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Occipital Neuralgia

Occipital Neuralgia

Occipital Neuralgia is a condition in which the occipital nerves, the nerves that run through the scalp, are injured or inflamed. This causes headaches that feel like severe piercing, throbbing or shock-like pain in the upper neck, back of the head or behind the ears.


The C3 dorsal ramus is a short nerve that arises from the spinal nerve and passes backwards through the C2-3 intertransverse space where it divides into a lateral and two medial branches. The deeper of the two medial branches winds around the waist of C3 articular pillar and enters the multifidus muscle. The superficial medial branch is known as the third occipital nerve. The third occipital nerve is also known as the lesser occipital nerve. It crosses the lateral and dorsal aspects of the lower half of the C2-3 zygapophysial joint, it then passes across the lamina of C3 before turning backward and upwards to pierce semispinalis capitis and splenius capitis to become cutaneous over the suboccipital area. The articular branches to the joint arise from the deeper aspect of the nerve as it crosses the joint.

Anatomically, the C2-3 joint differ markedly from the other upper cervical synovial joints. The joints of the atlas lie ventral to the emerging spinal nerves, the C2-3 zygapophysial joints lie behind the intervertebral foramina in sequence with the other zygapophysial joints and are the highest synovial joints associated with an intervertebral disc at the same level. Functionally they represent a transition zone between the C1-C2 level, which accommodates rotation of the head, and the lower cervical spine, which accommodates flexion and extension of the neck.


Occipital neuralgia can be the result of pinched nerves or muscle tightness in the neck. It can also be caused by a head or neck injury. Occipital neuralgia can either be primary or secondary. A secondary condition is associated with an underlying disease.

Although any of the following may be causes of occipital neuralgia, many cases can be attributed to chronic neck tension or unknown origins.

  1. Osteoarthritis of the upper cervical spine
  2. Trauma to the greater and/or lesser occipital nerves
  3. Compression of the greater and/or lesser occipital nerves or C2 and/or C3 nerve roots from degenerative cervical spine changes
  4. Cervical disc disease
  5. Tumors affecting the C2 and C3 nerve roots
  6. Gout
  7. Diabetes
  8. Blood vessel inflammation
  9. Infection


Symptoms of occipital neuralgia include continuous aching, burning and throbbing, with intermittent shocking or shooting pain that generally starts at the base of the head and goes to the scalp on one or both sides of the head. Patients often have pain behind the eye of the affected side of the head. Additionally, a movement as light as brushing hair may trigger pain. The pain is often described as migraine-like and some patients may also experience symptoms common to migraines and cluster headaches.

Diagnostic methods:

According to the International Classification of Headache Dis order (ICHDII), occipital neuralgias belongs to the same family as cranial neuralgias, central and primary facial pain, and other headaches. The diagnostic criteria are as below:

  1. Paroxysmal stabbing pain, with or without persistent aching between paroxysms, in the distribution of the greater, lesser, and/or third occipital nerve.
  2. Tenderness over the affected nerve (about 3 cm superomedially to the tip of the mastoid process).
  3. Pain is eased temporarily by local anaesthetic block of the nerve – definitive diagnosis.


Conservative management:

Conservative treatment includes posture correction and reducing the neuralgic and muscle pain. Pharmacological treatment may include 

  • tricyclic antidepressants, 
  • serotonin reuptake inhibitors, 
  • anticonvulsants (e.g., carbamazepine, oxycarbamazepine, gabapentin, pregabalin), and opioids. 
  • NSAID’s and 
  • paracetamol

The use of ergot derivatives is controversial. Infliximab has shown some benefit.

Interventional management

Local anaesthetic with or without steroid injection: Under repeated fluoroscopic screening a spinal needle is inserted by a lateral approach to the third occipital nerve. Three target points are selected to ensure that the variable course of the nerve across the C2-3 joint is adequately blocked. End point of the block is by achieving numbness over the cutaneous supply of third occipital nerve.
Botulinum toxin infiltrations: Botulinum as inhibitory effects on sensory nerve mediators like substance P, calcitonin gene related peptide, and glutamate may be involved in pain relief.
Pulsed radiofrequency treatment: Pulsed radiofrequency treatment is known to reduce pain, primarily by the induction of a low intensity electrical field around sensory nerves that result in depressed conduction and inhibition of long term activation in the lightly myelinated A delta fibers and the small unmyelinated C fibers. PRF treatment showed short term to intermediate term pain control.
Surgery: Indicated in refractory patients. It includes neurolysis, Occipital nerve stimulation and destructive surgeries.