According the classification of the International Association for the Study of Pain (IASP), occipital neuralgia is defined as a paroxysmal shooting, stabbing or crushing pain in the region of the greater or lesser occipital nerve, suboccipitally located, and radiation across the skull. The pain may be associated with a loss of sensation or dysaesthesia in the affected area.
Signs and symptoms
The patient complains of a shooting, stabbing or crushing pain in the neck radiating over the skull. A constant pain may persist between paroxysms. Due to overlap of the C2 dorsal root and the caudal part of the spinal trigeminal nucleus, the pain can radiate retro-orbitally.
The aetiology of occipital neuralgia is caused by damage or irritation to the greater or lesser occipital major/minor nerve, or to its course from the spinal cord into its terminal branches. The causes of this disturbance can be divided into three groups:
1. Vascular: irritation of nerve roots C1/C2 by a aberrant branch of the PICA, dural arteriovenous fistulas at the cervical level, bleeding from a bulbocavernosous hemangioma, cervical intra-medullar cavernous hemangioma, giant cell arteritis, fenestrated vertebral artery compressing nerve roots C1/C2, aberrant course of the vertebral artery.
2. Neurogenic: schwannoma near the craniocervical junction, schwannoma of the occipital nerve, C2 myelitis, and muscular/tendons.
3. C1/C2 osteoarthritis, atlantodental sclerosis, hypermobile posterior arc of the atlas, cervical osteochondromas, osteolytic lesion of the skull, excessive callus formation after fracture C1/C2.
Clinical examination can show dysaesthesia or hyperesthesia in the area of the greater and lesser occipital nerves, and pressure pain over the course of these nerves with a positive Tinel sign (pain after tapping on the over the nerve).
Additional Somatic Diagnostics
Cervical X-ray is recommended to exclude other possible causes. CT scan of the craniocervical junction when there is suspicion of osseous pathology, such as atlantodental osteoarthritis.
A diagnostic test block with local anaesthetic to the most painful nerve can confirm the diagnosis.
Additional Psycho-cognitive Diagnostics
- RAND-36 (quality of life)
- VAS-Pain (maximal, minimal, actual, average/week)
- PCS (catastrophising)
- HADS (fear and depression)
Whether or not somatic treatment is indicated is based on the pain diagnosis. Based on the findings of the pain questionnaires, additional diagnostics and/or multidisciplinary treatment comprising various non-somatic treatments may be necessary.
- Non-steroid Anti-inflammatories (short period)
- Tricyclic antidepressants
- Anticonvulsives: carbamazepine, oxcarbazepine, gabapentine en pregabaline.
Interventional Pain Treatment
- Single injection with corticosteroids of the occipital nerves
- PRF treatment occipital nerve
- Test block of upper cervical nerve roots
- PRF treatment of upper cervical nerve roots