Occipital headaches explained – Dr Ivan Ramos-Galvez

They are not a headache. They are more a pain in the head. More specific, a pain at the back of the head (occiput, occipital area or nuchal area) moving forwards around the ears towards the crown of the head and sometimes as far forward as into the eyes. It is a piercing pain that can come in waves.
The most common cause of these symptoms is pain through the occipital nerves. These are the nerves that arise from the spine and supply the back of the scalp. There are three occipital nerves on each side, so six in total. The most commonly involved are the Greater Occipital and the Third Occipital, with the Lesser Occipital being rarely a source of pain.
Occipital neuralgic pain from irritation of the Third Occipital Nerve is a common presentation of referred pain from wear-and-tear of the spine at the top of the neck. The symptoms include neck pain with painful movements of the neck, which not only are lessened and accompanied by crunching noises, but also refer pain into the back of the neck and sometimes as far forward as the eyes. Muscle spasm of the Trapezius Muscle is often seen. It is a natural reaction to the wear and tear of the bone frame of the spine. When this happens, the small nerves that will feed into the Occipital nerve will have some pressure around them that will translate into pain. These symptoms often affect both sides of the neck/head.
Occipital neuralgic pain from irritation of the Greater Occipital Nerves starts at the back of the neck and travels around the ears. It is related to the area of distribution of the nerve and, although true compression of the nerve is rare, we commonly see that conditions where there is muscle tension in the neck and shoulders, this will give rise to symptoms of pain and stiffness in the back of the head. Common triggers include whiplash secondary to accidents where the head is unexpectedly shaken about, stress, repetitive strain injuries of the shoulder girdle such as desk-based work, compression/entrapment syndromes affecting the nerve or simply cold wind at the back of an unprotected head/ears. Very rarely, surgery can damage these nerves giving origin to pain and changes in sensation and feeling. In contrast with problems related to the Third Occipital nerve, when a true compression of the Greater Occipital Nerve exists, there is often sensitivity to gentle rubbing over the hair or gentle touch of the skin in the scalp or even numbness. The pain in these situations is often episodic and in spasms. It radiates as an electricity shock along the whole of the nerve or even across the head into the back of the eyes. Whilst true compressions of the nerves are frequently unilateral, other causes of neuralgia, such as stress, muscle tension, whiplash or wear and tear of the spine often give bilateral symptoms.
The main elements we consider to reach a diagnosis of occipital neuralgia are:
• Clinical history that explains pain in the area where the nerve would be
• Examination confirming tenderness to palpation of the area behind the head where the occipital nerves would be. This would often refer forwards along the nerve, sometimes as far as the eye.
• Examination of the neck, paying attention to the movements of the head and to the way the pain behaved when the head is moved.
• Positive response to a diagnostic injection of local anaesthetic and steroid around the nerves.
Imaging can be beneficial at excluding rare causes of these symptoms such as tumours and to point out towards the degree of wear and tear that may be at the top of the neck, around the first 2 vertebrae.
The treatment of occipital neuralgia can be very rewarding, as often it will respond very well to an injection. Simple measures such as physiotherapy and massage can also be very beneficial, but, unless the trigger is identified and changed, the symptoms will return. For people who are not keen on having needles into the back of their heads, tablets can be of some use.
The use of tablets can be guided by the frequency and severity of the symptoms.
• In cases where the pain is episodic and predictable, i.e. it follows a pattern and the symptoms can be expected to follow certain activities,  a simple anti-inflammatory or a muscle relaxant on an as-required basis can be useful and do not need to be taken every day, restricting their use to just before doing the activity that is known to cause the pain.

• Cases where the symptoms are continuous or their occurrence is unpredictable, can be treated with regular medication. These are tablets taken only at night that can be beneficial as they will not only help with sleep, but also can help to reduce the muscle spasms often associated with the nerve symptoms and reduce the pain as such by having a direct effect at dampening the irritability of the nerve. However, whilst these tablets can be very beneficial, they can also be accompanied by multiple and unpleasant side effects, including drowsiness, tiredness, lethargy, exhaustion and a dry mouth.
Injections are probably the most efficacious way to treat this type of pain. The effect tends to be felt within a few minutes of the injection and for some patients it can be life-changing.

• Injections around the third occipital nerve are carried out in an operating theatre under sedation with the help of a portable x-ray machine to guide the needle into the correct position.

• Injections on the greater occipital nerves can be carried out in the clinic room under some local anaesthesia. The nerves are superficial and can be reached with a small needle similar to the needles used for a blood test.

• For those cases where the injections are beneficial but not long-lived, some other options available will include using techniques that prolong the effect, either by electrically treating the nerve itself with radiofrequency or by injecting Botulinum Toxin A (Botox) into the same area.

• Botox can be a very effective way to produce pain relief. Research suggests that, other than acting by relaxing the muscles that are tight, it acts directly upon the nerve and has a direct analgesic effect. The effects of Botox upon a muscle is in average 3 months. However, the effect upon a nerve can last longer
The expected benefit of these treatments is variable, but often measured in months or even years.
If you suffer from any of these symptoms and would like advice from a specialist, please contact the London Pain Clinic for a consultation on 0207 118 0250 or email us at info@londonpainclinic.com