Sharp, electric pain running from the base of the skull up the back of the head — and one of the few headaches with a treatment that also confirms the diagnosis.
How it presents
Paroxysms of stabbing or shock-like pain in the distribution of the greater or lesser occipital nerve — from the top of the neck, over the back of the head, sometimes as far as behind the eye on the same side. Between the jolts there is often a persistent ache.
Two features are close to characteristic. The scalp over the affected nerve is tender enough that brushing your hair, wearing a hat or lying on a pillow hurts. And pressing on the nerve where it emerges below the base of the skull reproduces the pain.
Treatment that is also a test
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 elsewhere and the diagnosis needs to move, most often toward cervicogenic headache or migraine.
Relief commonly outlasts the anesthetic by weeks. How the next block is timed depends on how long the last one held and on what is happening clinically — not on a fixed series.
Why it is missed
Because it is one-sided and can radiate behind the eye, it gets called migraine. Because it follows neck movement, it gets called a pulled muscle. The scalp tenderness is the feature that most reliably points the right way, and it is rarely asked about.