Occipital neuralgia describes a shooting pain in the back of the head.
There are 3 different ways to look at this problem.
- There has been direct injury to the occipital nerve complex
- The shooting pain is actually referred pain from a cervical joint
- 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).
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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.
Degenerative Bone Diseases
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.
Headaches of several types can follow acoustic neuroma surgery.
No obvious explanation
Most people can cope with ‘ordinary’ occipital neuralgia if they know what the pain is – especially 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 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.
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