Occipital Neuralgia: The Basics

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Occipital neuralgia (ON) is a primary headache disorder presenting symptoms that are sometimes confused with migraine. ON impacts the greater, lesser, and third occipital nerves that run up the neck muscles and exit near the base of the skull, providing sensation from the back to the top of the head and behind the ears. A relatively rare condition, ON affects 3.2/100,000 people per year.

Entrapment and irritation of the nerves have been proposed as the cause of ON, but the cause has yet to be established. It can be easily triggered by simply touching the affected region. Allodynia of the scalp can occur during an ON attack, and a dull ache can continue between attacks.

The International Headache Society’s International Classification of Headache Disorders, 3rd Edition (ICHD-3), is the “gold standard” for diagnosing and classifying headache disorders. Here are the description, diagnostic criteria, and symptoms of ON as set forth in the ICHD-3:

13.4 Occipital neuralgia

Description:

Unilateral or bilateral paroxysmal, shooting or stabbing pain in the posterior part of the scalp, in the distribution of the greater, lesser or third occipital nerves, sometimes accompanied by diminished sensation or dysaesthesia in the affected area and commonly associated with tenderness over the involved nerve(s).

Diagnostic criteria:

A. Unilateral or bilateral pain fulfilling criteria B-E

B. Pain is located in the distribution of the greater, lesser and/or third occipital nerves

C. Pain has two of the following three characteristics:

  1. recurring in paroxysmal attacks lasting from a few seconds to minutes
  1. severe intensity
  1. shooting, stabbing or sharp in quality

D. Pain is associated with both of the following:

  1. dysaesthesia (impairment of sensitivity to touch) and/or allodynia apparent during innocuous stimulation of the scalp and/or hair
  1. either or both of the following:

a) tenderness over the affected nerve branches

b) trigger points at the emergence of the greater occipital nerve or in the area of distribution of C2

E. Pain is eased temporarily by local anaesthetic block of the affected nerve

F. Not better accounted for by another ICHD-3 diagnosis.

Comments:

The pain of 13.4 Occipital neuralgia may reach the fronto-orbital area through trigeminocervical interneuronal connections in the trigeminal spinal nuclei.

13.4 Occipital neuralgia must be distinguished from occipital referral of pain arising from the atlantoaxial or upper zygapophyseal joints or from tender trigger points in neck muscles or their insertions.

Occipital neuralgia can be difficult to diagnose and treat, and is sometimes misdiagnosed as migraine. If you suspect you may have ON, but have not been diagnosed with it, consult your physician. If your physician is unfamiliar with ON, remember that there’s never anything wrong with seeking a second opinion. Migraine and headache specialists are generally best qualified to diagnose and treat ON.

Sources:

Headache Classification Committee of the International Headache Society. “The International Classification of Headache Disorders, 3rd edition (beta version).” Cephalalgia. July 2013 vol. 33 no. 9 629-808 10.1177/0333102413485658

Holdridge, Ashley, DO. Understanding Occipital Neuralgia. The American Migraine Foundation. July 26, 2016.

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