Occipital Neuralgia

Timothy C. Hain, MD Page last modified: June 4, 2012

You may also be interested in our many pages on migraine on this site

Occipital nerves

Image from http://www.scienceofmassage.com/dnn/som/journal/1204/medical.aspx	Origin of occipital nerves from http://en.wikipedia.org/wiki/File:Gray800.png. View is from back of skull.

Occipital neuralgia is usually due to trauma to the occipital nerve (ON), often caused by an auto-accident where the head impacts the headrest. Other causes are spondylosis of the upper cervical spine (C1-C2), or rarely focal neuropathies due to diabetes or tumor (Ehni and Benner, 1984). The nerve may become entrapped beneath the attachments of the trapezius and semispinalis capitis muscles to the occipital bone (Loukas et al, 2006).

In occipital neuralgia, there are paroxysms of severe occipital pain, that often resemble severe migraines. The pain may be so severe that blood pressure rises to extreme levels. Some authors report eye pain from occipital neuralgia. (Mason et al, 2004), and even dental pain has been reported (Sulfaro et al, 1995).

Occipital neuralgia can sometimes be successfully treated with blocks of the occipital nerve, sometimes followed by radio-frequency ganglioneurectomy.  Medications are usually not helpful for occipital neuralgia, but when ON is combined with migraine (which is common), then it makes sense to treat both.  (Sahai-Srivastava et al, 2011).

There are two branches to the occipital nerve -- the greater and lesser. Most of the time, the injury is to the greater ON.  The ON takes origin from the C2 nerve root. Damage to the C2 nerve root, and prossibly also the upper cord, can cause occipital neuralgia.

A review of occipital neuralgia that is very comprehensive can be found in an article by Vanelderen et al. (2010).

What tests are appropriate for occipital neuralgia ?

An MRI or CT scan of the skull base is the most common test. Vascular imaging may be done to look for carotid or vertebral dissection or vascular compression. In many instances no tests at all are needed.

How is neuralgia treated ?

Occipital neuralgia can be extremely painful, and there are several approaches. In general a nerve blocks and several classes of drugs are used.

Image from http://www.rsdinfocenter.com/blog/2011/11/occipital-nerve-block-useful-to-relieve-rsdcrsp-pain/

Blocks are injections of medication intended to temporarily deaden pain nerves. They are ordinarily done by anesthesiologists in a pain clinic, or neurologists in a headache clinic. An example is shown above. For occipital neuralgia, if the site of injury is the nerve itself such as when the nerve is bruised on the headrest of a car, the nerves should be blocked. The nerves have a fairly long course and several papers have been written concerning th eoptimal locaiton to block (e.g. Natsis et al, 2006).

If the site of injury is one of the upper cervical nerve roots, then a more complex C2 cervical nerve block may need to be used.  This generally requires X-ray control.

If a block works temporarily it usually wears off as the anesthetic effect stops. To obtain a more lasting effect, a more permanent procedure is to damage the nerve.

• Radiofrequency ganglio-neurectomy involves damaging a nerve by heating it with microwaves. It is less invasive than rhizotomy. This procedure is usually performed by pain clinic physicians. According to Vanelderen (2010), pulsed radiofrequency treatment is a promising treatment.
• Rhizotomy surgery means cutting of nerves. Rhizotomy may be used to convert a neuralgia into a numbness. Andrychowski et al (2009) discuss surgical approaches. While effective, rhizotomy has been replaced by several less invasive procedures.
• Ganglionectomy is a more drastic procedure. According to Acar et al (2008), C2 or C3 ganglionectomies are associated with short term pain relief (less than 3 months).
  

Oral medications for nerve pain

Aspirin or acetominophen, nonsteroidal analgesics such as torodol, and narcotics are frequently used for neuralgia. Usually non-narcotic pain killers are not strong enough to control neuralgia pain, but they are worth a try anyway. Narcotic medications are addictive and there is usually an attempt to use other medications first.

Topical medications for nerve pain

In general, topical treatment for nerve pain is a good idea. It avoids many side effects, and addiction.

• Zostrix is a cream that is available over the counter. It us used both for arthritis and post-herpetic neuralgia. It is not used for trigeminal neuralgia. It starts to work only after four days of application. Zostrix works by depleting substance P from nerve endings.
• Xylocaine preparations, such as are used for sunburn, are also sometimes used. 5% lidocaine Gel has been studied and shown to have good results with no side effects (Rowbotham et al, 1995).
• Aspirin dissolved in chloroform is used in some countries for neuralgia. The technique is to crush aspirin tablets, dissolve them in chloroform, and apply to the painful area (King, 1993). According to Rubin (2001), there is conflicting evidence regarding Zostrix, and the aspirin preparation alluded to above is of "questionable value".
• EMLA cream has also been used.  EMLA contains a local anesthetic -- it is similar to sunburn sprays (e.g. "solarcaine").
• A ketamine lotion has been reported effective for postherpetic neuralgia. Soybean lecithin granules (250g Spectrum LE 102) were mixed with 150 ml isopropyl palmitate and stirred at least 12 hours. Ketamine (10 ml) was added to a final concentration of 5mg ketamine/mol gel (Quan et al, 2003). Ketamine has also been found useful via other routes.
• A lidocaine patch has been approved by the FDA for pain. It has been our observation that this method is effective for most types of local nerve pain but it is extremely expensive.  We don't know why an old drug like lidocaine put into a patch should cost so much.

Stimulators for intractable occipital neuralgia.

Implanted peripheral nerve systems have been reported to provide good durable results (Slavin et al, 2006; Weiner et al, 1999). We have not seen this in patients in our practice.

Anticonvulsants used for pain.

These are commonly used for trigeminal neuralgia. Tegretol (carbamazepine), Dilantin (phenytoin), and Neurontin (gabapentin) are the most commonly used drugs (Robotham et al, 1998). The author of this review often uses Trileptal (oxcarbamazine). They are given in doses similar to used for epilepsy, but more leeway is given to the patient in adjusting the dose up and down, depending on the amount of activity of the neuralgia. Sodium Valproate has also been used for this purpose. Recently, oxcarbazepine (Trileptal) has become available. Although it is not FDA approved for this indication, it behaves similarly to carbamazepine. Adjunctive agents may be used in this situation. These include baclofen and amitryptyline (see following).

Antidepressants used for pain.

These are mainly used for post-herpetic neuralgia. Amitriptyline is the most commonly used. Nortryptyline, Desipramine and others can also be used. Some authors claim that amitriptyline should be started within 3-6 months of onset of shingles to get optimal relief (Bowsher, 1994). SNRI type antidressants such as Cymbalta are used for neuropathic pain. It has been suggested that for this use, beta-blockers should be avoided (Yalcin et al, 2009)

Case example of treated occipital neuralgia:

A middle age woman experienced an automobile accident, and thereafter developed severe headaches with pain behind her right ear, nose bleeds, and loss of smell and taste.  There was tenderness and wincing on palpation of the area behind the right ear. A tentative diagnosis of Eagles syndrome was proposed, but X-rays did not bear this out.  Diagnostic blocks of the occipital nerve abolished the pain.  She subsequently had RF-ganglioneurectomy, with complete relief of headache for 6 months.

References:

• Acar, F., J. Miller, et al. (2008). "Pain relief after cervical ganglionectomy (C2 and C3) for the treatment of medically intractable occipital neuralgia." Stereotact Funct Neurosurg 86(2): 106-112.
• Andrychowski, J., Z. Czernicki, et al. (2009). "Occipital neuralgia: possible failure of surgical treatment - case report." Folia Neuropathol 47(1): 69-74.
• Ehni, G. and B. Benner (1984). "Occipital neuralgia and the C1-2 arthrosis syndrome." J Neurosurg 61(5): 961-965.
• Loukas, M., A. El-Sedfy, et al. (2006). "Identification of greater occipital nerve landmarks for the treatment of occipital neuralgia." Folia Morphol (Warsz) 65(4): 337-342.
• Mason, J. O., 3rd, B. Katz, et al. (2004). "Severe ocular pain secondary to occipital neuralgia following vitrectomy surgery." Retina 24(3): 458-459.
• Natsis, K., X. Baraliakos, et al. (2006). "The course of the greater occipital nerve in the suboccipital region: a proposal for setting landmarks for local anesthesia in patients with occipital neuralgia." Clin Anat 19(4): 332-336.
• Sahai-Srivastava, S. and L. Zheng (2011). "Occipital neuralgia with and without migraine: difference in pain characteristics and risk factors." Headache 51(1): 124-128.
• Sulfaro, M. A. and J. P. Gobetti (1995). "Occipital neuralgia manifesting as orofacial pain." Oral Surg Oral Med Oral Pathol Oral Radiol Endod 80(6): 751-755.
• Vanelderen, P., A. Lataster, et al. (2010). "8. Occipital neuralgia." Pain Pract 10(2): 137-144.
• Vanelderen, P., T. Rouwette, et al. (2010). "Pulsed radiofrequency for the treatment of occipital neuralgia: a prospective study with 6 months of follow-up." Reg Anesth Pain Med 35(2): 148-151.
• Yalcin, I., N. Choucair-Jaafar, et al. (2009). "beta(2)-adrenoceptors are critical for antidepressant treatment of neuropathic pain." Ann Neurol 65(2): 218-25.
• Weiner, R. L. and K. L. Reed (1999). "Peripheral neurostimulation for control of intractable occipital neuralgia." Neuromodulation 2(3): 217-221.