Author: Emilie Touma, BA; Sharoon Qaiser, MD, MBBS  
University of Kentucky College of Medicine, Lexington, KY

Reviewed: January 2022

SUMMARY

Occipital neuralgia (ON) is a headache disorder that causes shooting or stabbing pain in the back of the head.  

The word “occipital” refers to the back side of the head. The word “neuralgia” means nerve pain.  

This type of headache is not common. Fewer than 3 in 100,000 people experience ON every year. However, in many cases, it may stay undiagnosed.  

ON is thought to be even more rare in children. Statistics about ON in children are unknown at this point in time.

Disorder Overview

DESCRIPTION

Occipital neuralgia is a specific type of headache. It is located in the upper neck and upper back of the head.  

A headache due to ON will begin suddenly. It will begin with a brief, piercing or shock-like pain that spreads upward to the top of the head. ON may be felt on both sides of the head, or on just one side. Typically, the headache waxes and wanes throughout the episode. In addition to the headache, ON may cause sensitivity to light and scalp tenderness. Children who experience ON may also have migraine headaches or other types of headaches.  

Occipital neuralgia, while uncomfortable, is not a life-threatening condition. The cause of ON is thought to be compressed nerves in the neck and spine. However, the exact cause of a patient’s ON headaches is not always known.  

A patient may experience some relief after treatment with: 

• Rest, conservative treatments  
• Other treatment options 
• Nerve blockade injections 

If initial treatment does not work, doctors will be able to recommend alternative options to help manage the pain.

SIGNS AND SYMPTOMS

Pain in Occipital Neuralgia 

Occipital neuralgia is associated with sudden, severe pain in the back region of the head. The pain may be: 

• Shooting 
• Stabbing 
• Sharp 
• Like an electric shock 

The pain is described as severe. It may cause significant discomfort for the patient.  

Patients with ON may also experience the following in the occipital region: 

• Tenderness 
• Numbness 
• Decreased sensation 

Tenderness, numbness, and decreased sensation may be experienced with or without headache symptoms. 

Location in Head 

The back side of the head is supplied by many nerves. Some of these nerves can contribute to ON. The pain of ON occurs in the area supplied by three occipital nerves: 

• The greater occipital nerve 
• The lesser occipital nerve 
• The third occipital nerve 

Each ON attack may be on one or both sides of the head. The back of the head is the most common area for pain. However, pain may be felt in the neck or forehead, or behind the eyes. 

Timing 

Each attack of stabbing or shooting pain may last from a few seconds to minutes. The frequency of these episodes varies. Multiple attacks in a single day are possible.  

In some cases, an attack can be triggered by pressing the upper part of neck on the same side.

CAUSES

The exact cause of occipital neuralgia remains unknown. It is thought that irritation of the nerves that supply the back of the head contributes to ON. There is usually no clear cause of the nerve irritation. However, it is thought that: 

• Nerves may be irritated anywhere along their course, from their point of origin to their insertion in the scalp.  
• In some cases, the nerves get entrapped in the neck and scalp muscles.  
• Inflammation, infection, surgery, or trauma in the head or neck may contribute to nerve irritation. 

LABORATORY INVESTIGATIONS

Diagnosing Occipital Neuralgia in Adults and Children 

Occipital neuralgia is a clinical diagnosis in adults. This means that doctors can usually make a diagnosis using only: 

• A detailed patient health history 
• A physical exam 

Bloodwork, imaging, and other lab investigations are not required to make a diagnosis in adults.  

However, this is not the case for children. ON is quite rare in children. The International Headache Society suggests testing and imaging to rule out other causes of occipital pain.

Imaging in Occipital Neuralgia 

Taking pictures of the head is the best and most common way to investigate these headaches in children. This can take two forms: 

• Magnetic resonance imagining (MRI). This is considered the superior option for looking for causes of ON. MRI is safe. It includes no risk of radiation. It may require sedation in younger children. 
• Computed tomography scan (CT scan). If pictures of the head reveal concerning findings, more testing may be needed.  

TREATMENT AND THERAPIES 

The treatment of most headaches can be divided into three categories:  

• As-needed treatments 
• Preventative treatments 
• Alternative treatments 

For occipital neuralgia treatment, no hard guidelines exist. This is due to a lack of adult and pediatric studies. However, the treatments outlined below can help manage the pain of ON attacks. All treatments should be discussed with a medical provider.  

As-Needed Treatments 

As-needed treatments help treat a headache while it is occurring. However, attacks of ON are usually brief and self-limiting. Over-the-counter pain medicines are therefore not suggested for these headaches.  

Preventative Treatment 

Conservative Treatments 

A few children may experience neck tightness in between attacks of ON. Using simple measures like heating pads, massage or physical therapy may provide some relief. In some cases, anti-inflammatory medications may be used for a short period of time.    

Occipital Nerve Block 

The first preventative treatment usually tried for ON is an occipital nerve block. The goal is to block the pain signals that may contribute to ON headaches. A nerve block can provide immediate or extended relief. A nerve block injection will include: 

• A steroid. The most commonly used steroid is dexamethasone. 
• A numbing medicine. The most commonly used anesthetic (numbing) agents include:
  • Lidocaine
  • Bupivacaine 

An occipital nerve block is performed by a specialist trained in this procedure. This specialist will inject specific areas supplied by: 

• The greater occipital nerve 
• The greater and lesser occipital nerves 

If the block works, it may also help to confirm the diagnosis.  

Side effects of this procedure can include: 

• Pain at the injection site 
• Infection 
• Bleeding 

It is important to note that an occipital nerve block does not cure ON. Instead, it acts as a temporary prevention tool. Those who respond to the nerve block may require multiple nerve blocks a year to continue to benefit from it. The response to this treatment varies from patient to patient. Some may remain headache-free for a period of days. Others may remain headache-free for weeks.  

Oral Medicines 

In some cases, patients do not benefit from an occipital nerve block. In other cases, they are not comfortable with injections. In these cases, they may be prescribed oral medicines.  

There is no strong evidence that oral medicines are effective in occipital neuralgia. However, there is some evidence that some common headache medicines can help. These medicines include: 

• Gabapentin 
• Pregabalin 
• Amitriptyline 
• Nortriptyline 
• Oxcarbazepine 

These medicines are usually tolerated by patients. This means that the side effects do not cause patients to stop taking the medicine. Side effects include: 

• Sleepiness 
• Dry mouth 
• Dizziness 
• Electrolyte imbalance  

These medicines may require occasional blood work. The blood work will check electrolyte levels.  

Some patients will respond to these medicines and tolerate them well. These patients can continue to take oral medicines over a period suggested by a neurologist.

Alternative Treatments for Occipital Neuralgia 

Some patients may not respond to or tolerate a nerve block or oral medicine. These patients may be offered alternative treatments. Alternative treatments are usually offered in a specialized center. There is no conclusive evidence that they are effective for ON. However, they are used for other headache types. For this reason, they may be used for ON, too.  

Alternative treatments include:

OUTLOOK

Occipital neuralgia attacks may cause significant problems for children. This can happen if attacks are frequent and occur throughout the day. Children with ON may not be able to keep up with school performance or social activities. However, since most attacks are brief and occur without any trigger, educational accommodations are not usually offered.  

Occipital neuralgia may accompany other headache disorders in children. A healthy lifestyle can help prevent headaches in general. Headaches, including ON, may be prevented with: 

• Good hydration 
• Regular exercise 
• A healthy diet 

Patients who respond to an occipital nerve block may experience relief lasting from weeks to months. In some cases, alternative treatments may offer more permanent relief.

RELATED DISORDERS

The pain experienced in occipital neuralgia may be mimicked by other headache disorders. These include:

Occipital neuralgia is not common, especially in children. Therefore, careful investigation is necessary to rule out other potential causes of occipital pain.

The information in the CNF Child Neurology Disorder Directory is not intended to provide diagnosis, treatment, or medical advice and should not be considered a substitute for advice from a healthcare professional. Content provided is for informational purposes only.  CNF is not responsible for actions taken based on the information included on this webpage. Please consult with a physician or other healthcare professional regarding any medical or health related diagnosis or treatment options. 

Research

ClinicalTrials.gov for Occipital Neuralgia (birth to 17 years)

These are clinical trials that are recruiting or will be recruiting. Updates are made daily, so you are encouraged to check back frequently.   

 ClinicalTrials.gov is a database of privately and publicly funded clinical studies conducted around the world. This is a resource provided by the U.S. National Library of Medicine (NLM), which is an institute within the National Institutes of Health (NIH). Listing a study does not mean it has been evaluated by the U.S. Federal Government. Please read the NLM disclaimer for details.    

Before participating in a study, you are encouraged to talk to your health care provider and learn about the risks and potential benefits.   

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