Occipital Neuralgia

Occipital neuralgia describes a shooting pain in the back of the head.

There are 3 different ways to look at this problem.

  1. There has been direct injury to the occipital nerve complex
  2. The shooting pain is actually referred pain from a cervical joint
  3. There is actually a serious problem with the bones or nerves in the base of the skull or top 3 cervical vertebrae.

1. Direct Injury to the Occipital Nerve

The occipital nerves sit within the scalp at the back of the head.  If there has been a direct blow to the back of the head, then after a period of days or weeks shooting pain can start. The point of injury is usually very tender to touch and produces the sharp, shooting pain.


A local anaesthetic injection to freeze the occipital nerve will relieve the pain rapidly.

In my own practice, this is how I usually use the diagnosis 'occipital neuralgia'.

2. Referred Pain from Neck Joints

In most people with occasional shooting pains in the back of the head, the source is not serious.  In almost every case the most likely source is from stiff or painful cervical facet (zygoapophysial) joints.

A manoeuvre called a passive accessory intervertebral movement can detect abnormal cervical facet joints.

Pressure across a restricted facet joint will usually reproduce the pain.

Treatment for pain referred from a cervical facet joint is usually a combination of physiotherapy (low velocity cervical mobilisations) and use of short course of anti-inflammatory drugs.

Neuropathic pain medications like Gabapentin, Pregabalin and Amitryptiline can also be used in long standing cases.

It is my view that most people who are labelled with 'occipital neuralgia' actually have cervical facet joint dysfunction.

There are some cases of very severe cervical facet joint arthritis which have required fairly invasive and drastic surgery to treat the pain (C1-2 arthrosis).

3. Serious and Rare Causes

In a review of 65 published articles, I've identified 8 different categories of occipital neuralgia.

It is important to understand that people with these serious causes will have relentless and severe levels of pain.  They will not be describing a 'nuisance' level of discomfort.

Vascular Causes

  • Arterial Compression by loop of vertebral artery - 8 cases
  • Temporal Arteritis presenting as occipital artery inflammation - 3 cases
  • Cavernoma within upper cervical cord - 2 cases
  • Dural Arterio-venous fistula - 2 cases


Benign Tumours

  • Schwannoma of occipital nerve - 2 cases
  • Schwannoma foramen magnum - 1 case
  • Osteochondroma - 1 case
  • Meningioma of foramen magnum - 1 case

Malignant Tumours

  • Metastatic Cancer - only one case published but would be more common that that
  • Lymphoma - 2 cases
  • Plasmacytoma - 1 case

Note that there is an occipital condyle syndrome with occipital pain and weakness of the tongue due to involvement of the hypoglossal nerve at the base of the skull.

Degenerative Bone Diseases

  • C1-2 joint arthrosis - frequent
  • Osteoporotic vertebral collapse -1 case folowing cervical manipulation
  • Atlanto-axial joint dislocation - 1 case

Post-operative

  • C1-2 level fusion surgery
  • Acoustic Neuroma Surgery

Headaches of several types can follow acoustic neuroma surgery.

No obvious explanation

  • Familial - there are 2 families, one Chinese and 1 Swiss, with neuralgic pains in the back of the head and throat
  • Non-familial - I still suspect that most of these have unidentified benign cervical facet joint or soft tissue syndromes

Treatment

Most people can cope with 'ordinary' occipital neuralgia if they know what the pain is - expecially if the attacks of pain are few and far between.

More frequent cases might be best using Neuropathic Medicines like Gabapantin.  If there is a neck joint problem, then physiotherapy is a drug-free approach.

If there is a more serious cause identified (which is highly unlikely) then the treatment will depend on the cause found.

If you found this page helpful, why not share on Facebook or Twitter:

References

If there are no references listed, please notify me, as this box should contain a list of information sources, or a link to a 'Systematic Review' of the topic discussed on this page.

Here are 65 references from a systematic review of the Medline database. The spreadsheet of occipital neuralgia references is available via Google Drive.