A one-sided headache that isn't migraine

Migraine is thought to originate deep inside the brain. This isn't the case for all headache disorders. Sometimes, peripheral nerves closer to the skin's surface can mimic some of the symptoms of migraine. It often takes a trained headache specialist to unravel the mystery and recommend the right treatment. One of those headache disorders is occipital neuralgia.

Occipital neuralgia is rare, affecting 3.2 out of every 100,000 people each year. The ICHD-3 beta places it in a separate category, distinguishing it from migraine or tension-type headaches. the category is called "cranial neuralgia", simply meaning "pain in the head." Officially, occipital neuralgia has no known cause. However, there are some who believe nerve entrapment may contribute to its development. Whiplash, inflammation, or compression of nerves by arteries or tumors may explain this types of pain. More studies are needed to confirm this theory.

Patients with occipital neuralgia experience scalp tenderness and aching all the time. Simply touching the affected area can set off a series of painful stabbing attacks. Some patients describe the pain as “shock-like.” This condition can significantly impair a patient’s daily life because simply turning the head, brushing the hair, putting on a hat, or lying on a pillow can trigger attacks. Pain can occur on one or both sides of the back of the head. Between attacks, patients may experience reduced sensation across the back of the head. The affected nerves exit the spinal column at C2 and spread upward across the back of the head. Sometimes the pain can spread to the trigeminal nerve complex, producing pain in the forehead, eyes, cheeks, and jaw.

ICHD-3 beta Diagnostic criteria:

A. Unilateral or bilateral pain fulfilling criteria B-E
B. Pain is located in the distribution of the greater, lesser and/or third occipital nerves
C. Pain has two of the following three characteristics

1. Recurring in paroxysmal attacks lasting from a few seconds to minutes
2. Severe intensity
3. Shooting, stabbing or sharp in quality

D. Pain is associated with both of the following:

1. Dysaesthesia (reduced sensation) and/or allodynia apparent during innocuous stimulation of the scalp and/or hair
2. Either or both of the following:

a) tenderness over the affected nerve branches
b) trigger points at the emergence of the greater occipital nerve or in the area of distribution of C2

E. Pain is eased temporarily by local anaesthetic block of the affected nerve
F.  Not better accounted for by another ICHD-3 diagnosis.

Differential Diagnosis:

Because occipital pain is a common symptom of many headache disorders, it is important that your doctor rule out other explanations for occipital pain before settling on a diagnosis. Here’s a breakdown of how occipital neuralgia differs from more common headache disorders.


Both migraine an occipital neuralgia may respond to occipital nerve blocks. However, the pain of a migraine attack lasts 4-72 hours while individual attacks of occipital neuralgia last only minutes. The quality of the pain is different, too. Migraine pain is often throbbing or pulsing where occipital neuralgia pain is sharp, shooting, or stabbing. Migraine pain is typically moderate-to-severe. Occipital neuralgia pain is always severe.

Cluster Headache

Both occipital neuralgia and cluster headache attacks are severe in intensity. However, occipital neuralgia does not typically produce autonomic symptoms such as conjunctival tearing, eyelid drooping, nasal congestion, etc.

Hemicrania Continua

Hemicrania continua can also present with occipital tenderness, but has more in common with cluster headache than occipital neuralgia because of the presence of autonomic symptoms

Cervicogenic headache

Cervicogenic headache and occipital neuralgia both produce pain in the neck and back of the head. However, the quality of cervicogenic headache pain is more often dull and achy (like that of a tension-type headache) rather than sharp or stabbing.

Nerve or muscle pain originating from other areas of the cervical spine can be distinguished from occipital neuralgia by a trained neurologist. In rare cases, arterial inflammation or other irritation of nerve roots may be responsible for occipital pain.  A qualified headache specialist will be experienced enough to screen for all potential diagnoses and offer the proper treatment. During an exam, eliciting a pain response by pushing on the occipital nerves is a good indication for occipital neuralgia. Because it affects only a specific set of nerve, elimination of the pain after a nerve block injection often confirms the diagnosis.


Conservative treatment often involves the application of warm compresses, massage, and/or physical therapy. Anti-inflammatories and muscle relaxants may also be used for acute flare-ups. Anticonvulsants and/or tricyclic antidepressants may be tried as preventives, too. A more aggressive approach is the use of nerve block injections which are usually effective for up to 12 weeks. For refractory occipital neuralgia, pulsed radiofrequency and occipital neurostim implants may be necessary.

If you think you are experiencing symptoms consistent with occipital neuralgia,
please see a headache specialist to confirm the diagnosis and start getting treatment.
As with all other headache disorders, early intervention produces the best results.

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