Two Pains, One Mechanism
Carpal tunnel syndrome is widely understood, both by physicians and the general public. A nerve is compressed at the wrist, leading to pain, numbness, tingling, and functional impairment in the hand. The median nerve, as it passes through a tight anatomical space, becomes irritated. Symptoms may worsen at night, radiate up the arm, or cause fine motor difficulty. Once diagnosed, treatment is straightforward: brace it, decompress it, or release the pressure surgically. And most importantly, no one questions whether the pain is real.
Now imagine if carpal tunnel syndrome had never been discovered. Imagine if we treated hand pain solely with antidepressants, muscle relaxants, and ergonomic advice. Imagine if patients were told that their normal nerve conduction studies in their arm meant their symptoms were psychosomatic. Imagine if bracing helped some, but others were simply told to live with it. And imagine that the word “carpalgia” was used as a catch-all term for all forms of wrist and hand pain, no matter their origin.
This, in many ways, is what has happened with chronic migraine and occipital neuralgia. Pain that originates from nerve compression has been absorbed into broader diagnoses. Anatomical causes have been overshadowed by biochemical theories. And a simple, physical explanation—like carpal tunnel in the neck—is too often overlooked.
Understanding Compression and Referred Pain
The median nerve in the wrist and the greater occipital nerve at the back of the head have something in common: they are both long, peripheral sensory nerves vulnerable to entrapment. When the median nerve is compressed at the carpal tunnel, it causes pain that radiates into the hand. When the greater occipital nerve is compressed at base of the skull—by muscle, fascia, or connective tissue—it refers pain in the head, often mimicking the distribution of migraine.
In both cases, the pain is real. The origin is anatomical. And the problem is mechanical. But the response from the medical system could not be more different.
With carpal tunnel, we have physical exams that provoke symptoms, diagnostic tests that are trusted, and a wide consensus on treatment strategies. With occipital nerve compression, patients often undergo years of negative scans and inconclusive diagnoses. They are labeled with chronic migraine or tension headache. They may be offered injections or medications, but rarely are they evaluated for whether the nerve itself is physically compressed.
The discrepancy lies not in the nature of the problem, but in our awareness of it.
The Power of Naming and Recognition
Carpal tunnel syndrome benefits from a clear, anatomically based name. It describes both the problem and the location. This clarity empowers diagnosis, education, and referral. It tells both patient and provider: this is something we can understand, and potentially fix.
In contrast, migraine is a term that has grown so broad that it now encompasses a wide array of symptoms and mechanisms. It has become a container diagnosis—used when pain is recurrent, disabling, and unexplained. While migraine as a vascular or neurologic condition certainly exists, the diagnosis is often stretched to include pain that may have a very different origin.
If we named occipital nerve compression something like “cervical neural tunnel syndrome,” perhaps it would receive the same clarity and respect. If a positive response to a nerve block were seen as diagnostic more patients might be steered toward definitive relief. But as it stands, the lack of anatomical emphasis in headache medicine leaves many in the dark.
Misclassification and Consequences
When hand pain is misdiagnosed, the consequences are obvious: delayed treatment, prolonged disability, unnecessary medications. The same holds true for chronic head pain. When patients are misdiagnosed with migraine and the true cause is nerve compression, the outcome is years of ineffective therapies. Medications might dull the pain temporarily, but they don’t remove the source. Patients may be told they have medication-overuse headaches, refractory migraine, or even psychosomatic pain.
This misclassification is not benign. It erodes trust, damages function, and perpetuates suffering. The patient is doing everything right—following instructions, taking medications, avoiding triggers—but the pain persists. In reality, no amount of medication can decompress a nerve, just as no pill can open a pinched carpal tunnel.
The problem lies not in the patient, but in the framework we use to understand their symptoms.
Why Surgical Thinking Matters
Surgical intervention for carpal tunnel is widely accepted because it addresses a clear anatomical problem. The logic is elegant: if the nerve is compressed, release the compression. In the right patient, results are predictable and often permanent.
Occipital nerve decompression surgery follows the same principle. In patients whose symptoms align with known nerve distributions, who experience relief with diagnostic blocks, and whose physical exams reproduce their symptoms, surgical release can dramatically change their lives. The procedure is outpatient. The risks are low. And the outcomes, in the right hands, are compelling.
But unlike carpal tunnel, this surgery remains largely unknown. Patients rarely hear about it from neurologists or primary care providers. Many are told surgery is not appropriate, or that it doesn’t work. Yet those same providers would never hesitate to refer a patient with carpal tunnel to an orthopedic surgeon.
This inconsistency is not clinical—it is cultural.
A Call to Reframe
It is time to reframe how we think about chronic headache. Not every patient with head pain has migraine. Not every case of temple, scalp, or behind-the-eye pain is vascular or hormonal. Some are mechanical. Some are the result of nerves that are physically irritated, compressed, or entrapped.
These cases deserve the same clarity and attention we give to carpal tunnel. They deserve an evaluation that includes palpation of nerve pathways, testing with nerve blocks, and consideration of decompression when appropriate. And most importantly, they deserve to be believed.
The future of headache care lies not just in better drugs, but in better listening. In better naming. In better frameworks for thinking.
Seeing the Pattern, Changing the Outcome
When a patient describes numbness, tingling, and pain in the hand, we think of the wrist. When a patient describes sharp, radiating, pressure-like pain in the head, we should think of the nerves. The logic is no different. The anatomy is just less familiar.
Carpal tunnel syndrome taught us that compressed nerves cause real, tangible pain. That lesson should not be confined to the hand. It belongs at the base of the skull, in the temple, above the orbit. It belongs anywhere a nerve can be pressed and a person can suffer.
It is time to extend the same clarity and compassion to headache sufferers that we offer to those with wrist pain. Because once you recognize the pattern, the path forward becomes obvious. And once you relieve the pressure, the pain doesn’t just improve. It goes away.
If chronic head pain truly stems from nerve compression, then the role of a migraine surgeon becomes not only relevant, but essential. These specialists offer a structural solution where medications fall short—identifying and decompressing the nerves responsible for daily suffering. For patients misdiagnosed or left without answers, partnering with a migraine surgeon can mean the difference between a life of management and one of lasting relief.
