How to Treat Occipital Neuralgia, a Common and Underdiagnosed Headache

What is occipital neuralgia?

Occipital (back of the head) neuralgia (nerve pain) is a type of head and neck pain that originates from injury to the occipital nerves. Occipital nerves provide sensation to the back of the head.

Although medical literature describes occipital neuralgia as a rare condition, it is one of the most common conditions we encounter in our neurology practice at Ochsner.

Symptoms of occipital neuralgia

The pain is sharp, shooting, throbbing, burning and/or stabbing. It typically radiates from the back of the head upward to the scalp and occasionally to the temple and eyes. The condition may cause the involved area(s) to be tender to touch. The pain varies in severity, frequency and duration. The pain can affect one side of the head or both sides.

Causes of occipital neuralgia

The causes of the occipital nerve(s) injury include:

poor posture
trauma
inflammation
compression (pinching).

In most cases, the pain develops with no identifiable cause or preceding event.

Treatment for occipital neuralgia

The initial treatment of choice for occipital neuralgia, according to medical literature, is occipital nerve block, using anesthetic agent with or without steroids. However, in our clinic, we have achieved remarkable success with anti-neuropathic pain medications, specifically amitriptyline.

We rarely utilize occipital nerve block and other interventions.

Amitriptyline is an old antidepressant with nerve pain-controlling properties. We rarely use amitriptyline for depression nowadays and it is utilized for nerve pain, migraine, tension headaches, insomnia and irritable bowel syndrome. In our own experience, it is the most effective treatment for occipital neuralgia with response rates exceeding 90%. Conservative complementary treatments that help manage the pain include:

heating pads
massage therapy
physical therapy.

Our next treatment of choice is typically botulinum toxin injections. It provided excellent pain relief in cases that do not respond to or unable tolerate amitriptyline’s side effects.

When none of the abovementioned therapeutic options help our patients, we refer them to a pain management specialist to consider interventional options. Various procedures can be utilized, including:

occipital nerve block
pulsed radiofrequency, which works by delivering bursts of radiation that interrupts the nerve signals and consequently reducing the pain
cryotherapy (freezing), which deactivates the nerve utilizing extremely low temperatures and occipital nerve stimulation utilizing neurostimulator in severe intractable cases.

Occipital nerve surgical decompression may benefit very few selected patients in extreme cases when all other treatments fail to control the pain and the pain is severe and disabling.

Prognosis

Occipital neuralgia relief varies among patients depending on the cause and the extent of nerve injury. It can be short-lived but can also turn into a problem that comes and goes or that is an ongoing problem.