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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.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

  1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalgia. 2013; 33(9) 779-
  2. Holdridge, A., DO. (2014, November 7). Occipital Neuralgia. American Migraine Foundation. Retrieved January 22, 2016, from


  • Neece
    4 years ago

    This was a very informative and enlightening article, however Cluster Headaches sufferers do have autonomic symptoms, esp the conjunctival tearing, eyelid drooping, nasal congestion, and a few others. I was diagnosed in 1997 with this condition, normally I go into remission for 4 years after oxygen therapy. But this time around the headaches were everyday, 2 times a day lasting up to 5 hrs each round, with migraines in between, and no relief for 3 months, worst 3 months of my life, I would have rather been in back labor for a week than feel this insane pain.

    I tried Topamax, it almost stopped the daily attacks, but the side effects weren’t outweighing the benefits after 2 months. So I started to just use the Lidocaine nasal spray and herbal tea made just for this issue. This is taking the edge off but it isn’t going away. However if insurance ever approves the oxygen, my headaches will go into remission again, and hopefully 4 years! I can handle a migraine, even if I get them 3-4 times a week, at least meds work for them on me, and ofc a dark quiet room.

    But I also noticed that my clusters are on one side, front to back literally. And as soon as ones about to hit, almost like clockwork, my eyelid droops & runs, nose runs, and then the ice pick feeling in my eye starts (about 10 mins from eyelid to pain). Pain is in one eye, but both eyes have the other symptoms.

    PT on neck seemed to slightly help, but only relieving the lower pain in the back of my head. They’ve tried a lot of medicines, pain killers, NSAIDs, you name it. NSAIDs do help a little, caffeine a little, but out of everything oxygen has always done the trick.

  • Tammy Rome author
    4 years ago

    I am a cluster headache patient, too. You are correct that they do produce autonomic symptoms. Perhaps you misunderstood the article.

    It says, “However, occipital neuralgia does not typically produce autonomic symptoms…” It does not state that CH doesn’t produce autonomic symptoms.

    Oxygen is the only thing that’s ever worked for me, too. Happy to meet another CH patient! 🙂

  • Sara
    4 years ago

    Thanks for the interesting highlight on this lesser known headache disorder Tammy. In October I was inpatient at MHNI and they determined that my headache disorder actually has three facets: intractable migraine with persistent aura without infarction, cervicogenic headache, and occipital neuralgia. I meet some, but not all of the criteria for trigemenal neuralgia so I also got slapped with atypical facial pain. My headache specialts believe the. Cervicogenic headache and neuralgia trigger my migraines. I take a whole host of preventative meds, and in addition I have been getting regular superficial nerve blocks in addition to deep cervical facet blocks C2-C5. I am considering ablation. Now I wonder if I need to be asking about occipital stimulation as well. Sincerely, Still Experiencing Daily Migraine.

  • jo17151
    4 years ago

    Wow – what timing! I’ve been getting Botox injections since 2012 that have reduced both the frequency and severity of migraines (down to about 1/week when the Botox is effective).

    After my last treatment (Dec 9/15) I ended up with occipital neuralgia. I received a nerve block Dec 23 and swore that I’d rather have the pain from the Occipital neuralgia than from the pain at the sites of the nerve block.

    The effects of the nerve block have worn off and the symptoms are not as severe as they were prior to the nerve block – and the neuro told me that because it was the needles used to inject the Botox that must have hit nerves to cause it – the pain and other symptoms should only last 5-6 weeks. It’s been 8 weeks now.

    I’m pretty torn about even proceeding with another Botox treatment in March – however, once this treatment wears off and I’m getting migraines 3x per week, I will probably reconsider.

    This reaction is apparently quite uncommon and I wouldn’t want anyone to not try Botox based on my experience. I have a number of other medical conditions, so I’m almost not surprised that I had some rare freaky response.

    I see the neuro on Friday afternoon – if I’m just slow, but moving in the right direction, I think I can tolerate this till it passes (just because of the pain from the nerve block and to minimize my exposure to steroids). I also want to see if I’m at a high risk to have this reaction again at my next Botox appointment (or if the Botox can be given and he can just skip the occipital area)

    Kinda rambling! thanks for the great article

  • jlane
    4 years ago

    I’ m 63 and in good health but get headaches, sometimes migraines every week. I take Mega Magnesium twice a day & I think it helps relax my muscles & I believe my headaches are not as severe now, although on occasions a migraine sneaks up on me & I have to be sick to finally get better.
    I take imigran, they help on occasions if taken early & so does aspirin helps as well taken early but not every time. My neurologist wants me to get on a preventative…Propranolol (beta blockers I believe they are called) but it slows your heart rate I’m told. Doesn’t sound good to me. I need advice on this please. Can someone help me out, thanks in advance

  • Tammy Rome author
    4 years ago

    There are hundreds of different preventive options that can be tried. All medicines have side effects. The trick is finding an effective one with side effects you can tolerate. Remember that just because a side effect is listed, doesn’t mean that you will experience it. Everyone responds differently. Please talk to your doctor about your concerns. There may be other options that can be tried. The most common categories of preventives include beta blockers, calcium channel blockers, anti-seizure medicines, tricyclic antidepressants, SSRIs, SNRIs, and even some dietary supplements. There is no one medicine that works for everyone. Plus, some patients do better with Botox, nerve blocks, or other non-pill preventives like Cefaly or SpringTMS.

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