Occipital neuralgia is a nerve compression disorder that occurs at the base of the skull and the back of the neck, originating from the C2 and C3 nerve roots. These nerves exit behind the neck and travel up to the top of the back of the head.
Causes of Occipital Neuralgia
The causes of occipital neuralgia can include a whiplash injury, a concussion where the head strikes something (often leading to a whiplash), ganglion cysts pressing on the nerve, or tight muscles pressing on the nerve. In some cases, the exact cause remains unknown.
Symptoms of Occipital Neuralgia
The pain typically starts at the base of the neck and extends to the back of the head. Some patients describe the sensation as if something is literally running through their head from the base of the skull to the eye, like a javelin piercing through, or they may feel as though a horn is going from the back of their head to their forehead. This is a debilitating disorder that, if not treated and controlled, can cause intense pain.
Diagnosing Occipital Neuralgia
Occipital neuralgia can be evaluated by gently palpating the back of the skull. There are three branches of nerves on each side that can be pinched. The greater occipital nerve is typically the largest and occupies most of the space at the back of the scalp, extending to the back of the head. The lesser occipital nerve is more lateral, closer to the ear, and positioned at the base of the skull behind the ear. The third and smallest nerve is called the third occipital nerve.
Diagnostic Nerve Blocks
A diagnostic nerve block involves placing a needle with numbing medication along the course of the suspected pinched nerve. If the pain disappears and the area the nerve travels to goes numb (e.g., the back of the head), this is considered a positive and successful nerve block, confirming the diagnosis.
Treatment Options for Occipital Neuralgia
As a peripheral nerve surgeon, there are several options available for treating occipital neuralgia, depending on the findings from the physical exam. These options may include nerve decompression or nerve release, particularly of the greater occipital nerve, which is the larger of the nerves. In some cases, nerve decompression or removal (resection) of smaller nerves like the third occipital nerve or the lesser occipital nerve may be necessary.
In rare, refractory cases where decompression fails, nerve removal may be considered. Success rates for these procedures are generally high, with an estimated 85% success rate in reducing symptoms. Some patients are completely cured, while others may experience less successful outcomes. The success of the procedure often depends on factors such as the severity of the injury, how long symptoms have persisted, and other individual factors.
Recovery from Surgery
Post-surgical soreness from manipulating the back of the head and neck muscles can take 4 to 6 weeks to recover. Most patients are able to move their head from side to side without too much difficulty within the first two weeks. Overall, treatment for occipital neuralgia can be very successful in appropriately referred patients who have consistent physical evaluations and respond well to diagnostic blocks, especially when other less invasive procedures have failed.