Occipital Neuralgia

Occipital neuralgia is defined as a paroxysmal shooting or stabbing pain in the distribution of the greater or lesser occipital nerves accompanied by diminished sensation or dysesthesia in the affected area. The pain originates in the suboccipital region and radiates over the vertex. A suggestive history and clinical examination with short-term pain relief after infiltration with local anesthetic confirm the diagnosis.

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Occipital Neuralgia Summary

Occipital neuralgia (ON) is a relatively rare primary headache disorder. The cause of occipital neuralgia is unknown, however, entrapment and irritation of the nerves have been proposed. When conservative measures are ineffective, occipital nerve blocks are a convenient and relatively benign tool for diagnosis and management of occipital neuralgia. Nerve ablation techniques (pulsed radiofrequency) can provide sustained pain relief in some patients. 

Causes Of Occipital Neuralgia

Often, damage or irritation of the greater or lesser occipital nerve is the cause of the neuralgia. There are various potential causes of irritation: vascular, neurogenic, muscular and osteogenic.


  • Irritation of the nerve roots C1/C2 by an aberrant branch of the posterior inferior cerebellar artery
  • Dural arteriovenous fistula at the cervical level
  • Giant cell arteritis


  • Schwannoma in the area of the cranio cervical junction
  • C2 myelitis
  • Multiple sclerosis


  • C1/C2 arthrosis, atlantodental sclerosis
  • Cervical osteochondroma
  • Osteolytic lesion of the cranium
  • Exuberant callus formation after fracture C1/C2

Post surgical

  • Foramen magnum decompression
  • Surgery at cerebellopontine angle
  • Upper cervical spine surgery

Criteria For Diagnosis Of Occipital Neuralgia

  • Pain in the distribution of the greater or lesser occipital nerves
  • Stabbing quality pain that occurs in paroxysms, which may ache between paroxysms
  • Tenderness on palpation along the affected nerve
  • Positive response to local anesthetic

Clinical Features

Patients complain of a shooting or stabbing pain in the neck radiating over the cranium. Constant pain can persist between the paroxysms. The pain can be perceived in the retro-orbital area caused by overlap of the C2 dorsal root and the trigeminal nucleus. Vision impairment/ocular pain (67%), tinnitus (33%), dizziness (50%), nausea (50%), and congested nose (17%) can be present because of connections with cranial nerves VIII, IX, and X, and the sympathetic trunk.

Examination Findings

Hypoasthesia or dysesthesia in the area of the greater and lesser occipital nerve as well as tenderness to pressure over the course of the nerve can be observed. A positive Tinel’s sign (pain upon percussion over the nerve) can be present. Clinical presentation and a temporary improvement with a local anesthetic diagnostic block of the occipital nerve confirm the diagnosis. False-positive results can occur with migraine and cluster headaches.

Differential Diagnosis

Tumors, infection, and congenital anomalies (Arnold- Chiari malformation) should be ruled out. Occipital neuralgia can be mistaken for migraine, cluster headache, tension headache, and hemicrania continua. Other structures may cause similar pain, such as the upper cervical facet joints (C2-C3), osteoarthritis of the atlantooccipital or atlantoaxial joint, giant cell arteritis and tumors of the cervical spinal column.

Management Of Occipital Neuralgia

Conservative management

Conservative treatment focuses on reducing secondary muscle tension and on improving posture. Non-pharmacological treatments like TENS and acupuncture can be tried.

Pharmacological treatment

Anti neuropathic drugs like tricyclic antidepressants and antiepileptics (gabapentin, pregabalin) can help relieve the symptoms.

Interventional Treatments For Occipital Neuralgia

Occipital nerve block

Infiltration of local anaesthetic and steroid around the occipital nerve can be diagnostic and therapeutic as well. The injection is performed under real-time ultrasound guidance for greater accuracy and safety.

Occipital nerve ablation (Pulsed radiofrequency treatment)

Pulsed radiofrequency lesioning of the occipital nerve is indicated in patients who show a positive response to diagnostic occipital nerve blocks. This procedure can relieve symptoms associated with occipital neuralgia on a long-term basis.

Botox injection for occipital neuralgia

Injection of botulinum toxin can be helpful in relieving symptoms associated with occipital neuralgia.

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Dr Murli Krishna

Consultant Pain Medicine