Two features point at occipital neuralgia rather than migraine. First, the pain is electric and shooting, not throbbing. Second, the scalp over the nerve is so tender that a hairbrush, a hat or a pillow hurts.
The confusion is easy to understand. Occipital neuralgia is one-sided. It can radiate (spread) forward as far as behind the eye. And it can be severe. People link all three things 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 feeling from the back of the head. When one is irritated or compressed, the result is paroxysms (bursts) of stabbing or shock-like pain along that nerve’s path. It runs from the top of the neck, over the back of the head, and sometimes forward to the eye on the same side. Between the jolts there is often a steady background ache.
ICHD-3 describes it as unilateral or bilateral paroxysmal shooting or stabbing pain in the distribution of the occipital nerves. It comes with dysesthesia or allodynia (pain or odd feeling from a light touch) during innocuous (harmless) stimulation of the scalp. There is also 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. That is because migraine also produces cutaneous allodynia (skin pain from light touch) during attacks. Here is the difference. In occipital neuralgia the tenderness is focal — over one nerve, present between attacks. Migraine allodynia is spread out 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. That both treats the episode and settles the diagnosis. If it does not go, the pain is coming from somewhere else, and the diagnosis needs to move. Most often it moves toward cervicogenic headache or migraine.
That logic only holds if the injection actually reached the nerve. This is why we place these under ultrasound guidance. The occipital artery runs alongside the nerve. Ultrasound shows both and keeps the needle away from the vessel. So a block that fails is information, not a possible miss.
Relief commonly outlasts the anesthetic by weeks — longer than the drug alone explains. There is no fixed course of three. The gap between blocks 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. That can make the picture look muddier than it is. The occipital nerves meet at the same trigeminocervical relay (a pain hub) that generates migraine pain. So blocking them can modulate (turn down) a migraine even when the occipital nerve is not the main generator.
So a partial response does not confirm occipital neuralgia. A complete end to the pain in the nerve’s territory does, in someone with focal tenderness over that nerve.
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 (neck) joints is a third thing — see cervicogenic headache.
Do I need an MRI first?
Not usually. Doctors diagnose occipital neuralgia clinically. That means from the pain pattern, the focal tenderness and the response to a block. Imaging is used to rule out 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 lasts 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.
A numbing block of the occipital nerve answers the question on this page: if the pain stops, the nerve was the source. That test and the occipital neuralgia treatment after it are part of our St. Louis headache clinic.
Sources
- Headache Classification Committee of the International Headache Society. ICHD-3, 13.4 Occipital neuralgia. ichd-3.org