Overview:
Occipital neuralgia, also known as C2 neuralgia or, rarely, Arnold’s neuralgia, is a medical condition characterized by chronic pain in the upper neck, back of the head and behind the eyes.
Not to be confused with trigeminal neuralgia, occipital neuralgia is a neurological condition of the occipital nerves. These nerves that run from the top of the spinal cord at the base of the neck up through the scalp get inflamed or damaged. Occipital neuralgia can be confused with a migraine, or other types of headaches, because the symptoms can be quite similar. Occipital neuralgia is a distinct type of headache characterized by piercing, throbbing, or electric-shock-like chronic pain in the upper neck, back of the head, and behind the ears, usually on one side of the head. The scalp may also be tender to the touch, and eyes especially sensitive to light. Occipital neuralgia is a distinct disorder that requires an accurate diagnosis to be treated properly.
The location of pain is related to the areas supplied by the greater and lesser occipital nerves, which run from the area where the spinal column meets the neck, up to the scalp at the back of the head.
The pain is caused by irritation or injury to the nerves, which can be the result of trauma to the back of the head, pinching of the nerves by overly tight neck muscles, compression of the nerve as it leaves the spine due to osteoarthritis, or tumors or other types of lesions in the neck. Localized inflammation or infection, gout, diabetes, blood vessel inflammation (vasculitis), multiple sclerosis and frequent lengthy periods of keeping the head in a downward and forward position are also associated with occipital neuralgia. In many cases, however, no cause can be found.
While less frequent in multiple sclerosis patients than trigeminal neuralgia patients who endure occipital neuralgia may experience long instances of considerable pain or discomfort. Washing the hair or lying on a pillow might become very difficult. Additionally, the pain associated with occipital neuralgia can be similar to a headache or migraine, so it’s easy for occipital neuralgia to be mistaken for something else and go undiagnosed.
Seldom is occipital neuralgia a presenting symptom in newly diagnosed patients but is more commonly found in those who already have been diagnosed.
The Occipital Nerves:
Where trigeminal neuralgia is a disorder of the fifth cranial (trigeminal) nerve that causes extreme, sporadic, sudden burning or shock-like facial pain in the areas of the face where the branches of the nerve are distributed with pain episodes that last from a few seconds to as long as two minutes and may occur in quick succession. Occipital neuralgia occurs via the lesser and greater occipital nerves.
The occipital nerve runs from the top of the spinal cord between the C1 and C2 vertebrae and up the neck and up the scalp. When the occipital nerve is damaged, inflamed, or irritated, an individual might experience pain that begins at the back of the head and radiates forward. The significance and amount of pain may well be debilitating.
Conditions Associated with Occipital Neuralgia:
There are certain conditions that are commonly associated with occipital neuralgia, although the type is not limited to only occipital neuralgia.
A few of these conditions include:
- Multiple sclerosis
- Fibromyalgia
- Porphyria
- Some infections, such as AIDS or shingles
- Chronic renal insufficiency
- Certain medications
- Trauma to the back of the head
- Injury in the area of the C1 & C2 vertebrae
- Neck tension and/or tight neck muscles
- Osteoarthritis
- Tumors in the neck
- Cervical disc disease
- Infection
- Gout
- Diabetes
- Blood vessel inflammation
In multiple sclerosis occipital neuralgia is more often caused by demyelinated regions associated with the occipital nerves.
Symptoms of Occipital Neuralgia:
The main symptom of occipital neuralgia is chronic headache. The pain is commonly localized in the back and around or over the top of the head, sometimes up to the eyebrow or behind the eye. Because chronic headaches are a common symptom of numerous conditions, occipital neuralgia is often misdiagnosed at first, most commonly as tension headaches or migraines, leading to unsuccessful treatment attempts. Another symptom is sensitivity to light, especially when headaches occur.
Occipital neuralgia is characterized by severe pain that begins in the upper neck and back of the head. This pain is typically one-sided, although it can be on both sides if both occipital nerves have been affected. Additionally, the pain may radiate forward toward the eye as it follows the path of the occipital nerve(s). Individuals may notice blurred vision as the pain radiates near or behind the eye. The pain is commonly described as sharp, shooting, zapping, an electric shock, or stabbing. The bouts of pain are rarely consistent, but can occur frequently depending on the damage to the nerves. The amount of time the pain lasts typically varies each time the symptom appears, it may last a few seconds or be almost continuous. Occipital neuralgia can last for hours or for several days.
Other symptoms of occipital neuralgia may include:
- Aching, burning, and throbbing pain that typically starts at the base of the head and radiates to the scalp
- Pain on one or both sides of the head
- Pain behind the eye
- Sensitivity to light
- Sensitivity to sound
- Slurred speech
- Pain when moving the neck
- Difficulty with balance and coordination
- Tender scalp
- Nausea and/or vomiting
Diagnosing Occipital Neuralgia:
If you think you may have occipital neuralgia, make an appointment with your doctor. Your doctor will ask questions about your medical history and any injuries you may have had, and perform a physical exam. He or she should press firmly around the back of your head where the occipital nerve resides to see if he can reproduce your pain. Your doctor may also give you an anesthetic nerve block to see if it relieves the pain. If it works, occipital neuralgia is likely the cause of the pain. If your doctor feels your case is not typical, he or she may order blood tests, an MRI scan and/or X-Ray of the upper spine to rule out if disease or injury may be causing the pain.
For treatment to work, it is very important that you receive an accurate diagnosis. For example, if you have occipital neuralgia and are prescribed migraine medication, you may not get relief.
Multiple Sclerosis patients should set up an appointment to see their neurologist should any of the symptoms above or combination thereof begin to occur on a fairly frequent basis. Your neurologist may order a MRI scan to take a look to see if any new lesions in your central nervous system might be causing occipital neuralgia.
Treatments:
Treatment of occipital neuralgia depends on what is causing the inflammation or irritation of the occipital nerves. The first course of action is to relieve pain. If the pain from trigeminal or occipital neuralgia isn’t too severe, it might be worth trying some home therapies to find relief.
Therapies for Mild Occipital Neuralgia:
- Rest in a quiet room
- Neck massage
- Heating pad
- Over-the-counter pain medications, like Advil or Tylenol, might also alleviate symptoms.
If pain is persistent, a physician might be able to suggest non-surgical methods of pain relief.
Prescription Medications For Occipital Neuralgia:
- Anticonvulsants such as such as Tegretol (carbamazepine) and Neurontin (gabapentin)
- Muscle relaxants such as Baclofen
- Antidepressants
- Non-steroidal anti-inflammatories
- Oral opiate based pain medications
Alternative Therapies:
Alternative therapies may also be helpful at times.
- Acupuncture is the strategic insertion of thin, sanitized needles to provide pain relief.
- Chiropractic care can be effective at times, although it’s always a good idea to discuss alternative treatments with a physician before pursuing them.
Botox Injections:
Another potential alternative treatment is a Botox injection. These injections are most commonly known for their cosmetic uses, because Botox is actually a paralytic toxin. This can be useful for getting rid of facial wrinkles, but it can also block impulses sent along nerves, thereby blocking the pain signals.
Radiofrequency Ablation:
This procedure includes cauterizing painful nerves to cut off pain signals. The nerve will most likely heal eventually, which usually means the return of trigeminal or occipital neuralgia pain. However, if successful, the procedure can be repeated.
Injected Medications:
Nerve block injections typically contain an anesthetic like lidocaine. Some include a steroid, as well, to reduce inflammation. These injections are delivered directly to the affected nerve. Patients who receive nerve block injections often feel relief very quickly. Nerve block injections are also very useful in diagnosing occipital neuralgia.
Extreme Treatments:
More extreme treatments, such as surgical treatments, carry higher risks, so it’s important to have a solid diagnosis before pursuing a surgical procedure. If, for example, a nerve block injection applied to the occipital nerve provides pain relief, then a surgical procedure focusing on the occipital nerve has a good chance of providing pain relief.
However, as stated by Johns Hopkins Medicine:
“If a patient’s pain does not reliably improve with occipital nerve blocks, we do not recommend proceeding with any of the more drastic measures.”
More invasive treatment options include surgery to cut away part of the nerve or remove whatever’s putting pressure on it. Surgeries to treat trigeminal or occipital neuralgia are the most high-risk treatment options, but they can potentially give longer-lasting relief.
Research:
- Patients with Multiple Sclerosis and occipital neuralgia may be relapsing. Symptoms responded well to high dose corticosteroids. Relapse should be considered in patients with MS who present with occipital neuralgia.
- The use of implanted occipital nerve stimulators appears to be an effective treatment option for chronic headache, including occipital neuralgia.
- Although not every patient is a candidate, cervical ganglionectomy (surgical removal of a nerve tissue mass) can be an effective treatment option for occipital neuralgia.
