Timothy C. Hain, MD Page last modified: June 4, 2012
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|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).
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.
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.
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.
In general, topical treatment for nerve pain is a good idea. It avoids many side effects, and addiction.
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.
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).
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)
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.
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