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How to Treat Occipital Neuralgia?


Occipital neuralgia (nerve pain) affects the occipital nerve at the back of the skull, resulting in sharp, stabbing, or burning pain. The pain can be at one or many areas. In addition, tenderness and tightness can be present at the neck and posterior scalp muscles.

Where is the occipital nerve located?

The occipital nerve is located in the posterior skull (head), originating in the spinal cord. It has three branches that traverse the occipital bone: the greater occipital nerve, the lesser occipital nerve, and the third occipital nerve.

If you’re curious about the word occiput, it is from the Latin words “ob," meaning against, and “caput," meaning head. In 1758 the Middle English word occiput was translated to "back of the head."

What are the symptoms of occipital neuralgia?

Pain at the back of the head or neck radiates to the scalp or posterior orbital (behind the eye) area. The pain can be burning, throbbing, sharp, stabbing, or aching. Sensitivity to light can be present. The pain may last a few seconds, minutes, or hours.

What causes occipital neuralgia?

Occipital neuralgia is caused by inflammation, irritation, or pressure on the occipital nerve, caused by numerous conditions, including:

  • Muscle tightness or spasms
  • Enlarged blood vessel or bleeding
  • Arthritic conditions like rheumatoid arthritis and osteoarthritis
  • Trauma
  • Tumors of the brain and spinal cord
  • Multiple sclerosis (MS)
  • Gout
  • Diabetes

However, sometimes the etiology (cause) cannot be determined.

How common is occipital neuralgia?

One study in the Netherlands found the incidence of occipital neuralgia to be 3.2 per 100,000 people and was more common in women than men, but not by a significant amount.

How is occipital neuralgia diagnosed?

The medical history and physical exam are essential. A history of posterior skull pain is usually present.

In addition to a complete physical exam, a focused neurological exam should be performed that includes an examination of neck and scalp muscles and sensation of the scalp.

Full laboratory tests should be done, especially to rule out other causes of the symptoms, such as infection, rheumatoid arthritis, diabetes, gout, tumors, etc.

Imaging scans consist of plain x-rays, computed tomography (CT or CAT) scans, or magnetic resonance imaging (MRI) tests. Plain x-rays only show bones, while CT and MRI will allow visualization of the soft tissues.

The best way to precisely diagnose occipital neuralgia is a direct injection of an anesthetic, called a nerve block, right into the path of the occipital nerve; it is a diagnostic test and a treatment simultaneously.

What other conditions need to be ruled out?

Pain from different headaches can mimic occipital neuralgia, including migraine, tension, or cluster headaches; thus, evaluation for these conditions need to be done.

What are the treatments for occipital neuralgia?

A: Medications can help with pain and inflammation.

  • Over the counter pain medication such as Tylenol (acetaminophen) and aspirin
  • Non-steroidal anti-inflammatory drugs (NSAIDs), available by prescription and over the counter
  • Muscle relaxers
  • Antidepressants like tricyclic type and serotonin reuptake inhibitors
  • Anti-seizure medication such as carbamazepine (Tegretol) and gabapentin (Neurontin)
  • Opioids for short-term treatment
  • The immunosuppressant medication infliximab (Remicade)

B: Injections

After the diagnostic nerve block, there can be future nerve blocks, called therapeutic, performed with different substances, including:

  • A local anesthetic
  • A local anesthetic with an added steroid
  • Botulinum toxin A

C: Conservative treatments not involving medications, injections, or surgery include the following:

  • Exercise is an ideal treatment for neck and muscle tightness. Cardiovascular (aerobic) exercises can be combined with weight training (anaerobic exercise) and stretching. Proper stretching of the neck muscles can often relieve the pain of occipital neuralgia.
  • Physical and occupational therapists can assist with designed stretching, a home exercise program, and proper posturing.
  • Chiropractic care for release of cervical spasm and misalignment.
  • Acupuncture can help.
  • Heat and ice. The old-fashioned idea was to use ice for the acute injury (first 24 hours) and then use heat. However, every person is different; some respond better to ice, and some respond better to heat.
  • Lifestyle changes can help with musculoskeletal issues: see the doctor regularly, eat a healthy diet, avoid tobacco and alcohol, and get enough sleep.

D: Surgical treatments should be considered when patients do not respond to other treatments and repeated injections.

Occipital decompression, also called occipital release surgery, is done by the surgeon by eliminating compression of the occipital nerve by blood vessels, connective tissues, or muscles. Occasionally, the release may be temporary with a resumption of the symptoms.

Other surgical procedures use precise needles and consist of the following:

  • Cryoablation or freezing of the nerve
  • Nerve stimulation uses electrical impulses to disrupt the transmissions through the occipital nerve.
  • Thermal radiofrequency ablation uses radiofrequency waves to create heat and destroy nerve tissue.

What is the prognosis (disease forecast) for someone with occipital neuralgia?

With the correct diagnosis and proper treatment, pain relief can be quickly achieved.

Key takeaways:

Occipital neuralgia involves pain of the occipital nerve producing a sharp, stabbing, and burning pain of the posterior scalp radiating to the eye.

Anything that places pressure on the occipital nerve can cause occipital neuralgia, including muscular issues, enlarged blood vessels, trauma, arthritis, cranial tumors, gout, and diabetes.

Diagnosis is made by physical exam, laboratory tests, and imaging studies; however, an occipital nerve block is the best diagnostic test.

Treatment for occipital neuralgia consists of medications, therapeutic injections (nerve blocks), conservative treatments, and surgery.

References:

Choi, Il, and Sang Ryong Jeon, ‘Neuralgias of the Head: Occipital Neuralgia’, Journal of Korean Medical Science, 31.4 (2016), 479–88 https://doi.org/10.3346/jkms.2016.31.4.479

‘Definition of OCCIPUT’ https://www.merriam-webster.com/dictionary/occiput

Djavaherian, Derek M., and Kevin B. Guthmiller, ‘Occipital Neuralgia’, in StatPearls (Treasure Island (FL): StatPearls Publishing, 2022) http://www.ncbi.nlm.nih.gov/books/NBK538281/

‘Occipital | Etymology, Origin and Meaning of Occipital by Etymonline’ https://www.etymonline.com/word/occipital

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