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.