SCOPE: Evaluation and management of occipital neuralgia in adults. Includes ICHD-3 diagnostic criteria, differentiation from migraine/tension-type/cervicogenic headache, diagnostic and therapeutic nerve blocks, pharmacotherapy, and interventional procedures. Covers ED acute management, inpatient evaluation for refractory cases, outpatient chronic management, and ICU considerations for severe refractory pain or post-procedural monitoring. Excludes primary headache disorders unless part of differential.
DEFINITIONS:
- Occipital Neuralgia (ICHD-3 13.4): Unilateral or bilateral paroxysmal, shooting or stabbing pain in the posterior part of the scalp, in the distribution(s) of the greater, lesser, and/or third occipital nerves, sometimes accompanied by diminished sensation or dysesthesia in the affected area; commonly associated with tenderness over the affected nerve(s)
- Greater Occipital Nerve (GON): Arises from the dorsal ramus of C2 (with contribution from C3); emerges between the obliquus capitis inferior and semispinalis capitis at the superior nuchal line, medial to the occipital artery
- Lesser Occipital Nerve (LON): Arises from the ventral rami of C2-C3; courses along the posterior border of the sternocleidomastoid muscle
- Third Occipital Nerve (TON): Arises from the dorsal ramus of C3; crosses the C2-C3 facet joint; innervates lower occipital region
- Diagnostic Block Criteria (ICHD-3): Pain is temporarily relieved by local anesthetic block of the affected nerve(s); this is both diagnostic and part of the formal criteria
- Cervicogenic Headache: Headache caused by a disorder of the cervical spine (C1-C3), distinguished from occipital neuralgia by its referred, non-neuralgic quality
PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting
Acute occipital pain; diagnostic confirmation per ICHD-3 criteria
2-3 mL :: SC/deep :: once :: 2% lidocaine (2-3 mL) OR 0.5% bupivacaine (2-3 mL) injected at medial third of line between external occipital protuberance and mastoid process; aspirate before injection; may add methylprednisolone 40 mg or triamcinolone 20-40 mg
Local infection, allergy to local anesthetic, coagulopathy
Pain in LON distribution (lateral occiput, behind ear)
1-2 mL :: SC :: once :: 2% lidocaine (1-2 mL) OR 0.5% bupivacaine (1-2 mL) injected at posterior border of SCM, one-third distance from mastoid to occiput
Local infection, allergy, coagulopathy
Pain relief; vasovagal reaction
STAT
ROUTINE
ROUTINE
STAT
Ketorolac
IV/IM
Acute pain; anti-inflammatory
30 mg; 15 mg :: IV/IM :: once :: 30 mg IV/IM (15 mg if age >65, renal impairment, or weight <50 kg); max 5 days total NSAID use
GI bleeding, renal failure, active peptic ulcer, CABG within 14 days
Renal function, GI symptoms
STAT
ROUTINE
-
STAT
Naproxen
PO
Acute exacerbation; anti-inflammatory
500 mg :: PO :: BID :: 500 mg BID with food; max 1250 mg/day; limit 10-14 day course
GI bleeding, renal failure, NSAID allergy, third trimester pregnancy
GI symptoms, renal function, BP
ROUTINE
ROUTINE
ROUTINE
-
Cyclobenzaprine
PO
Cervical muscle spasm contributing to occipital nerve irritation
5 mg; 10 mg :: PO :: TID :: Start 5 mg TID; increase to 10 mg TID if needed; max 30 mg/day; short course (2-3 weeks)
MAOIs within 14 days, hyperthyroidism, heart failure, arrhythmia
25-50 units :: IM :: q12wk :: 25-50 units total divided across GON and LON regions bilaterally; inject at occipital insertion points; onset 1-2 weeks; repeat q12 weeks
Infection at injection site, known hypersensitivity, neuromuscular junction disorders (MG, Lambert-Eaton)
Pain scores, neck weakness, dysphagia (rare with occipital injection)
-
-
ROUTINE
-
Lidocaine 5% patch
Topical
Localized occipital pain; adjunct to oral therapy
1-2 patches :: Topical :: daily :: Apply 1-2 patches to occipital region; 12 hours on / 12 hours off; cut to size as needed
Allergy to amide-type local anesthetics
Skin irritation
-
ROUTINE
ROUTINE
-
Capsaicin 0.075% cream
Topical
Adjunct for localized occipital pain; neuropathic pain
Thin layer :: Topical :: TID-QID :: Apply thin layer to occipital region TID-QID; initial burning is expected (decreases over 1-2 weeks); wash hands after application; avoid eyes/mucous membranes
GON block with steroid (ultrasound-guided) (CPT 64405, 76942)
Local injection
Confirmed occipital neuralgia with positive diagnostic block; recurrent episodes
2-3 mL :: SC/deep :: q4-8wk :: 0.5% bupivacaine 2-3 mL + methylprednisolone 40 mg (or triamcinolone 40 mg); US-guided for precision; landmark: medial third of line from external occipital protuberance to mastoid process; repeat q4-8 weeks as needed (limit 3-4 steroid injections per year)
Active infection, coagulopathy, allergy to injectate
Pain scores, duration of relief, steroid side effects (skin atrophy, glucose elevation in diabetics)
-
ROUTINE
ROUTINE
-
C2 nerve root block (fluoroscopy-guided)
Local injection
Refractory to peripheral nerve blocks; suspected C2 root origin
1-2 mL :: Perineural :: once :: 0.5% bupivacaine 1-2 mL +/- dexamethasone 4 mg; fluoroscopy-guided with contrast confirmation; performed by interventional pain specialist or neuroradiologist
Active infection, coagulopathy, vertebral artery anomaly
Post-procedure neurologic exam; monitor for vertebral artery injury, spinal cord injury, high spinal block
-
ROUTINE
ROUTINE
-
Pulsed radiofrequency ablation (PRF) of GON or C2 dorsal root ganglion
Percutaneous
Refractory occipital neuralgia; positive diagnostic block but short-lived relief from repeated injections
N/A :: Percutaneous :: once :: 42 degrees C, 120 seconds x 2-3 cycles; fluoroscopy or US-guided needle placement at GON or C2 DRG; performed by pain specialist; non-destructive (pulsed, not thermal)
Active infection, coagulopathy, implanted cardiac device near field
Post-procedure pain assessment; monitor for numbness, dysesthesia, infection
-
ROUTINE
ROUTINE
-
C1-C2 (atlantoaxial) facet joint injection
Local injection
Suspected C1-C2 facet-mediated pain contributing to occipital neuralgia
0.5-1 mL :: Intra-articular :: once :: 0.5% bupivacaine 0.5-1 mL + triamcinolone 20 mg; fluoroscopy-guided with contrast arthrogram; performed by interventional pain specialist
Active infection, coagulopathy, vertebral artery anomaly
Diagnosis confirmed by clinical features and/or positive diagnostic nerve block; pain controlled with oral medications; no red flags; outpatient follow-up arranged within 2-4 weeks
Admit to hospital
Intractable pain despite ED nerve block and parenteral analgesics; need for IV medications or serial nerve blocks; diagnostic uncertainty requiring urgent imaging; suspected secondary cause (dissection, mass)
ICU admission
Suspected vertebral artery dissection with neurologic deficits; post-procedural complication requiring close monitoring; hemodynamic instability related to pain crisis or anaphylaxis from procedural agents
Outpatient neurology/headache follow-up
All patients with new diagnosis of occipital neuralgia; medication titration and monitoring; assessment of treatment response at 4-6 weeks
Interventional pain referral
Failed 2+ oral medication trials at adequate doses; recurrent need for nerve blocks (>3 per year); candidate for PRF, botulinum toxin, or neurostimulation evaluation
Medication management for stable patients; metabolic monitoring (labs for carbamazepine, gabapentin renal dosing); annual reassessment of treatment plan
ICHD-3 diagnostic criteria for occipital neuralgia (13.4): pain in distribution of occipital nerves, tenderness over nerve, temporary relief with anesthetic block
ICHD-3 diagnostic criteria require all of the following: (1) unilateral or bilateral pain in distribution of GON, LON, or TON; (2) pain has two of three: recurring paroxysmal attacks lasting seconds to minutes, severe intensity, shooting/stabbing/sharp quality; (3) tender to palpation over the affected nerve; (4) pain temporarily relieved by local anesthetic block
The greater occipital nerve block is the cornerstone of both diagnosis and initial treatment; a positive response (>50% relief) is required for definitive ICHD-3 diagnosis
GON landmark: palpate external occipital protuberance (EOP); the GON is approximately at the medial third of a line drawn from EOP to mastoid process; the occipital artery pulse may be used as an adjacent landmark
Occipital neuralgia frequently coexists with migraine; treat both conditions when present
Distinguish from cervicogenic headache: occipital neuralgia is neuralgic (paroxysmal, shooting), while cervicogenic headache is referred, dull, and provoked by neck movement
Red flags requiring urgent imaging: sudden onset, fever, weight loss, neurologic deficits, history of cancer, anticoagulation, trauma, age >50 with new headache
Avoid overuse of nerve blocks with steroid (limit 3-4 per year) due to risk of local tissue atrophy and systemic steroid effects
When starting carbamazepine, screen for HLA-B*1502 in patients of Asian descent (risk of Stevens-Johnson syndrome / toxic epidermal necrolysis)
Pulsed radiofrequency (42 degrees C) is preferred over conventional thermal radiofrequency (80 degrees C) for occipital nerves to avoid deafferentation pain and permanent numbness
Occipital nerve stimulation should be reserved for truly refractory patients after multidisciplinary evaluation including psychological assessment