What is Occipital Neuralgia?
Occipital neuralgia (ON) is a condition causing pain at the back of the head, typically affecting one of three nerves: the greater occipital nerve (GON), the lesser occipital nerve (LON), or the third occipital nerve (TON). The pain from this condition can come and go quickly, lasting from a few seconds to a couple of minutes, and is often described as a piercing or stabbing feeling. This type of pain originates directly from an issue with one of these nerves.
It’s crucial that doctors understand the different potential causes (or differential diagnosis) for this condition and the specific criteria used for diagnosing occipital neuralgia. Once diagnosed, there are numerous treatments available, several of which have proven to be highly effective in managing this condition.
What Causes Occipital Neuralgia?
Occipital neuralgia, or ON, is a condition that affects the nerves in the back of the head, causing severe headaches. In about 90% of cases, this pain occurs due to problems with the greater occipital nerves (GON). Approximately 10% of cases result from issues with the lesser occipital nerves (LON), and it’s rare for the third occipital nerves (TON) to be involved. This pain usually happens when one of these nerves is squeezed at certain points in the anatomy of your head.
According to the third edition of the International Classification of Headache Disorders (ICHD-3), most traditional neuralgias, or nerve pains, are no longer believed to come from primary nerve problems. This might be due to conditions like herpes zoster (shingles), other infections, or demyelinating lesions, which are damaging spots on the protective cover of nerve fibers.
Infrequently, other sensory nerves in the skin can cross over into the typical area served by the occipital nerves. There was one instance where the suboccipital nerve, which is another nerve in the back of your head, provided a skin branch in the normal area of the greater occipital nerve. Differences like this one could contribute to unrelenting neuralgia, or nerve pain, in that region.
Risk Factors and Frequency for Occipital Neuralgia
In a research study done in the Netherlands, they found that 8.3% of people with facial pain had a condition called ON. This condition occurs in about 3.2 out of every 100,000 people. The average age when people are diagnosed with this is 54.1 years.
Signs and Symptoms of Occipital Neuralgia
Occipital neuralgia, abbreviated as ON, is a condition that often starts as a headache at the back of the head. It’s important to check for this condition if you experience this type of headache. Characteristics of ON include sudden, sharp or stabbing pain that lasts for a few seconds to minutes. Continuous, dull pain generally points to a different health issue. There are criteria to diagnose ON. in addition to headaches, you should also experience sensitivity, altered sensation, or discomfort in the affected area. You might also find that tapping over the nerve’s path, especially where it emerges at the base of the skull, triggers symptoms. This is known as a positive Tinel’s sign. The pain from ON can be on one or both sides, but it usually starts on one side and then might extend to both over time. Approximately one-third of patients with ON experience symptoms on both sides.
These symptoms of ON include:
- Headache originates at the back of the head
- Sudden, sharp or stabbing pain lasting from seconds to minutes
- Sensitivity, altered sensation, or discomfort in the affected area
- Positive Tinel’s sign (pain triggered by tapping over the nerve’s path)
- Pain usually starts on one side but can extend to both sides over time
Testing for Occipital Neuralgia
Once your doctor has collected a summary of your health history and completed a physical check-up, they may diagnose your condition by numbing the nerve that they think is causing you problems. They do this using a local anesthetic, which is a medicine that causes temporary numbness. Under the guidelines set by the International Classification of Headache Disorders (ICHD-3), this step is necessary to confirm the diagnosis.
You should feel relief from your pain for at least the same amount of time that the local anesthetic normally lasts. However, keep in mind that single tests like this can sometimes give ‘false positives’ or inaccurate results up to 40% of the time, making it seem like you have the condition even if you don’t. That’s why it’s wise to do this numbing test a second time. If both tests show the same results, your doctor will be more sure of their diagnosis.
Since pain in the nerve (occipital neuralgia or ON) is usually caused by pressure, your doctor might also want to take pictures of the area in question with a scanner, especially if there’s a chance an abnormal growth or lesion may be affecting the nerve.
Treatment Options for Occipital Neuralgia
There are several ways to treat occipital neuralgia (ON). The simplest treatments, like immobilizing your neck with a collar, physical therapy, and using cold therapy, haven’t been proven to be much better than a placebo (a treatment that won’t affect the condition but can make you think you’re getting better).
Medications like non-steroidal anti-inflammatory drugs, antidepressants, serotonin-norepinephrine reuptake inhibitors (which regulate chemicals in the brain), and anticonvulsants (which can relax your muscles) can help reduce symptoms. There’s also a treatment where doctors use anaesthetic to block the nerves that are causing your pain, and they sometimes add a steroid to it, though this has given varied results. Botox injections are another treatment option which could cause fewer side effects than many other techniques.
Doctors might use an approach based on physical landmarks on your body to block the nerves causing your pain. This method is fairly easy to do and fairly safe just as long as careful planning is done. However, it may not be particularly reliable, and it could increase the risk of a false positive result (meaning, the test says you have the condition but you actually don’t). To make sure the procedure is more precise, doctors can use ultrasound-guided techniques.
There are more advanced treatments for ON:
* Doctors could consider using radiofrequency ablation (RFA), which uses heat to destroy the nerves causing pain, after a local anaesthetic block confirms the diagnosis. While this could bring long-term pain relief, it may also lead to a sharp sensitivity to sensory stimuli, numbness, constant pain, and painful lump of nerve tissue. Another option is chemical neurolysis, which uses chemicals like alcohol to destroy the nerve, but it carries the same risks as thermal RFA.
* Neuromodulation is a procedure where doctors place nerve stimulator leads at the base of your skull where the occipital nerve emerges. To test if this treatment could work for a patient, temporary leads are first used, and if they provide more than 50% pain relief for several days, permanent leads may eventually be implanted. However, there may be risks like surgical site infection or the leads moving around or breaking after the operation.
* Cryoablation is a treatment done by clinicians where, using an ultrasound guide, they apply cold to the nerves to stun them but not cause permanent damage.
Last but not least, surgery should only be considered once all other treatment options have been explored and found not to work. However, according to a study, most patients have felt significant pain relief after the operation. Other surgical techniques that have been shown to be effective include partial removal of a muscle in the neck that, when flexed, can cause pain, and C2 gangliotomy, a process that removes a bundle of nerve cells in the neck, even though it can cause a few days of intermittent nausea and dizziness.
What else can Occipital Neuralgia be?
Occipital neuralgia (ON) is a condition that can be mistaken for other disorders that also cause headaches or facial pain. This is due to the fact that the occipital nerves are connected to several cranial nerves, and this can lead to a range of symptoms like difficulty seeing, feeling dizzy, or having a blocked nose.
The conditions that are often confused with occipital neuralgia include:
- Migraines
- Cluster headaches
- Tension headaches
- Hemicrania continua (a type of severe headache)
Another source of confusion can be neck pain that originates from the upper disc, facet, or the muscles and ligaments in the neck. This pain can be referred to the back of the head (occiput) but doesn’t cause the classic sharp, neuropathic pain seen in occipital neuralgia.
An important step to correctly identify ON from other disorders is to see if the pain is relieved with an occipital nerve block, a type of pain relief treatment.
What to expect with Occipital Neuralgia
Basic intervention treatments often offer short-term relief. Occasionally, diagnosis injections made of local anesthetic, with or without added steroids, can provide pain relief for up to several months. The more advanced treatments described above can lead to improved conditions that last anywhere from weeks to years.
Possible Complications When Diagnosed with Occipital Neuralgia
Reports have been published about complications arising from medical procedures. One study examined more than a hundred patients who went through a specific procedure called thermal Radiofrequency Ablation (RFA). Unfortunately, one patient experienced severe internal bleeding within the brain and tragically passed away. The doctors believe that high blood pressure during the procedure may have been the cause. In the same study, another patient developed a condition called Brown-Sequard syndrome due to a spinal cord injury after the RFA procedure.
Common Complications:
- Internal bleeding in the brain
- High blood pressure during procedures
- Brown-Sequard syndrome due to spinal cord injury
Preventing Occipital Neuralgia
Like all health conditions, it’s essential that patients fully understand their diagnosis, the tests that might be conducted, any medication that could be prescribed, and any treatment options that might be recommended. The explanation of these things should be in simple language that suits the patient’s education level and background. It’s also crucial to consider the patient’s lifestyle and how their condition and any possible treatment might impact it.
The pros and cons of every medication or treatment should be clearly explained, as well as any other options that might be available. It’s important that doctors and patients work together to make decisions about their healthcare. This approach ensures that medical decisions take the patient’s circumstances and wishes into account, making the treatment plan more personalized and effective.
