Greater Occipital Nerve

Original Editor - Riccardo Ugrin

Top Contributors - Riccardo Ugrin

Description[edit | edit source]

Posterior primary divisions of the upper three cervical nerves.

The occipital nerves are a group of 3 nerves that arise from the C2 and C3 spinal nerves.

  • Greater Occipital Nerve
  • Lesser Occipital Nerve
  • Third Occipital Nerve

The Greater Occipital Nerve (GON) is the biggest purely afferent nerve that arises from the medial division of the dorsal ramus of the C2 spinal nerve. It runs backward between the C1 and C2 vertebrae and traverses between the inferior capitis oblique and semispinalis capitis muscles from underneath the suboccipital triangle. While traveling to the subcutaneous layer, the GON is found to pierce the semispinalis capitis muscle bilaterally[1]. Then it perforates the aponeurotic fibrous layer of the trapezius and the sternocleidomastoid[2] to travel to the scalp and the superior nuchal line[3].

This complex involvement with the nearby musculature may make this nerve a potential source of nerve compression, entrapment, or irritation[4].

The GON innervates the skin of the back of the scalp up to the vertex of the skull, the ear, and the skin just above the parotid gland. Because of that it supplies sensation the scalp at the top of the head, over the ear and over the parotid glands.

Some anatomic variations should be noted by physicians to understand better the topography of the GON and the nearby vasculature.

Vascularization[edit | edit source]

The GON is also closely associated with the occipital artery. After the GON perforates the semispinalis capitis, it travels with the occipital artery that is medial to the nerve. It is also shown that the GON and the occipital artery have an intimate relationship that could differ into an helical fashion.

This connection between the GON and the occipital artery may be useful in patients with migraine or occipital neuralgia[5], as many of these patients report having pulsatile symptoms, and their headaches may contain a vascular component.

Function[edit | edit source]

Sensory[edit | edit source]

The occipital nerves mainly carry sensory fibers. In particular the GON innervates the skin of the back of the scalp up to the vertex of the skull, the ear, and the skin just above the parotid gland.

The GON constitutes the main sensory afferent nerve through the C2 root, and this afferent input is directly relayed to the C2 dorsal horn.

Clinical relevance[edit | edit source]

  • The GON, togheter with the Lesser Occipital Nerve and the Third Occipital Nerve, are commonly associated with occipital neuralgia, cervicogenic headaches, and migraine headaches[3]. Occipital neuralgia is a type of headache characterized by a paroxysmal stabbing pain in the posterior area of the scalp.
  • The entrapment of the GON at its piercing point of the tendinous aponeurotic attachment of the trapezius at the superior nuchal line is known as the most common cause. In addition to this, also a spasm of sub-occipital muscles caused by functional or anatomical instability of Atlanto-axial joint can lead to an entrapment of the GON below the superior nuchal.
  • Because the chronic continuous and noxious afferent input caused by GON entrapment seems to be associated with sensitization and hypersensitivity of the second-order neurons in the trigeminocervical complex[6], a population of neurons in the C2 dorsal horn characterized by receiving convergent input from dural and cervical structures[7].
  • The trigeminocervical neurons showed convergent synaptic input from the supratentorial dura mater, from the ipsilateral GON, and from the contralateral GON[8]. Studies provide clear evidence of anatomic and functional coupling between nociceptive dural afferents and cervical afferents in the GON on to neurons in the trigeminocervical complex.
  • These convergent neurons may be sensitized during headache and may be involved in the clinical phenomenon of hypersensitivity, spread, and referred pain to trigeminal and cervical dermatomes by which pain originating from an affected tissue is perceived to originate from a distant receptive field[8].
  • The sings and symptoms of a occipital neuralgia could also be similar to a Cervicogenic Headaches. For more clinical reasoning please see Anterior Neck and Cervicogenic Headaches.
  • Because occipital neuralgia is associated with cranial nerves 8, 9, and 10, patients may experience nausea, dizziness, vision impairment, and congestion in the nose.

Treatment[edit | edit source]

Contraindication[edit | edit source]

The symtpoms of an occipital neuralgia could dissimilate red flags. Before treatment is needed to assess:

Conservative Treatment[edit | edit source]

Anticonvulsants, nonsteroidal anti-inflammatory drugs and muscle relaxants are usually first-line treatments for occipital neuralgia[10].

Other conservative treatment options consist of correction of posture to decrease the compression from sub-occipital muscles and the trapezius and reducing muscle pain. The change of maintained posture on computer, for example, could relax the muscular activity of the sub-occipital muscles and prevent an occipital nerve entrapment. Pauses from the sitting position and self-mobilization of the cervical spine can also be useful.

Dry needling therapy could also been considered as conservative approach in patient with occipital neuralgia[11].

The manual therapy oriented to mobilisation and manipulation of the neck can also be considered as a conservative treatment, expecially if associated to a exercise program to the muscles of the neck[12]. Strengthening exercises[13] [14]including deep neck flexors and upper quarter muscles. For more indication for physical therapy management please see Cervicogenic Headache.

If patients do not respond clinically to these treatments or minimally invasive procedures, other invasive treatments, such as nerve blocks or neurotomy, may be considered.

References[edit | edit source]

  1. Tubbs RS, Salter EG, Wellons JC, Blount JP, Oakes WJ. Landmarks for the identification of the cutaneous nerves of the occiput and nuchal regions. Clin Anat. 2007 Apr;20(3):235-8
  2. Bovim G, Bonamico L, Fredriksen TA, Lindboe CF, Stolt-Nielsen A, Sjaastad O. Topographic variations in the peripheral course of the greater occipital nerve. Autopsy study with clinical correlations. Spine (Phila Pa 1976). 1991 Apr;16(4):475-8
  3. 3.0 3.1 Yu M, Wang SM. Anatomy, Head and Neck, Occipital Nerves. [Updated 2021 Nov 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
  4. Won HJ, Ji HJ, Song JK, Kim YD, Won HS. Topographical study of the trapezius muscle, greater occipital nerve, and occipital artery for facilitating blockade of the greater occipital nerve. PLoS One. 2018;13(8)
  5. Shimizu S, Oka H, Osawa S, Fukushima Y, Utsuki S, Tanaka R, Fujii K. Can proximity of the occipital artery to the greater occipital nerve act as a cause of idiopathic greater occipital neuralgia? An anatomical and histological evaluation of the artery-nerve relationship. Plast Reconstr Surg. 2007 Jun;119(7):2029-2034
  6. Piovesan EJ, Kowacs PA, Tatsui CE, Lange MC, Ribas LC, Werneck LC. Referred pain after painful stimulation of the greater occipital nerve in humans: evidence of convergence of cervical afferences on trigeminal nuclei. Cephalalgia. 2001 Mar;21(2):107-9
  7. Son BC. Referred Trigeminal Facial Pain from Occipital Neuralgia Occurring Much Earlier than Occipital Neuralgia. Case Rep Neurol Med. 2020 Aug 24;2020
  8. 8.0 8.1 Bartsch, T., Goadsby, P.J. The trigeminocervical complex and migraine: Current concepts and synthesis. Current Science Inc 7, 371–376 (2003).
  9. Tancredi A., Caputi F. Greater occipital neuralgia and arthrosis of C1-2 lateral joint. European Journal of Neurology 2004, 11: 573–574
  10. Dougherty C. Occipital neuralgia. Curr Pain Headache Rep. 2014 May;18(5):411.
  11. Bond BM, Kinslow C. Improvement in clinical outcomes after dry needling in a patient with occipital neuralgia. J Can Chiropr Assoc. 2015;59(2):101-110.
  12. Racicki S, Gerwin S, Diclaudio S, Reinmann S, Donaldson M. Conservative physical therapy management for the treatment of cervicogenic headache: a systematic review. J Man Manip Ther. 2013;21(2):113-124
  13. Luedtke, Kerstin, et al. "Efficacy of interventions used by physiotherapists for patients with headache and migraine—systematic review and meta-analysis." Cephalalgia 36.5 (2016): 474-492.
  14. Fritz JM, Brennan GP. Preliminary Examination of a Proposed Treatment-Based Classification System for Patients Receiving Physical Therapy Interventions for Neck Pain. Physical Therapy. 2007;87:513-524.