Occipital Neuralgia

What is Occipital Neuralgia?

Occipital neuralgia is a neuropathic pain condition involving the greater occipital nerve, the lesser occipital nerve, or both. These nerves originate from the C2 and C3 cervical nerve roots and travel upward through the suboccipital muscles and across the scalp. When they are compressed, entrapped in tight muscle tissue, or inflamed, the result is sharp, shooting, or burning pain in the back of the scalp.

The condition can arise from direct nerve compression, injury to the upper cervical spine, tight suboccipital musculature, whiplash, or degenerative changes at C2-C3. It is sometimes confused with migraine or cervicogenic headache, though the pain quality and location are distinctive. Firm pressure over the greater occipital nerve at the base of the skull typically reproduces the pain, and relief following a targeted nerve block is both diagnostic and therapeutic.

Left untreated, the pain can become constant rather than episodic and extend across the entire scalp on the affected side. Catching it early and intervening at the nerve level gives the best outcomes.

Symptoms

• Shooting, stabbing, or electric-shock pain starting at the base of the skull and spreading up and over the head
• Pain usually on one side, though both sides can be affected
• Scalp tenderness, especially when brushing the hair or resting the head on a pillow
• Sensitivity to light in some cases, but no visual aura
• Pain that radiates behind the eye on the affected side
• Tenderness to palpation along the occipital nerve pathway at the back of the skull

How We Treat It

The first step is an ultrasound-guided occipital nerve block. A small volume of local anesthetic and steroid is injected precisely at the greater or lesser occipital nerve. Relief after this block confirms the diagnosis and provides meaningful pain reduction, often lasting weeks to months. We repeat this procedure as needed, with the steroid component working to reduce perineural inflammation over time.

For patients with frequent recurrence who find nerve blocks helpful but short-lived, pulsed radiofrequency treatment to the occipital nerve is a longer-duration option with a good safety profile. We also evaluate for a contributing cervical cause: if C2-C3 joint pathology is driving the nerve irritation, addressing that source directly produces more lasting results than treating the nerve alone.