Occipital neuralgia or migraine?

Two features point at occipital neuralgia rather than migraine: the pain is electric and shooting rather than throbbing, and the scalp over the nerve is tender enough that a hairbrush, a hat or a pillow hurts.

The confusion is understandable. Occipital neuralgia is one-sided, it can radiate forward as far as behind the eye, and it can be severe — three things people associate with migraine. But the quality of the pain and the scalp findings are different, and so is the treatment.

What occipital neuralgia actually is

The greater and lesser occipital nerves carry sensation from the back of the head. When one is irritated or compressed, the result is paroxysms of stabbing or shock-like pain in that nerve’s territory — from the top of the neck, over the back of the head, sometimes forward to the eye on the same side. Between the jolts there is often a persistent background ache.

ICHD-3 describes it as unilateral or bilateral paroxysmal shooting or stabbing pain in the distribution of the occipital nerves, with dysaesthesia or allodynia during innocuous stimulation of the scalp, and tenderness over the affected nerve.¹ That last part — tenderness over the nerve — is the thing to check.

Side by side

Points to occipital neuralgia

• Electric, shooting, stabbing paroxysms — not a throb
• Pain running from the base of the skull upward, following the nerve
• Scalp allodynia: brushing hair, wearing a hat, or lying on a pillow hurts
• Pressing where the nerve emerges below the skull base reproduces the pain
• Relief when the nerve is anesthetized

Points to migraine

• Pulsating, building over minutes to hours
• Nausea, or sensitivity to both light and sound
• Made worse by routine physical activity
• Attacks lasting 4 to 72 hours
• A history of aura in some people

Scalp sensitivity is where people get caught out, because migraine also produces cutaneous allodynia during attacks. The difference is that in occipital neuralgia the tenderness is focal — over one nerve, present between attacks — while migraine allodynia is diffuse and tracks the attack.

The block that is also a test

This is the useful part. An occipital nerve block places local anesthetic directly around the nerve. If the pain goes, that nerve was the source, which both treats the episode and settles the diagnosis. If it does not go, the pain is arising somewhere else and the diagnosis needs to move — most often toward cervicogenic headache or migraine.

That logic only holds if the injection actually reached the nerve, which is why we place these under ultrasound guidance. The occipital artery runs alongside the nerve; ultrasound shows both, keeps the needle away from the vessel, and means a block that fails is information rather than a possible miss.

Relief commonly outlasts the anesthetic by weeks — longer than the pharmacology alone explains. There is no fixed course of three. The interval is set by how long the last one held and by what is happening clinically.

Where the two overlap

Occipital nerve blocks are also used in migraine and in cluster headache, which can make the picture look muddier than it is. The occipital nerves converge on the same trigeminocervical relay that generates migraine pain, so blocking them can modulate a migraine even when the occipital nerve is not the primary generator.

So a partial response does not confirm occipital neuralgia. A complete abolition of the pain in the nerve’s territory, in someone with focal tenderness over that nerve, does.

Common questions

Is occipital neuralgia the same as a pinched nerve in the neck?

No, though they can coexist. Occipital neuralgia is irritation of the occipital nerve itself; cervical radiculopathy is compression of a nerve root in the neck. Pain referred from the upper cervical joints is a third thing — see cervicogenic headache.

Do I need an MRI first?

Not usually. Occipital neuralgia is diagnosed clinically from the pain pattern, the focal tenderness and the response to a block. Imaging is used to exclude other causes when the history suggests them. See occipital neuralgia treatment.

How long does the relief last?

It varies widely between people. The anesthetic wears off in hours but relief often persists for weeks. We time the next block by how long the last one held, not by a schedule. See occipital nerve block.

Does the injection hurt?

The needle is fine and the injection takes seconds. Scalp numbness over the back of the head afterwards is expected and wears off over several hours. There is no sedation and you drive yourself home. See occipital nerve block.

Sources

1. Headache Classification Committee of the International Headache Society. ICHD-3, 13.4 Occipital neuralgia. ichd-3.org