Occipital Neuralgia

Abstract

Occipital neuralgia is usually the result of blunt trauma to the greater and lesser occipital nerves. Less commonly, repetitive microtrauma from working with the neck hyperextended or looking for prolonged periods at a computer monitor whose focal point is too high, thus extending the cervical spine, may also cause occipital neuralgia. Occipital neuralgia is characterized by persistent pain at the base of the skull with occasional sudden, shocklike paresthesias in the distribution of the greater and lesser occipital nerves. Tension-type headache, which is much more common, occasionally mimics the pain of occipital neuralgia. The treatment of occipital neuralgia consists primarily of neural blockade with local anesthetic and steroid, combined with the judicious use of nonsteroidal antiinflammatory drugs, muscle relaxants, tricyclic antidepressants, and physical therapy.

Keywords

occipital neuralgia, tension-type headache, occipital nerve, brain tumor, cervical spine, tricylic antidepressants, occipital nerve blocks, cervical epidural blocks

ICD-10 CODE M53.82

The Clinical Syndrome

Occipital neuralgia is usually the result of blunt trauma to the greater and lesser occipital nerves ( Fig. 7.1 ). The greater occipital nerve arises from fibers of the dorsal primary ramus of the second cervical nerve and, to a lesser extent, from fibers of the third cervical nerve. The greater occipital nerve pierces the fascia just below the superior nuchal ridge, along with the occipital artery. It supplies the medial portion of the posterior scalp as far anterior as the vertex. The lesser occipital nerve arises from the ventral primary rami of the second and third cervical nerves. The lesser occipital nerve passes superiorly along the posterior border of the sternocleidomastoid muscle and divides into cutaneous branches that innervate the lateral portion of the posterior scalp and the cranial surface of the pinna of the ear.

Less commonly, repetitive microtrauma from working with the neck hyperextended (e.g., painting ceilings) or looking for prolonged periods at a computer monitor whose focal point is too high, thus extending the cervical spine, may also cause occipital neuralgia. Occipital neuralgia is characterized by persistent pain at the base of the skull with occasional sudden, shocklike paresthesias in the distribution of the greater and lesser occipital nerves. Tension-type headache, which is much more common, occasionally mimics the pain of occipital neuralgia.

Signs and Symptoms

A patient suffering from occipital neuralgia experiences neuritic pain in the distribution of the greater and lesser occipital nerves when the nerves are palpated at the level of the nuchal ridge. Some patients can elicit pain with rotation or lateral bending of the cervical spine.

Testing

No specific test exists for occipital neuralgia. Testing is aimed primarily at identifying an occult pathologic process or other diseases that may mimic occipital neuralgia (see “ Differential Diagnosis ”). All patients with the recent onset of headache thought to be occipital neuralgia should undergo magnetic resonance imaging (MRI) of the brain and cervical spine. MRI should also be performed in patients with previously stable occipital neuralgia who have experienced a recent change in headache symptoms. Computed tomography scanning of the brain and cervical spine may also be useful in identifying intracranial disease that may mimic the symptoms of occipital neuralgia ( Fig. 7.2 ). Screening laboratory tests consisting of a complete blood count, erythrocyte sedimentation rate, and automated blood chemistry should be performed if the diagnosis of occipital neuralgia is in question.