Occipital neuralgia refers to irritation and/or damage to the Greater Occipital Nerve(s) or, sometimes, to the Lesser Occipital Nerve(s). These nerves exit the spinal cord in the high neck region on both sides, run along the back of the head, and extend up to the forehead. Headaches can be due to irritation of this nerve alone. More often, though, occipital neuralgia causes focal head pain that serves as a trigger for migraine headaches. In our office we routinely examine patients to look for tenderness of these nerves. Other nerves that can be irritated and cause pain around the posterior portion of the head or neck include the third occipital nerve, the suboccipital nerve, the greater auricular nerve, and the cutaneous branches of the upper spinal nerves.
Occipital neuralgia can occur in any person and there is not always an obvious cause. Possible causes include trauma to the back of the skull or prior skull surgery. Anything that chronically compresses the nerves may also be an issue such as sleeping in a manner that puts pressure on the nerves, having a tight ponytail (or other tight hair configurations) or wearing a wig. Certain individuals may also be prone to occipital neuralgia because the nerve is held too firmly by its surrounding fibrous tissue. In other cases, the nerve runs through the muscle in the back of the head (occipitalis) or is being compressed by spasm of this muscle. Pain in the distribution of the greater occipital nerve may also be 'referred' pain, meaning the cause is deeper, such as compression of the C2 (cervical nerve root number two) nerve root in the spine.
Avoid further damage to the nerves by avoiding compression of the nerve. In addition, applying ice (in a towel or plastic bag) to the base of the nerve for 10 minutes at a time may reduce the pain temporarily.
In our office, patients are often treated with a series of occipital nerve blocks. These are injections at the base of the nerve (in the occipital region) using lidocaine (or some other local anesthetic) sometimes combined with a steroid. The injections are very safe and often result in an immediate reduction in pain. Injections can be performed twice a week for 2-3 weeks. The benefit is variable. For some patients the nerve blocks work and the problem never again recurs. For many more, the nerve blocks are helpful, but the problem may return.
Other Treatment Options
Some medications (Lyrica, Neurontin, Elavil), when taken on a daily basis, reduce the sensitivity of nerves and can tried for this condition. Botox, which in this context acts like a long-acting muscle relaxer, can be injected into the occipitalis muscle thereby relaxing it and potentially reducing pressure on the occipital nerve. We sometimes also refer to pain management specialists who perform deeper injections (C2 or C3 dorsal root ganglion blocks) or even perform procedures that involve controlled damage of these nerves (radiofrequency ablation) in order to reduce the pain in a more permanent manner. Surgical release of the nerves may also be performed, in severe cases of intractable pain (that responds temporarily to the types of injections mentioned above). Finally, a very promising technique is the implantation of wires over the occipital nerves which provide continuous stimulation of the nerves while also blocking the transmission of pain signals (see