Occipital Neuralgia

Occipital Neuralgia is a rare condition and fall under sub classification of headaches. In this condition usually occipital nerves i.e. GON (greater occipital nerve), LON (Lesser occipital nerve) and/or TON (Third occipital nerve) gets inflamed and causes headaches travelling with in their dermatomal pathways usually upwards starting from the base, side and back of the skull and radiating upwards towards the back of eyes and behind the ear.

Causes-

Occipital neuralgia is sub-classified into 2 types;-

1. Primary Occipital neuralgia-Primary neuralgia could be due to pinched nerve, muscular tightness or head and neck injury resulting into compression of GON , LON and/or TON.
2. Secondly Occipital neuralgia- Secondly occipital neuralgia usually present resulting to an underlying disease, I.E-

• • Osteoarthritis of upper cervical spine
  • Secondry to direct trauma to occipital nerve/s
  • Degenerative disk resulting into compression of the nerve roots.
  • systemic conditions like Gout, Diabetes, infection, cancer, vascular inflammation

Symptoms-

Usually patient reports intense severe symptoms like constant sharp, shocking and stabbing pain travelling from neck to the side of head and behind the ears, pain often refer behind the orbital socket on ipsilateral side of neural involvement and aggravates due to touch or combing/brushing the hair as well due to cutaneous supply of occipital nerves.

Patient reports pain symptoms alike migraines, Tension type or cluster headaches so good DD is a must to identify the cause.

Testing and Diagnosis-

Diagnosis for Occipital neuralgia can be tricky due to lack of gold standard testing and inconclusive evidence. However, diagnostic validity is better when physical and neurological exam is conducted together. if results are inconclusive than further imaging like MRI or CT scan can be ordered to reveal multi dimensional view for the likely compressed structures. Some doctors would prefer to use occipital nerve block procedure to confirm and treat the condition.

Treatment-

Treatment can conservative or surgical depending on the severity of condition and clinical resigning of doctor.

Conservative intervention-

Thermo Therapy;- Patient often responds feeling better with the use of heat than cold pack. however, it is recommended to add a layer of towel or clothing between skin and heat pack to avoid injuries like burn and over stimulation of occipital cutaneous nerves.

Oral medications;-

• NSAID's
• Muscle relaxants
• Anti convulsants

Percutaneous nerve blocks- doctor administer 1cc injection of lidocaine and corticosteroid usually on the entrapment sites btw inion and mastoid process.

Surgical Intervention-

Usually surgical interventions in Occipital neuralgia are preferred when conservative treatment and nerve block injections fails to relieve the symptoms.

Occipital nerve neuromodualtion- nerve stimulating electrodes are placed on the sides of GON usually a the base of skull and nerve is stimulated using the device. this procedure can also be used with migraine, cluster and cervicogenic head aches.

Dorsal Rhizotomy- In this procedure Ventrolateral margins of C1, C2 and C3 spinal nerves are separated usually at the entry points or complete upper cervical rhizotomy can also be performed by surgeon and patients usually reports reduced pain along with the loss of sensation in the scalp. however, this intervention is not proven to be 100% effective as small population had also reported loss of sensation in scalp without any reduction int he pain.

Peripheral Neurectomy- This procedure have shows better efficacy than dorsal rhizotomy with large number of patient responding pain relief. However, more studies are required to prove the efficacy.

Surgical decompression- This treatment has also shows contra version efficacy with 62% subjects responding with the pain relief according to a previous study. however, it is recommended for physician to take anatomic location of occipital nerves and variations to reduces post operative risks and increase the benefit of the procedure.

Physiotherapy Treatment-

Although dry needling therapy and acupuncture have shown benefits and pain relief as compared to medication but evidence has been inconclusive due to study design and smaller sample size.

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