Occipital neuralgia is a miserable nagging soreness and pain in the back of the head. I tell patients to think of occipital neuralgia as “sciatica of the head”. It is typically felt in the suboccipital region (where the base of the skull meets the top of the neck) and radiates variably into the back and top of the head and behind the ears. It can less commonly even radiate to the frontal areas (by the trigeminocervical circuitry in the upper cervical spinal cord and brainstem). It can be one sided or both sides. The pain is often described as an intense stabbing, sharp, shooting, shocking, or burning pain. It often occurs in attacks of pain which may last seconds to minutes, but can also be a continuous unrelenting pain. Sometimes it may not be as intense and may be a lower-level pain such as pressure, aching, soreness or throbbiness. The back of the head often feels very sore or tender. The pain and tenderness often increases by pushing on the back of the head and along the skull base, or lying on the back of the head. Some patients may have a sensation of numbness or tingling in the back of the head. Associated neck pain is typically in the mix too.
The cause of occipital neuralgia is most commonly idiopathic, meaning there isn’t a specific cause. If you have had surgery or an injury to the back of the head, this can cause scarring of the tissues in the back of the head and base of the skull where the occipital nerves travel. This scarring can pull, twist, and tangle up the occipital nerves over time which causes persistent occipital pain in the back of the head. Sometimes the cause can be from a lot of arthritis in the upper cervical spine, tight muscles through the upper neck and skull base, or following a viral illness which can cause them to become inflamed.
Although patients often have isolated occipital neuralgia, I see many patients with occipital neuralgia who also have associated migraine and chronic migraine
. This always creates an even more miserable feedback loop between frequent exacerbations of both the occipital neuralgia and migraine. The reason is because these two headache types influence and feed into each other. For example, 70% of patients with straightforward episodic migraine will get neck pain and tightness at the beginning of a migraine attack. So, if someone is stuck in a smoldering cycle of chronic migraine (15-30 days per month), neck pain and occipital neuralgia are commonly associated. The flip side is if someone has structural abnormalities in the cervical spine (herniated disc, injury, whiplash, etc.), it can also be a contributor to frequent or daily headaches (especially if they have a history of migraine).
A more detailed discussion of occipital neuralgia and its treatments including occipital nerve blocks can be read here.