Occipital neuralgia: Symptoms and treatments

Occipital neuralgia is a painful condition that is often confused with migraines. But the causes of occipital neuralgia — and the treatments — are quite different.

What is occipital neuralgia?

Occipital neuralgia is a rare but painful condition that causes severe, piercing headaches. The pain is felt in the back of the head, behind the ears, or in the upper neck.

For some people, just combing their hair or lying on a pillow can cause excruciating pain. For others, occipital neuralgia is felt as numbness.

There are three occipital nerves that run through each side of your scalp and transmit feeling to your brain: the greater occipital nerve, lesser occipital nerve, and third occipital nerve. Irritation of any of these nerves can cause symptoms of occipital neuralgia.

Causes of occipital neuralgia

Occipital neuralgia may be caused by a pinched nerve in your neck, an injury to your scalp or skull, or tight muscles that press on nerves.

Occipital neuralgia can also be caused by certain health conditions such as arthritis, gout, diabetes, degeneration in the spine, infection, or inflammation.

There is limited information on how many people are affected by occipital neuralgia. However, a 2021 study of 800 people in a hospital-based headache clinic found that about 25% of patients there had occipital neuralgia.

Occipital neuralgia symptoms

The symptoms of occipital neuralgia can come on suddenly and without warning. Symptoms include a shooting, throbbing, burning, or aching pain that can last from seconds to minutes.

The pain often starts at the back of the head and spreads to one or both sides of the head. It can be felt in your scalp, upper neck, and behind your eyes and ears. Your scalp may become extremely sensitive and tender.

Occipital neuralgia symptoms can be triggered by certain movements, like turning your head or pressing on your scalp.

The symptoms of occipital neuralgia are similar to migraine symptoms. There can be overlap between the two conditions; some people with migraines also have occipital neuralgia.

The difference between occipital neuralgia and migraines is that migraines often are accompanied by nausea and sensitivity to light. If you have sudden or sharp pain in your scalp or the back of your head but don't feel nauseous or light sensitive, occipital neuralgia may be the cause.

Diagnosing occipital neuralgia

Diagnosing occipital neuralgia begins with a physical and neurological exam. Occasionally, diagnostic imaging tests, such as magnetic resonance imaging (MRI) and computed tomography (CT) scans, can help with diagnosis.

Your doctor may refer you to a specialist who may inject a local painkiller and steroid into the area around one of the occipital nerves. If you feel relief, that can confirm a diagnosis of occipital neuralgia.

The doctor may also use a handheld ultrasound device to look for the occipital neuralgia trigger points — the areas where the occipital nerve is being irritated — that are causing your pain. Pinpointing the trigger points can help guide treatment.

You may have a sense of where your occipital neuralgia trigger points are based on where your pain begins or where you feel pain the most.

Occipital neuralgia treatment

Treatment for occipital neuralgia involves addressing the root cause of the pain as well as the pain itself.

Nonsurgical treatments

Nonsurgical treatments aim to ease the pain of occipital neuralgia and relax tight muscles that may be contributing to symptoms. They include:

• regular exercise such as stretching and yoga
• applying heat from heating pads to the scalp or where the pain is felt most
• physical therapy or massage therapy to help relax muscles and ease pressure in the tender area
• oral medications including nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or aspirin, muscle relaxers, and anticonvulsants to relieve pain caused by occipital neuralgia
• injections of steroids, Botox, and/or nerve blocks to calm and numb overactive nerves.

Surgical treatments

If nonsurgical treatments are not effective in relieving pain, there are several surgical treatment options for occipital neuralgia. They include:

• occipital nerve stimulation, in which electrodes placed under the skin near the occipital nerve send small electrical currents to block the sensation of pain
• spinal cord stimulation, in which electrodes placed between the spinal cord and vertebrae block pain messages to the brain
• ganglionectomy, which involves removing certain nerve cells near the top of the spine
• occipital release surgery, a procedure to relieve pressure on the greater occipital nerve, which is the most common trigger point for occipital neuralgia. This surgery is often considered a last resort when other treatments have failed.

Occipital neuralgia clinical trials

People with occipital neuralgia can consider participating in a clinical trial, to help doctors learn more about the condition and ways to treat it. You can search for occipital neuralgia clinical trials through ClinicalTrials.gov database, a service of the National Library of Medicine.