What is a neuralgia?

The term neuralgia refers to inflammation of a nerve, and this can be any nerve or several nerves anywhere in the body.  The causes of neuralgia can vary from viral infection to trauma causing an inflammatory response, just like any part of the body would react to a traumatic event.  Neuralgias can be acute or chronic.  Acute neuralgia is limited by time and usually has a specific cause that when treated, allows the nerve to return to its normal state.  Chronic neuralgia is a long term inflammation of the nerve which often comes from repeated or ongoing injury.

What is occipital neuralgia?

Occipital neuralgia refers to an inflammation of the occipital nerves, found in the back of the head and neck.  There are three pairs of occipital nerves that commonly suffer from inflammation: the two Greater Occipital Nerves (GON) are found on each side of the upper neck at the base of the back of the scalp, the Third Occipital Nerves (TON) are found a few centimeters below the GON, and the Lesser Occipital Nerves (LON) are found on each side of the neck a few centimeters below the back of the ear.  Each of these nerves are sensory nerves, meaning they supply sensation (feeling) to part of the skin in the back and side of the head.  Though the GON is a large nerve that supplies sensation to most of the back of the scalp, the TON and LON supply sensation to only small areas about the size of a silver dollar each.

Occipital neuralgia refers to the inflammation of one or more of these occipital nerves and is often a chronic neuralgia that lasts for long periods of time.  While there can be many causes of occipital neuralgia, this condition occurs most commonly from the tightness of the tissues around the nerve in the back of the neck.  There are often tight bands of connective tissue that are pushing on the nerve, and a blood vessel, called the Occipital Artery, is often crossing the greater occipital nerve and putting further pressure on the nerve itself.  Muscles in the back of the neck are also a frequent problem.  Often the story in occipital neuralgia patients includes a history of whiplash.  This injury may have caused a small muscle tear that healed with normal scar tissue, but that scar tissue can push on the nerve causing chronic irritation.  Most occipital neuralgia patients cannot pinpoint a specific injury, though some certainly can.  

Because of tight tissues around these nerves, the repeated and often constant pressure on the nerve causes a chronic inflammation (chronic neuralgia).  In response to the nerve irritation, the muscles around the nerve tense up further, and this causes more irritation of the nerve…  A circular mechanism of chronic pain develops in many patients who suffer from occipital neuralgia.

What are the symptoms of occipital neuralgia?

Occipital neuralgia most often produces a pain syndrome that feels like a tightness, soreness, and pain in the back of the head and upper neck and then spreads upwards to a severe headache on one or both sides and back of the head.  Because pain is such a subjective sensation, different people may feel the symptoms of occipital neuralgia in different ways.  Sensations of throbbing may occur and this is often because the occipital artery, mentioned above, is crossing the greater occipital nerve.  With each heartbeat, the pressure in this artery increases and that pressure is transferred to the nerve, which produces a throbbing pain.  In other patients, shock-like or stabbing sensations may occur.  Still others feel a chronic ache in the upper neck..

Nearly all patients with clinically significant occipital neuralgia report some type of headache.  Patients may report “trigger points” in the neck or upper shoulders where knots of muscle can be felt from the tension that the irritated nerve produces.  Because of the severe headache component of occipital neuralgia, a large number of patients suffering from this condition carry a diagnosis of migraine headache, or a variant thereof.  Chronic migraine, status migrainosus, chronic headache, and tension headaches are all diagnoses that can be given to patients where the root cause of their pain is occipital neuralgia.

The diagnosis an misdiagnosis of occipital neuralgia

Initially, the diagnosis of occipital neuralgia is one of exclusion.  This means that patients come in with severe headaches and/or neck pain, and their workup does not show anything that would cause these issues.  Nearly all patients undergo an MRI of the head to make sure there are no lesions within the skull to cause a headache.  BECAUSE NONE OF THE OCCIPITAL NERVES ARE USUALLY SEEN ON MRI, THERE ARE NO IMAGING STUDIES THAT CAN MAKE THE DIAGNOSIS OF OCCIPITAL NEURALGIA.  This is an important point. Many patients think that because their studies don’t show a problem then there cannot be a specific reason for their pain, and this is not true. 

Another frequent occurrence surrounds a misdiagnosis of cervical spine disease.  Many, if not most adults have some degree of changes in their cervical spine when imaged with CT or MRI.  While it is possible that these spinal issues are causing impingement of the nerve roots which are causing the pain, it is very frequent that occipital neuralgia patients have had spinal fusion or spinal decompression and yet their pain persists.  This is because the irritation of the nerve is not at the spinal cord, but instead in the soft tissue and muscle of the head and neck, and manipulation of the spine does not solve the problem.

So how is the diagnosis of occipital neuralgia made?  To know for certain that the occipital nerves are the cause of pain, a nerve block must be performed at the nerve itself.  A diagnostic nerve block is performed with local anesthesia such as lidocaine, and this is done in the doctor’s office and takes about 5 minutes.  These injections are often confused with Botox injections or steroid injections, which are therapeutic injections and may or may not work even in cases of true occipital neuralgia (more about this can be found here.)  A diagnostic nerve block uses lidocaine because this drug quickly deactivates the nerve, though only for a short time.  After a few minutes, a patient with occipital neuralgia who has had this diagnostic nerve block will feel a significant improvement in their pain.  This is because this fast-acting drug has shut off the nerve itself, preventing the nerve from transmitting the irritation signals that are produced by the neuralgia.  This short term pain relief following this type of nerve block is diagnostic for occipital neuralgia.

Who treats occipital neuralgia?

The use of treatments including physical therapy, acupuncture, and some non-traditional modalities may be helpful in the treatment of occipital neuralgia.  There are many different types of doctors that treat occipital neuralgia, and often this is the case because the occipital neuralgia has been misdiagnosed as migraine or some other type of headache.  Many patients with occipital neuralgia see only their primary care doctor who prescribes pain relievers or migraine medication.  Worse yet, many patients are only seen in acute care settings such as the emergency room or urgent care, where a diagnosis as complex as occipital neuralgia is not even considered.

In other cases, occipital neuralgia patients are cared for neurologists who may or may not have made the diagnosis.  Many patients at the neurologist are chronically treated for headaches or migraines.  Other neurologists who have made the correct diagnosis may treat their patients with medications.  Often, when these medications are not helpful, a referral to a pain specialist occurs.  These pain doctors are yet other physicians who may be treating occipital neuralgia, or trying to treat other headache diagnoses in these patients.

Primary care doctors, urgent care and emergency room doctors, neurologists and pain specialists are all involved together in many severe cases of occipital neuralgia, though their treatments most often involve medications or minimally invasive procedures.  The last type of doctor that treats occipital neuralgia is the migraine surgeon.  These doctors are most often plastic surgeons with a specific interest in microvascular nerve decompression.  This term refers to the tiny blood vessels and nerves that specialized plastic surgeons are trained to operate on using high magnification and extremely delicate instruments.  These are often not the plastic surgeons who the average person thinks of as doing facelifts and breast implants (though many do both as well.)  Because of their expertise and familiarity with small blood vessels and peripheral nerves, these specialized surgeons are most experienced in relieving nerve inflammation and irritation from surrounding tissues.

How is occipital neuralgia treated?

Occipital neuralgia treatments vary from doctor to doctor and patient to patient.  While many primary care doctors are familiar with the different migraine drugs and use them commonly, some primary care doctors and those in more urgent care settings may use medications such as narcotics to try to treat the pain.  This is becoming less frequent with the current societal concerns regarding narcotic dependency, and for good reason.  Even though some patients may be cured from occipital neuralgia, a patient who has developed a dependency on narcotics may find weaning off of these drugs can be as problematic as the pain itself.

Neurologists and primary care doctors familiar with these neuralgias will often use specialized medications to treat patients with occipital neuralgia.  Drugs that work primarily on nerves themselves, such as Neurontin, may be utilized.  Some patients do respond to migraine medications, such as drugs in the triptan family, and the use of these medications is often “abortive.”  An abortive drug means that the drug is taken once the pain begins, in order to stop the pain from getting worse.  Beta blockers, antidepressants, and other medication may also be used in occipital neuralgia patients to try to prevent pain in the first place.  These drugs sometimes have a beneficial effect in migraine sufferers, and the two diagnoses are often confused.  Similarly, Botox may be used by neurologists in the standard fashion recommended for the treatment of migraine headaches.  Because some occipital neuralgia patients do have a muscular component to their nerve compression, this may work in some patients.  But because of the less specific locations of these Botox injections, a frequent story from occipital neuralgia patients is that the Botox works only sometimes.  Other occipital neuralgia patients who have nerve irritation from connective tissue or blood vessels crossing the nerves will have no response to Botox at all.

Pain specialists have other means of trying to treat occipital neuralgia, though Botox may also be used by these doctors.  Nerve stimulators, radiofrequency ablation, cryotherapy, and steroid nerve blocks are all minimally invasive means to try to attack the occipital neuralgia.  In those patients where these or less invasive modalities work, the patient receives a periodic improvement in their pain and thus a successful though often temporary solution to their discomfort.

Occipital neuralgia patients who end up in the migraine surgeon’s office are most often those who have failed more conservative therapies.  Many such patients have a long history of medications, imaging studies, and minimally invasive attempts at pain control which have all failed.  Many of these patients have all but given up on living a normal life, as the emotional aspect of occipital neuralgia can be devastating.  And because non-surgical doctors are often skeptical of surgery, most patients who bring the option of microvascular decompression up to their primary care doctor, neurologist, or pain doctor, are discouraged from seeing a surgeon.  Most of these other doctors are unfortunately unaware of the extensive studies and long term success that migraine surgery can have on occipital neuralgia.

The surgical treatment of occipital neuralgia

Microvascular decompression of the occipital nerves is most often called “Migraine Surgery,”  This is because other nerves in the face and temple region can also have neuralgias and be the cause of true migraine headaches, and the same procedures performed in the decompression of occipital nerves are used to surgically treat patients with migraine headaches.  Whichever nerves are being treated, the concept of nerve decompression for neuralgia remains the same.  These surgeries are aimed at preventing acute and/or ongoing irritation to the nerves from the surrounding tissues and structures. 

In the case of occipital neuralgia, as discussed earlier, there can be tight muscle, connective tissue, or blood vessels that constrict one or more occipital nerves.  Using well-hidden incisions, the migraine surgeon dissects down to the problematic nerve using fine instruments created specifically for delicate surgery.  Once the nerve is found it is traced toward its origin (proximally) and out toward its terminal branches (distally).  While the nerve is being dissected, each area of potential compression is released.  The occipital artery or any other small blood vessels crossing the nerve is divided.  Connective tissue or scar that is causing compression or kinking of the nerve is removed, and a channel is created in the surrounding muscle so that compression of the muscle no longer pushes on the nerve.  Additionally, a piece of fat is often placed next to the nerve in order to cushion it from surrounding tissue.  Because the surrounding tissue is no longer able to compress and irritate the nerve, the neuralgia is relieved and the pain most often improves as the nerve function returns to normal. 

In some cases, particularly in dealing with the smaller TON and LON, the nerve may be cut intentionally.  Because the area of numbness produced by eliminating these minor nerves is so small, the loss of feeling from cutting these nerves is most often not even be noticed by the patient.  It is rare to divide the larger GON because of the larger area of the scalp that it supplies sensation for, though in severe cases even these nerves may be cut.  Divided nerves can no longer transmit irritated nerve signals to the brain, and thus the pain is often relieved.  Importantly, experienced nerve surgeons know that the cut ends of nerves must be buried in nearby muscle to avoid the formation of a nerve scar (also called a neuroma.)

The surgical treatment for occipital neuralgia is most often an outpatient surgery and usually takes an experienced surgeon about 3 hours if all three nerves on both sides of the head and neck are involved.  If fewer nerves are involved, the surgery is shorter.  Recovery can take a bit of time because of the manipulation of muscle tissue involved in creating a channel for the nerve to lie in.  After a few weeks, however, patients are most often back to their life, and usually in a much more normal fashion as before surgery since their neuralgia pain is often significantly improved or eliminated.  The results of surgery for occipital neuralgia should be permanent.

There are few risks involved in migraine surgery.  In about 7% of cases, the procedure is unsuccessful.  In some of these patients, normal healing can produce some scar tissue that creates recurrent nerve compression.  In these few cases, a revision operation may be necessary and is most often successful in resolving the issue.  Persistent numbness is possible and rarely problematic.  Scarring is often hidden within the hair and not of concern. 

Occipital Neuralgia is often treatable, and surgical treatment of occipital neuralgia is often successful

No matter what the course of action taken by an occipital neuralgia patient, it is important to remember that this condition is often treatable by specialized doctors, and in many cases can be cured with surgery if less invasive measures fail.  It is important for head and neck pain patients to be their own advocates, as the diagnosis of occipital neuralgia may be overlooked or the diagnosis may be made late in the game, after ongoing suffering.  Education of the patient population as to their options must be the first step toward the relief of pain in occipital neuralgia patients.

If you have or suspect a diagnosis of occipital neuralgia, contact us at the Migraine Surgery Specialty Center where Dr. Lowenstein commonly educates and operates on patients with this condition.  As Dr. Lowenstein himself has suffered from occipital neuralgia, you are unlikely to find a physician as personally familiar with this illness nor as dedicated to the improvement of occipital neuralgia pain.

FAQs: Occipital Neuralgia

  • What is occipital neuralgia?

    Occipital neuralgia is an inflammation of the occipital nerves. There are three principal occipital nerves in the back of the neck and head- the greater occipital nerve (GON), the lessor occipital nerve (LON), and the third occipital nerve (TON). The inflammation of occipital neuralgia may involve any or all of these nerves.
  • What causes inflammation of the occipital nerves in occipital neuralgia?

    Inflammation can be caused by many different things, but in most cases it is compression of one form or another that causes inflammation in occipital neuralgia. While a local mass or tumor is a rare reason for this compression, most occipital neuralgia is caused by compression by muscles, small bands of fascia (connective tissue), or often blood vessels. The sensation of pulsating pain that many occipital neuralgia patients experience is often a manifestation of a pulsating artery that is pushing on one of the occipital nerves and causing pulsating pain.
  • What are symptoms of occipital neuralgia?

    Occipital neuralgia patients most often complain of pain which can be quite severe and debilitating, but a great many symptoms may accompany headaches in occipital neuralgia. Paresthesias, or strange sensations in the head and neck region are often experienced and can be accompanied by pain in the extremities and face. Nausea, vomiting, and dizziness are frequent symptoms of occipital neuralgia. Tinnitus or ringing in the ears can occur with or without pain, as the other symptoms can similarly come and go in an irregular fashion.
  • How is trauma related to occipital neuralgia?

    Traumatic injury of the head and neck is in many instances the instigating factor in the onset of occipital neuralgia. The whiplash injury of a car accident is a classic manner in which trauma can cause chronic inflammation of the occipital nerves. The sudden stretch of the nerve may cause direct inflammatory damage to any of the occipital nerves, but adjacent injury to muscle and connective tissue can cause swelling and compression of adjacent structures- including the nearby occipital nerves. Other issues, such as injury to the spine or nerve roots can also come from these types of injuries and must be evaluated when post-traumatic pain is experienced in the head and neck.
  • How is occipital neuralgia diagnosed?

    Occipital neuralgia is often a diagnosis of exclusion, meaning that when other causes of pain are ruled out, occipital neuralgia is then sometimes felt to be the cause. In fact, a very good diagnostic test for occipital neuralgia involves nerve blocks to the affected nerves. In most cases, a local anesthesia is injected at one of the nerves on either or both sides of the neck, and following a few minutes the patient’s pain is re-assessed. If the pain is improved but not gone, a second nerve is blocked. The third nerve can then be blocked if further improvement is sought. Successful reduction in pain by a nerve block is diagnostic for occipital neuralgia and also an indication that surgical decompression or disruption of the occipital nerves is likely to provide improvement or complete elimination of the patient’s symptoms.
  • How is occipital neuralgia treated?

    The pain and symptoms of occipital neuralgia are usually first treated with medications. Similar to the treatment of migraine headaches, drugs such as serotonin inhibitors, anti-convulsants, and anti-depressents are often used to try to control occipital neuralgia. Since non-narcotic pain medications such as Tylenol, aspirin and Motrin are often not successful, patients are sometimes started on narcotics to try to deal with occipital neuralgia pain. The difficulty with narcotic addiction and the need for increasing doses to achieve pain relief are extremely problematic and can lead to secondary and life threatening issues.If muscle constriction is primarily implicated in occipital neuralgia, the injection of Botox may allow for localized weakness of the tight muscles and can be helpful in providing medium range relief for occipital neuralgia pain. Botox mediated relief can be expected to last one to three months before needing to be repeated. Similarly, some patients experience improvement of their occipital neuralgia symptoms with injection of steroids around the nerves. Since steroids are known to decrease inflammation, it is felt that this type of injection lessens the inflammation at and around the nerves leading to improvement. Some patients may have nerve stimulators placed around the nerve to try to create an over-stimulation of the effected nerve. This overstimulation actually can prevent the nerve from transferring pain sensation and can be an effective way to reduce occipital neuralgia pain. Unfortunately these nerve stimulators are often placed by non-surgeons who may not be routinely locating the nerves. Because of the variability of the anatomy of the occipital nerves, such stimulators are often placed distant from the effected nerve and thus result in an unsuccessful outcome.
  • When and how is surgery effective for the treatment of occipital neuralgia?

    Surgery for occipital neuralgia is most often left as the last option for occipital neuralgia patients. When less invasive treatments are successful, the surgical option is not felt to be needed. For many patients who still have pain and other occipital neuralgia symptoms despite less invasive treatments, Dr. Lowenstein’s surgery for occipital neuralgia can provide lasting and often permanent improvement or relief. The surgical plan is dictated by pre-operative nerve blocks which show which nerves need to be manipulated. While sometimes only one or two nerves on one side of the neck need to be addressed, sometimes all three nerves on both sides are operated upon. The surgery is performed under general anesthetic in the prone, or face down position, and one to three incisions are used to gain access to the affected nerves. Depending on the condition of the nerves when they are identified, the nerves may be released of their surrounding compression, or they may be divided to prevent their further conduction of painful signals. Surgery for occipital neuralgia often takes one to three hours depending on the number and condition of the nerves to be addressed.
  • What are the expectations following surgery at Dr. Lowenstein’s Headache Center?

    Because surgery involves manipulation of the nerves themselves as well as the surrounding structures, patients may experience anything from immediate relief to temporary worsening of their symptoms. Variability in the improvement of the occipital neuralgia symptoms are not unusual for the first months following occipital neuralgia surgery, but in recent studies nearly 90% of patients experience long term improvement if not complete alleviation of their pain following occipital nerve surgery.

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