What is occipital neuralgia?

Occipital neuralgia (ON) is a condition in which the occipital nerves, the nerves that run through the scalp, are injured or inflamed. This causes headaches that feel like severe piercing, throbbing or shock-like pain in the upper neck, back of the head or behind the ears. It is not uncommon in a facial pain practice or in a headache clinic to hear from patients about pain in their face and head that originates, focuses, or culminates in the back of the head, the region that is called occiput. The patients’ description of the pain location may – and usually does – help in making  a correct diagnosis as most nerves in the head and neck region cover very specific anatomical distributions.

The trigeminal nerve, for example, is the main provider of sensation to the entire half of one’s face. – and, similarly, the sensation in the region behind the ear and above the hairline in the back of one’s head is supplied by a very specific group of nerves:, the occipital nerves. There are three occipital nerves on each side: the greater, the lesser, and the third occipital nerves, and all of them originate from the upper cervical spinal nerve roots, mainly from the second and third cervical levels (C2 and C3).

As the sensory information from the occiput is carried by the occipital nerves to the central nervous system, it travels through sensory ganglia and nerve roots and then enters the spinal cord in the upper part of the neck. There it is processed in the same area that is involved with sensation from the face and the rest of the head – the so-called trigemino-cervical complex. These intricate connections explain frequent overlap of the occipital pain with various migraine and headache conditions as well as some instances of occipital pain radiating into the forehead or getting aggravated by the facial pain. 

It is important to note that among many painful conditions that involve the occipital region, the true occipital neuralgia presents a very specific pain syndrome that can be successfully treated in most patients, as long it is properly diagnosed and addressed.

Occipital neuralgia pain

Occipital neuralgia (ON) is a relatively rare condition that manifests itself with pain on one or both sides of the head. Unilateral ON (on one side) is seen in 85% of cases. The pain usually starts in the back of the head and travels higher and toward the front, eventually  reaching the very top of the head (the vertex). It is described as shooting, electric-shock like, or stabbing in nature (and this in medical terminology is referred to as paroxysmal lancinating pain). Very often there is also a dull aching pain between the shooting attacks located in the same general area. 

The duration of attacks lasting from few seconds to few minutes, the severe intensity of pain, presence of either tenderness over the course of the occipital nerves or trigger points within the occipital area, as well as pain or discomfort observed with innocuous stimulation of the scalp or hair (such as hair brushing or shampooing that would not normally cause pain) are all characteristic features of ON. 

How is occipital neuralgia diagnosed?

Another classical feature that helps in making proper diagnosis is the improvement or disappearance of pain in response to numbing the nerve with an injection of local anesthetic in the vicinity of the nerve in question (nerve block). Such blocks are used to both diagnose and treat ON as the pain relief from a single injection may last quite long. In order to make diagnosis of ON, the patient is asked or tested for all of the above-mentioned above features, keeping in mind that other conditions that present with pain in the occipital region (migraines, cluster headaches and hemicranias, tension headaches, cervicogenic headaches that arise from dysfunction of the joints within the spinal column and neighboring cervical muscles, etc.) have to be ruled out first.

Very frequently, in order to rule out associated anatomical pathology, it is necessary to perform appropriate imaging of the head and neck – this would usually include MRI of the brain and the cervical spine. The imaging would allow detection of Chiari malformations, cervical spondylosis, vascular, and neoplastic conditions; in most ON cases the MRI studies are read as normal or almost normal.

What causes occipital neuralgia?

Interestingly enough, the exact source of pain in ON remains unknown – it is commonly accepted as a neuropathic pain condition, meaning that the underlying process is the malfunction of the nervous system. The occipital nerves, the culprit of ON, appear to be hyperactive and irritated but the reason for this irritation is often unclear. Multiple existing theories postulate compression or entrapment of the nerve or nerves anywhere along their course in the patient’s neck and head, but there is no consensus or a universally accepted understanding of the underlying pathology.

Treatment for occipital neuralgia

As with all chronic pain syndromes, the treatment of ON is administered in systematic fashion – starting from conservative measures: medications, interventions, and, ultimately, surgery. As the natural course of ON may be self-limiting and the pain may improve over time, it may be prudent to avoid risky interventions early on in the course of the disease, but medically-refractory cases (those not yielding to treatment) are often considered for invasive treatments as the pain may become disabling and making risks of interventional or surgical treatment justified.

The common initial treatments include application of cold and warm packs, massage, and physical therapy. Rest also frequently reduces the pain. 

Medication for occipital neuralgia

Among available medications, initial preference is given to conventional anti-inflammatory drugs and muscle relaxants. The next level of treatment would include those commonly used for neuropathic pain conditions- anticonvulsants and antidepressants, including gabapentin, amitriptyline, pregabalin, carbamazepine, and nortriptyline. Although useful in relieving the pain, the opioid medications are to be avoided in ON and other neuropathic pain conditions.

Nerve blocks

The nerve blocks are considered next. Your doctor may use the block or blocks for diagnostic and for therapeutic purposes. Nerve blocks may include both short- and long-lasting local anesthetics; the medications are injected in the vicinity of each suspected nerve, and as a result of injection the territory that the nerve supplies becomes temporarily numb. Along with numbness, patients experience improvement or complete relief of their ON pain, but duration of this relief tends to be longer than duration of numbness, and sometimes the pain relief may turn out to be long-lasting or even permanent. This course of events, however, is observed in only a small fraction of ON patients, and therefore the nerve blocks have to be repeated, usually with addition of corticosteroids to the local anesthetics, adding anti-inflammatory effect to the anesthesia.

Other non-surgical treatment options

Other interventional (non-surgical) ON treatment options include injections of botulinum toxin, pulsed radiofrequency treatments, and short-term electrical nerve stimulation (so called percutaneous electrical nerve stimulation or PENS). Each of these interventional modalities is able to provide significant reduction in pain intensity in a majority of ON patients, but the longevity of improvement varies from person to person and permanent pain relief is rarely seen.

Surgery for occipital neuralgia

Surgery is reserved for the most refractory patients who fail to respond to non-surgical treatments and those with intolerable pain who experience pain recurrence after the use of less invasive approaches. Although many specific surgical procedures are available for ON patients, all of them are divided into three main groups: decompression, neuromodulation, and neuro-destruction.

Decompression surgery is based on a presumption that the pain comes from the occipital nerve(s) being compressed along their course through the muscles and fascial layers with additional aggravation from neighboring arteries that are expected to travel next to the nerves. During surgery, the nerves are released at one or several points, usually by cutting the adjacent muscle and fascia, and the additional compression points from the vessels are protected by physical separation of neural and vascular structures.

In case of unsuccessful decompression or if the pain recurs due to scar formation, there is an option to interrupt transmission of painful signals or remove the hyperactive neural structures – this is accomplished by destructive interventions which include neurectomy or neurotomy, ganglionectomy, and rhizotomy that are aimed at the nerves, spinal ganglia, and spinal nerve roots, respectively. All of these interventions are considered established treatment options for ON, but the patients are expected to discuss with their surgeons the associated risks of complications and possibility of improvement, as well as contingency plans in cases of insufficient pain relief or pain recurrence.

A very different approach in treatment of ON is based on pain suppression with electrical stimulation that is delivered by an implanted device. This technique, called occipital nerve stimulation (ONS), was developed in the 1970’s and perfected to its current shape in late 1990’s. It  is now considered a standard approach to the treatment of medically-refractory ON pain. Several years ago, practice guidelines backed by a national neurosurgical society (the Congress of Neurological Surgeons) recommended ONS for ON patients based on evidence gathered through multiple peer-reviewed publications. Despite this, however, ONS remains one of those procedures that require a complicated approval process from most insurance companies.

The surgery for ONS includes implantation of one or two electrodes in the immediate vicinity of the nerve so that the electrical pulses can reach the nerve when the device is activated. During the initial testing period (the trial), the electrodes are connected to an external device to check for the degree of improvement and presence of any side effects; these temporary (externalized) electrodes are usually removed at the end of the trial.

Later on, the implantation of the permanent device involves insertion of both the electrodes and an internal pulse generator that serves as the power source and a “brain” of the ONS system. The devices available for ONS today allow patients to turn stimulation on and off, make it stronger and weaker, adjust settings, and switch between different programs based on pattern and severity of their pain.  All of this is done with an external “remote control” that communicates with the implanted generator using telemetry. Among multiple generators and systems available for ONS today there are some devices that are rechargeable and can last, with proper recharging, up to 15 years.

No surgical treatment of ON is perfect – each modality has its own set of risks and limitations – but with proper diagnostic evaluation and clear expectations of treatment it is possible to achieve lasting pain relief, so the diagnosis of ON should not be considered a lifelong burden but rather a treatable condition that can be improved and potentially cured as long as there is a well-informed patient and a team of experienced physicians and surgeons.

By Konstantin V. Slavin, MD, FAANS

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