Occipital neuralgia is characterized by pain in the suboccipital region and in the back of the head. A large number of patients have muscle tension headaches in the same distribution, but few of these patients have a true neuralgic pain.
Known causes of neuralgic pains in this area include trauma to the greater or lesser occipital nerves, compression of these nerves or the upper cervical roots by arthritic changes in the spine, and tumors involving the 2nd and 3rd cervical dorsal roots.
Signs and Symptoms
Continuous aching and throbbing pain on which shock-like jabs can be superimposed characterize occipital neuralgia. The pain is not triggered, but pressure over the occipital nerves can lead to an exacerbation. Both physical and emotional tension is common precipitating factors.
The region of the pain clearly establishes the diagnosis: the difficult task is determined whether the nerve lesion is primary or secondary. Vascular pains (migraine in the posterior scalp, or cluster headaches in the anterior scalp and face) are usually characterized by discrete attacks of throbbing pain, often associated with nausea and vomiting and other autonomic phenomena. Migraine is often terminated by ergot alkaloids; neuralgic pains are not. Muscle tension headaches are a variant of myofascial pain syndrome and are common. They are clearly stress-related. The patient usually has a long history of such headaches, which wax and wane over the years. Tender areas in the suboccipital muscles are frequently located by palpation. Positive finding from neurological examination lead to the suspicion of a structural lesion; roentgenography or CT scan assists in the diagnosis.
Obviously, when occipital neuralgia has a structural basis, treatment is aimed at the cause. In most patients, however, treatment is symptomatic. If the pains resemble those of tic douloureux, a trial of anticonvulsants might be worthwhile. If they resemble those of atypical facial pain, a tricyclic antidepressant and a phenothiazine can be tried. Local nerve blocks can help to establish the diagnosis and sometimes provide even longer relief than the duration of the agent used. Some have advocated the injection of local anesthetics and steroids, but controlled studies of the outcomes of such treatments have not been undertaken. Neurosurgeons have advocated sectioning of the 2nd and 3rd cervical roots or the greater and lesser occipital nerves. Information on the efficacy of these procedures is lacking; the vast majority of patients do not appear to require a surgical procedure.
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