Occipital Neuralgia
Occipital neuralgia is a headache syndrome characterised by recurrent, severe, electric shock-like neuropathic pain in the nape, back of the head and vertex, caused by irritation, inflammation or compression of the greater and/or lesser occipital nerves. Treatment is stepwise: medication, nerve blocks, physiotherapy, and in refractory cases decompression surgery or occipital nerve stimulation.
마지막 업데이트: 2026-06-07
Definition
Occipital neuralgia is characterised by recurrent, severe, electric shock-like neuropathic pain in the nape, back of the head and vertex, caused by irritation, inflammation or compression of the greater occipital nerve (C2-derived) and/or the lesser occipital nerve. It accounts for a small but significant proportion of chronic headache cases. The greater occipital nerve arises from the C2 nerve root and spreads to the scalp by piercing the neck muscles (particularly the semispinalis capitis); these anatomical passage points are prone to compression.
Causes and Risk Factors
In primary (idiopathic) cases no underlying cause is identified. Secondary causes include cervical spondylosis and degenerative disc disease (particularly at the C1-C2 and C2-C3 levels), neck trauma (whiplash), spasm of the neck muscles and myofascial pain, C1-C2 arthritis (rheumatoid arthritis, osteoarthritis), posterior fossa lesions, Chiari malformation, cervical radiculopathy and systemic causes of neuropathy such as diabetes mellitus.
Symptoms
The pain is typically unilateral (bilateral in some cases), begins in the nape and back of the head and may radiate to the vertex and temporal regions. It is electric shock-like, stabbing or burning; it may come in paroxysmal attacks or be superimposed on a continuous dull ache. Neck movements (extending or rotating the head), combing the hair, wearing a hat and leaning on a pillow can trigger the pain. Sensory disturbance (numbness or hypersensitivity) and allodynia may be found over the course of the nerve.
Diagnosis
Diagnosis is based on clinical examination and a diagnostic nerve block. On examination, palpation over the course of the greater occipital nerve (below the occipital protuberance, lateral to the midline) provokes severe pain (a Tinel-like sign), with sensory change in the same area. In the diagnostic block, local anaesthetic (with steroid when required) is injected into the nerve; temporary disappearance of the pain confirms the diagnosis. To assess secondary causes, cervical and brain imaging (MRI/CT) is performed to investigate cervical spondylosis, C1-C2 pathology, posterior fossa lesions and Chiari malformation. The differential diagnosis includes migraine, tension-type headache, cervical radiculopathy and temporal arteritis.
Medical (Conservative) Treatment
First-line treatment is medication: nonsteroidal anti-inflammatory drugs, muscle relaxants and neuropathic pain agents (gabapentin, pregabalin, tricyclic antidepressants). Physiotherapy (neck stretching and postural exercises, myofascial stretching, TENS) plays a supportive role. In secondary occipital neuralgia, treatment directed at the underlying cause (physiotherapy in cervical spondylosis, corticosteroids in temporal arteritis) is essential.
Interventional and Surgical Treatment
Greater occipital nerve blocks are both diagnostic and therapeutic: local anaesthetic and often steroid are injected along the course of the nerve; this provides temporary relief (from weeks to a few months) in a substantial proportion of patients and can be repeated at intervals, although it is not a permanent solution. In cases refractory to medication and blocks, decompression surgery (releasing the muscle band compressing the greater occipital nerve) can be performed and provides durable pain control in suitable cases; possible complications are sensory loss in the nape and wound infection. In chronic cases refractory to medication and surgery, occipital nerve stimulation (ONS) is a neuromodulation option: electrodes placed along the course of the nerve modulate pain perception; it is reversible and adjustable. Radiofrequency procedures may also be used in selected cases.
Prognosis
Occipital neuralgia is generally a condition that responds to treatment. Nerve blocks provide temporary relief in most patients; in refractory cases, decompression surgery or occipital nerve stimulation can offer long-term benefit. In secondary cases the prognosis depends on the treatability of the underlying cause. Because it can occur together with other headaches such as chronic migraine, accurate diagnosis and combined treatment when necessary are important. The treatment plan is individualised for each patient, and no outcome can be guaranteed in advance.
참고 문헌
- Greenberg MS. Greenberg's Handbook of Neurosurgery. 10th ed. Thieme; 2023:541-543.
- Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
- Dougherty C. Occipital neuralgia. Curr Pain Headache Rep. 2014;18(5):411.
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