Introduction: A Familiar Pain With an Overlooked Origin
Tension-type headache is among the most common diagnoses in medicine. Characterized by a bilateral, pressure-like sensation—often described as a “tight band” around the head—it is typically chalked up to stress, poor posture, sleep disturbance, or emotional strain. And while these factors may contribute to discomfort, they are not always the root cause. In fact, what many patients—and even many clinicians—consider to be a tension headache is something far more specific, anatomical, and treatable: occipital neuralgia.
Occipital neuralgia is a condition in which the greater and/or lesser occipital nerves become irritated or compressed as they travel from the upper cervical spine through the muscles and fascia at the back of the head. The result is a distinctive pattern of pain that overlaps significantly with what we commonly label as tension-type headache. But unlike generic “tension,” occipital neuralgia has an identifiable cause and, in many cases, a definitive solution.
Occipital neuralgia is so often misclassified as a tension headache, and in the right patients, nerve decompression surgery offers a path to lasting relief.
The Clinical Blur: Tension or Neuralgia?
The International Classification of Headache Disorders defines tension-type headache as a diffuse, mild-to-moderate pain without the features of migraine. It is non-pulsating, bilateral, and not aggravated by physical activity. Occipital neuralgia, on the other hand, is characterized by sharp, shooting, or aching pain in the distribution of the greater and/or lesser occipital nerves. But in practice, the distinction is far less clear.
Many patients with so-called tension headaches describe deep, aching pain that starts at the base of the skull and radiates up toward the crown or behind the eyes. Some report a “vise-like” grip around the head. Others experience stabbing or burning pain in the back of the scalp, worsened by neck movement or pressure on the occipital region. These symptoms often worsen with stress or muscle tension, leading both patients and providers to assume they are stress-induced.
But these patterns are classic for occipital nerve involvement. And when treated as muscle-related tension alone, the true cause goes unaddressed.
Why the Misdiagnosis Happens
The mislabeling of occipital neuralgia as tension headache stems from both familiarity and diagnostic limitations. Tension headaches are well-known, common, and non-threatening. They are easy to explain and require no imaging. Patients are reassured, told to hydrate, stretch, manage stress, or try over-the-counter medications. The diagnosis feels safe for both patient and provider.
Occipital neuralgia, by contrast, is less familiar. Many clinicians have never palpated the occipital nerves, much less performed a diagnostic block. The condition doesn’t show up on standard imaging. And because its symptoms are often less dramatic than migraine, it is frequently underappreciated.
Additionally, muscle tightness in the upper neck can coexist with nerve irritation, further muddying the waters. As a result, many patients are given muscle relaxants, physical therapy, or anxiety medication without ever being evaluated for nerve entrapment.
The Anatomy Behind the Pain
The greater occipital nerve arises from the C2-C3 spinal roots and travels through multiple layers of muscle, including the semispinalis capitis, trapezius, and occipitalis, before innervating the posterior scalp. The lesser occipital nerve originates from C2–C3 and supplies the lateral aspect of the scalp behind the ear.
Along their course, these nerves are vulnerable to compression, particularly where they pass through tight fascial tunnels or intersect with adjacent vascular structures. This compression can lead to inflammation, nerve sensitization, and referred pain that mimics tension-type headache.
Patients may describe pressure, stabbing, throbbing, or burning pain. Often, palpation of the nerve produces immediate symptom reproduction. In some cases, tight muscles are the source of compression. In others, fibrous bands or scarring are to blame. But in all cases, the pain has a physical, mechanical origin.
This is further complicated by the pain cycle that occurs in tension-type headaches. Patients who hold tension in the upper back and neck have tight compression around the occipital nerves, which causes the headache symptoms of tension headaches. The pain of the headache, in turn, causes the autonomic nervous system to kick into gear- fight or flight causes further muscle tension, which causes more pain. The cycle of pain continues and worsens.
The Turning Point: Diagnostic Nerve Blocks
One of the most powerful tools in distinguishing occipital neuralgia from nonspecific tension headache is the diagnostic nerve block. When a small amount of local anesthetic is injected near the occipital nerves, patients with true nerve-mediated pain often experience immediate relief. This breaks the cycle of pain, and can have a profound impact.
This temporary reprieve not only confirms the diagnosis, but offers emotional validation to patients who may have spent years being told their symptoms were vague or stress-related. It provides a roadmap for next steps and reframes the pain as something not just to be managed, but potentially resolved.
A Surgical Solution for the Right Patient
For patients who experience significant but temporary relief from diagnostic nerve blocks—and who have persistent, reproducible occipital symptoms—surgical decompression offers a lasting answer. The procedure involves releasing the nerve from surrounding muscle and fascial structures, often including the transection of constricting bands or vessels.
Performed through small incisions at the back of the scalp, the surgery is outpatient, with relatively low complication rates. And in experienced hands, the results can be transformative. Patients who once lived with daily, dull, unrelenting “tension” may find that the pain simply disappears.
This is not a theory—it’s a reality borne out in surgical centers where peripheral nerve decompression is routinely performed. In many cases, patients who had resigned themselves to lifelong headache management discover that what they were told was “just tension” was actually a solvable anatomical problem.
Why It Matters
Understanding the overlap between tension headache and occipital neuralgia is more than a diagnostic curiosity. It’s a matter of therapeutic direction. When nerve compression masquerades as muscle tension, patients are left cycling through ineffective treatments: endless physical therapy, Botox, chiropractic adjustments, or anti-anxiety medication. They may be labeled as difficult or complex. They may internalize the idea that their pain is something they simply have to live with.
But when we reframe tension-type headache as a possible symptom of nerve entrapment, we open the door to resolution rather than management. We offer patients the dignity of a clear cause. We invite them to consider that their pain is not mysterious or emotional, but anatomical—and that it can be fixed.
A New Paradigm for an Old Problem
Tension headaches have long been treated as benign and idiopathic. But for a significant subset of patients, the problem lies not in generalized muscle tightness or psychosocial stress, but in the compression of the occipital nerves. This is not a minor distinction. It changes the course of care. It offers a path to cure.
By expanding our diagnostic lens and embracing anatomical evaluation, we can help patients move beyond the narrative of “chronic tension” and into a new understanding of their pain—one that is specific, grounded in structure, and ultimately, treatable.
In some cases, what appears to be chronic tension-type headache or occipital neuralgia may actually be triggered by a past neck injury—especially a whiplash event. A whiplash headache can develop when trauma to the neck causes inflammation or entrapment of the occipital nerves, leading to persistent pain radiating across the back of the head. Recognizing the link between mechanical injury and nerve compression is essential for offering long-term relief, particularly for patients whose symptoms began after a car accident or sudden neck strain.
