What is occipital neuralgia?
Most 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 greater 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 of these nerves anywhere along its course can cause a shooting, zapping, electric, or tingling pain very similar to that of trigeminal neuralgia, only with symptoms 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 because 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?
There is not one test to diagnose occipital neuralgia. Your doctor may make a diagnosis using a physical examination to find tenderness in response to pressure along your occipital nerve. Your doctor may diagnose — and temporarily treat — with an occipital nerve block. Relief with a nerve block may help to confirm the diagnosis. For patients who do well with this temporary “deadening” of the nerve, a more permanent procedure may be a good option.
How common is occipital neuralgia?
True isolated occipital neuralgia is actually quite rare. However, many other types of headaches —especially migraines — can predominantly or repeatedly involve the back of the head on one particular side, inflaming the greater occipital nerve on the involved side and causing confusion as to the actual diagnosis. These patients are generally diagnosed as having migraines involving the greater occipital nerve, rather than as having occipital neuralgia itself.
Medications and a set of three steroid injections, with or without botulinum toxin, can “calm down” the overactive nerves. Some patients respond well to non-invasive therapy and may not require surgery; however, some patients do not get relief and may eventually require surgical treatment.
There are other treatment options such as burning the nerve with a radio-wave probe or eliminating the nerve with a small dose of toxin. However, these are not always the best choice since either treatment can permanently deaden the nerve, resulting in scalp numbness.
Surgical options include decompression of the greater occipital nerves along their course, called occipital release surgery.
In this outpatient procedure, the surgeon makes an incision in the back of the neck to expose the greater occipital nerves and release them from the surrounding connective tissue and muscles that may be compressing them. The surgeon can address other nerves that may be contributing to the problem, such as the lesser occipital nerves and the dorsal occipital nerves.
The surgery generally takes around two or three hours and is performed with the patient asleep under general anesthesia. Patients are able to go home the same day, and full recovery is generally expected within one or two weeks.
In some cases, occipital release surgery only works temporarily, and the pain returns. Further surgery to cut the greater occipital nerves can be performed after about a year, however, this procedure is regarded as a last resort since it would result in permanent scalp numbness.