralgia is entrapment of the greater occipital nerve. Neurolysis will destroy nerve fibres to interrupt pain signal transmission. This procedure has been shown to be effective in relieving pain and decreasing the consumption of analgesics.⁹

• Occipital nerve stimulation

An electrode called a neurostimulator will be placed under the skin at the base of the skull, where the occipital nerves emerge. This device will block pain messages from reaching the brain. Typically, there is an initial trial with temporary leads.. After a few days, permanent implantation will be considered if the trial is successful and the patients feel significant improvement.^1,10

• Neurectomy, C2 Gangliotomy, C2 Ganglionectomy 

These procedures involve surgical disruption, removal, or transection of the affected nerve portion to relieve pain. C2 ganglion is a group of nerve cell bodies connected to the occipital nerve. All of these procedures are aimed at interfering with the transmission of pain signals.⁸

Other similar conditions

When diagnosing occipital neuralgia, some similar conditions have to be ruled out. Several diseases have similar symptoms to occipital neuralgia, especially pain in the back of the head and neck. Important diseases to be excluded are: 

• Migraine
• Cluster headache
• Tension headache
• Hemicrania continua
• Cervicogenic headache
• Tumors, infections, and congenital anomalies⁷

FAQs

What is the exact cause of occipital neuralgia? 

Occipital neuralgia is caused by compression or irritation of the occipital nerve at the back of the head. The compression can result from various factors such as trauma, musculoskeletal disorders, overly tight neck muscles, neck compression, infection, inflammation, and disc disease.¹

How do you quickly relieve occipital neuralgia?

• Apply heat to the area of pain
• Massage the area to reduce muscle tension 
• Take over-the-counter drugs 
• Seek medical help if the pain won't go or gets worse.⁸

Can occipital neuralgia just go away?

In most cases, it needs treatment, whether it's conservative treatment or surgical treatment. But yes, sometimes it can go away on its own.¹

Is occipital neuralgia a serious condition? 

Occipital neuralgia is not commonly seen as a life-threatening disorder. Most people with occipital neuralgia can find relief through various therapies such as rest, medication, nerve blocks.In certain cases patients may opt for, surgical management such as occipital nerve neurolysis or occipital nerve stimulation.¹

How do I know if I suffer from occipital neuralgia?

You may have occipital neuralgia if you have symptoms such as continuous aching, burning, and throbbing pain with intermittent shocking or shooting pain that usually begins at the base of the head and progresses to the scalp on one or both sides of the head. However, be careful not to mistake  it for a migraine or other type of headache. Seek help from doctors for further examination and confirmation of the diagnosis.⁸

What is the best position to sleep in if I have occipital neuralgia?

The optimal sleeping position for occipital neuralgia is on the back, using a supportive pillow for proper neck alignment. If this is not possible, side sleeping with adequate neck support is an alternative. Elevating the head with pillows in any non-back position can also reduce nerve tension, alleviating pain and tingling associated with occipital neuralgia.¹¹

Can stress cause occipital neuralgia? 

Stress is not directly connected with occipital neuralgia. However, stress may exacerbate muscle tension and contribute to the symptoms experienced by people with this condition.¹

Summary

• Occipital neuralgia is a condition in which the occipital nerve is inflamed or injured. It can be caused by injuries, pinched nerves, tense neck muscles, disc disease, infections, and inflammation. 
• Typical symptoms include sudden and acute pain with shooting/throbbing sensations at the back of the head, upper neck, and behind the ears. 
• Two options for treatments: 

• Non-surgical: rest, physical therapy, compress, nerve block, botulinum toxin, and medications
• Surgical treatments: Surgical decompression, neurolysis, nerve stimulation, and neurectomy