Distinguishing between occipital neuralgia and migraines?

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Full Question:

I am trying to distinguish between occipital neuralgia and migraines. I have been diagnosed by a neurologist with the former, but not found any medication very reliable to help with the headaches. I recently went through a 6-week bout with vertigo. The headaches, which had been absent several weeks, returned with the vertigo, recurring intermittently during that 6-week period, often very intense. The vertigo has finally stopped, but the headaches are more persistent. Both an ENT and a PT were not able to elicit nystagmus for testing of BPPV, (nor did Epley maneuvers help), and I had an MRI, which was negative. So I am suspecting the vertigo was migraine induced. However, I have taken 40 mg. Relpax once, which made the headache worse, and 20 mg. a different time, and it didn't help. Am going to try Imitrex, but if that doesn't work, then I will have to conclude that these aren't migraines. I do have a history of ocular migraines, however, which present much differently, a 20 minute event, occurring once every 1-3 months. Have not had any of these since the onset of the vertigo or since.

Options which I am planning on pursuing at this point are PT and acupuncture for the headaches. Am wondering about asking the neurologist for an occipital nerve block. Besides helping the pain, it is supposed to be a way to truly diagnose occipital neuralgia. Also am considering seeing a headache/migraine specialty center, but the only one in my state is 2 1/2 hours away. Jane.

Full Answer:

Dear June;

Lots of topics woven into you question. We'll do our best to answer them. Occipital neuralgia and migraine should be reasonably easy to distinguish. Occipital neuralgia is an irritation of the greater occipital nerve, which provides sensation to the back of the head and up to the top of the head. The greater occipital nerves cover most of the back of the head and the lesser occipital nerves cover more forward, just behind and above the ears. Neuralgia pain can be sharp, burning, or electrical, but can also be less clearly defined, and these is often tenderness along the nerve when you press on it.

Migraine often involves moderate to severe pain, usually on one side of the head, with a throbbing quality. Migraines can be worsened by routine physical activity, and often cause nausea, vomiting, sensitivity to light and sound, and other symptoms. There's a good overview of the potential symptoms of migraine in Anatomy of a Migraine.

Vertigo can be a symptom of migraine and can occur either with the headache phase of a migraine or can occur independently of pain. It is important to have other causes of vertigo ruled out before you accept it as part of the migraine syndrome. Since you were evaluated by an ENT and had an MRI, it is certainly possible that your vertigo is migraine related. There are several forms of migraine. Vertigo can occur with vestibular migraine. You can find more about that form in _Vestibular Migraine - The Basics _.

I am always cautious about using treatments as diagnostic tools. This includes using a lack of response to "triptans" like Relpax as an exclusion of migraine, and occipital nerve blocks to diagnose occipital neuralgia. There are a lot of reasons why treatments fail, and only one of them is incorrect diagnosis. For example, many people will see limited benefit from triptans if they aren't used early in the migraine when the pain is still mild. The best data available for triptans suggests that even when taken at the correct time they are effective in only about 2/3 - 3/4 of the people who use them. Continue to try different triptans, like the sumatriptan you mentioned, and be certain to catch your migraines as early as possible.

It the closest headache and migraine specialist is that far away, they may not be the best solution for the chronic management of your headaches, but it could be very useful to get a firm diagnosis and treatment recommendations that your local neurologist or primary care doctor could use. On the other hand, with a shortage of qualified migraine and headache specialists, many patients travel long distance for the benefits of being treated by a specialist, and travel to their specialists about every three months. Since the big difference is the knowledge and experience of the specialist, we recommend that you choose a specific doctor rather than choosing a clinic or center.

Good luck,
David Watson, MD, and Teri Robert

About Ask the Clinician:

Dr. David Watson is a UCNS certified migraine and headache specialists and director of the Headache Center at West Virginia University. He and Lead Health Guide Teri Robert, team up to answer your questions about headaches and Migraines. You can read more about _ Dr. Watson_ or more about _** Teri Robert** _.

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