Occipital Neuralgia

What is occipital neuralgia

Greater occipital neuralgia (GON) can be caused by trauma or be unrelated to trauma.

It may be due to compression or irritation of the nerve by the muscles as the nerve passes through the semispinal capitis and trapezius.

Although “true” GON is described as paroxysms of electrical pain in the distribution of the nerve, other patients can have longer duration pain.

The pain can be referred in a suboccipital, hemicranial, temporal, frontal, orbital, periorbital, or retro-orbital distribution.

Similarly, lesser occipital neuralgia can occur with pain referred in the distribution of the nerve over the lateral scalp superior and posterior to the ear and sometimes in the ear.

On examination, there is tenderness over the involved nerve with reproduction of symptoms.

There may be hyperesthesia, dysesthesia, or paresthesia in the involved scalp. 

Primary and secondary headaches including temporal arteritis can mimic occipital neuralgia so diagnostic testing may be indicated.

Occipital nerve block with local anesthetic can be quite effective (but can also be effective for migraine).

presentation and treatment of occipital neuralgia

Occipital neuralgia is characterized by a sharp pain originating in the back of the head and radiating into the distribution of the greater and/or lesser occipital nerves, and sometimes into the eye. Symptoms can be triggered or unprovoked, and are often associated with dysesthesia in the same distribution. Most cases are unilateral, but bilateral occipital neuralgia does occur. Compression or trauma to the involved nerve(s) is often a cause, but many cases are idiopathic. Medical management with antiepileptic agents is first-line treatment, and local anesthetic injections can transiently relieve the pain and confirm the diagnosis. Surgical treatments include C2/3 ganglionectomy and occipital nerve stimulation.

Other treatments may include

  • physical therapy
  • NSAIDs
  • baclofen
  • carbamazepine
  • gabapentin
  • pregabalin
  • tricyclic antidepressants

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