What is occipital neuralgia?
Occipital neuralgia refers to sharp, shooting pain arising at back
of the head or upper neck, and spreading either to the top of
the skull, or to the temple region. This is frequently associated
with a dull or throbbing pain behind the eye. It may occur on
both sides. This pain is often reproduced by applying mild pressure
or tapping over the greater or lesser occipital nerves at the
back of the skull. Some patients may have pins and needles or
numbness over the scalp.
What are the causes of occipital neuralgia?
Occipital neuralgia may follow:
- trauma to the head or neck
- surgery to the back of the head or neck
- spinal instability (for example atlantoaxial subluxation
in rheumatoid arthritis)
- neuromas (‘lump’ formation in certain nerves)
- C2 nerve root entrapment by thickened ligaments in the
upper neck
How is occipital neuralgia treated?
Initially, occipital neuralgia is treated with pain medications,
local anaesthetic injections, and physiotherapy. Steroids are
sometimes used in the short-term. Avoidance of aggravating activities
and pressure over the nerves is important. The majority of patients
respond to such measures, but a small proportion require surgery.
Traditional neurosurgical strategies to manage this sometimes difficult
condition have included:
- Sectioning (cutting) or avulsion (removal) of the occipital
nerves. This procedure frequently fails, may cause significant
scalp numbness, and may occasionally lead to a more severe (‘deafferentation’)
pain syndrome. It is therefore usually not recommended as an
initial surgical approach.
- Radiofrequency ablation (controlled heating) of the offending
nerve may yield substantial symptomatic benefit, but the recurrence
rate is high.
- If the C2 nerve root ganglion is thought to be compressed
in the upper spine (between the C1 vertebra arch and C2 vertebra
lamina), surgical decompression may be of benefit.
- Symptomatic atlantoaxial subluxation may warrant a C1-2
fusion.
Peripheral nerve stimulation of occipital nerves has recently
emerged as an effective, well-tolerated, and low-risk technique
in patients with intractable occipital neuralgia. Over 70% of patients
appear to benefit from this new technique.
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