Pain Conditions
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      2. Pain Conditions

      Occipital Neuralgia

      Brief Overview: Occipital neuralgia (ON) is a form of neuropathic head/neck pain where the greater, lesser, or third occipital nerves are irritated or compressed, leading to intense, stabbing, or electric-shock–like pain at the base of the skull, scalp, and behind the ears. Pain most often affects one side but can be bilateral in about one-third of cases.

      Prevalence: The exact prevalence is unknown.

      Etiology: Pain arises from compression or irritation of the occipital nerves, often due to tight cervical muscles, joint arthritis, trauma (including whiplash), or mass lesions. For about 90% of patients, the greater occipital nerve is involved.

      Risk Factors:

      • Degenerative disc disease (DDD)
      • Diabetes
      • Gout
      • Osteoarthritis
      • Vasculitis
      • Prior neck trauma or strain

      Commonly Associated Conditions:

      • Cervical muscle strain
      • Vascular malformation
      • Neoplasms
      • Neuroinvasive infection (herpes)
      • Transverse myelitis

      Common Medications:

      • Gabapentin
      • Pregabalin
      • Carbamazepine
      • Baclofen
      • Amitriptyline
      • NSAIDs/Tylenol

      Common Labs, Imaging, and Tests:

      • MRI of the brain and c-spine with contrast
      • CT of the brain and c-spine with contrast
      • Diagnostic occipital nerve block

      Common Symptoms:

      • Intermittent neuropathic head/neck pain – typically described as severe, stabbing, electric, shock-like, sharp, shooting
      • Less common: tinnitus, nausea, dizziness

      Common Treatments:

      • Occipital nerve block – typically first-line treatment option
      • Botulinum toxin injections
      • Heat/cold therapy
      • Pulsed radiofrequency (PRF)
      • Occipital nerve decompression
      • Occipital nerve stimulation

      Physical Findings:

      • Tinel’s sign
      • Decreased range of motion of cervical spine muscles
      • Posterior neck muscle spasms
      • Diminished sensation in the affected area
      • According to UpToDate, “Pressure, palpation, or percussion over the occipital nerve trunks may also reveal local tenderness, trigger the background discomfort, or elicit paresthesias along the distribution of the affected nerve”

      Potential Complications and Contraindications:

      • Misdiagnosis as migraine or other headaches delays treatment
      • Repeated injections risk infection, nerve damage, or temporary numbness
      • Surgical interventions carry typical risks (infection, nerve injury, device complications)

      General Health and Lifestyle Guidance:

      • Practice neck stretches and posture exercises (e.g., chin tucks)
      • Use ergonomic head positioning, especially during screen time or driving
      • Manage stress and muscle tension with relaxation, massage, or gentle movement

      Suggested Questions to Ask Patients:

      • Where exactly is your pain located and how long does it last?
      • Does pressing on the back of your head trigger your pain?
      • Have you had nerve blocks or physical therapy before? Did they help?
      • Do you have any other symptoms like visual sensitivity or jaw/neck stiffness?

      Suggested Talking Points:

      • Improving posture and managing muscle tightness often helps prevent future flare-ups
      • Notify your healthcare provider if you have any worsening, persistent, or changing symptoms
      • Surgery may be indicated if other treatment options aren’t effective

      Sources: