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Occipital Neuralgia

What is occipital neuralgia?

Most of the feeling in the back and top of the head is transmitted to the brain by the two greater occipital nerves. There is one nerve on each side of the head. Emerging from between bones of the spine in the upper neck, the two occipital nerves make their way through muscles at the back of the head and into the scalp. They sometimes reach nearly as far forward as the forehead, but do not cover the face or the area near the ears; other nerves supply these regions.

Irritation of one these nerves anywhere along their course can cause a shooting, zapping, electric, or tingling pain very similar to that of trigeminal neuralgia, only with symptoms located on one side of the scalp rather than in the face. Sometimes the pain can also seem to shoot forward (“radiate”) toward one eye. In some patients the scalp becomes extremely sensitive to even the lightest touch, making washing the hair or lying on a pillow nearly impossible. In other patients there may be numbness in the affected area. The region where the nerves enter the scalp may be extremely tender.

What causes occipital neuralgia?

Occipital Neuralgia may occur spontaneously, or as the result of a pinched nerve root in the neck (from arthritis, for example), or as the result of prior injury or surgery to the scalp or skull. Sometimes “tight” muscles at the back of the head can entrap the nerves.

How is occipital neuralgia diagnosed?

Occipital neuralgia can be diagnosed—and temporarily treated—by an occipital nerve block. For patients who do well with this temporary “deadening” of the nerve, a more permanent procedure may be a good option. These treatments include cutting the nerve surgically, “burning” the nerve with a radio-wave probe, or eliminating the nerve with a small dose of an injected toxin.

Obviously any procedure that deadens the nerve permanently is likely to leave some degree of permanent numbness in the scalp. A few patients may do well with procedures that “spare” the affected occipital nerve—a surgeon could decompress the nerve by removing any impinging muscles or scar tissue, or a pain specialist could implant an occipital nerve stimulator, a pacemaker-like device that stimulates the nerve with electricity resulting in tingling rather than pain.

Because all of these procedures are invasive, carrying some degree of risk of permanent complication, we generally first try to use medications to “calm down” the over-active nerves. Some patients respond quite nicely to non-invasive therapy.

How prevalent is occipital neuralgia?

True isolated occipital neuralgia is actually quite rare. However many other types of headaches —especially migraines — can predominately or repeatedly involve the back of the head on the one particular side, inflaming the greater occipital nerve on the involved side and causing confusion as to the actual diagnosis. We generally refer to these patients as having migraines involving the greater occipital nerve, rather than as having occipital neuralgia itself.

If a migraine patient has headaches exclusively at the back of the scalp at one side, it may be tempting to perform one of the above permanent procedures to quickly “fix” the problem. Since migraines are thought to be due to a problem in the patient’s brain, however, and not the nerve itself, after a procedure it is possible that these patients might discover that their headaches have moved to another location, or that there is some improvement in pain but continued episodes of nausea, light-sensitivity, etc. We therefore only rarely recommend these procedures in migraine patients, especially since there have been no scientific studies proving that they work over the long haul.

If a patient’s pain does not reliably improve with occipital nerve blocks, we do not recommend proceeding with any of the more drastic measures.

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