Occipital Neuralgia (Cervicogenicheadache)

Synonyms:Occipital myalgia-neuralgia syndrome, Occipital headache, Occipital neuropathy, Occipital neuritis, Arnold neuralgia, Third occipital headache, cervical migraine.The International Headache Society categorizes occipital neuralgia as a cranial neuralgia and defines it with three diagnostic features: paroxysmal stabbing pain in the distribution of the occipital nerves with tenderness over the affected nerves temporarily relieved by local anesthetic block.Occipital neuralgia can occur in the distribution of the greater and lesser occipital nerves. However, the greater occipital nerve is more commonly involved (90%); in addition, unilateral symptoms are more common (85%). The condition appears to be more common in women.Pharmacologic therapy with NSAID’s or acetaminophen as well as other analgesics may be used. Tricyclic antidepressants, anticonvulsants, and muscle relaxants may also prove useful.Rehabilitative treatments that may help with pain from occipital neuralgia include heat or cold therapy, massage, avoidance of excessive cervical spine flexion-extension or rotation, acupuncture, and application of transcutaneous electrical nerve stimulation. Patients will often benefit from adaptive equipment at home and work, such as a telephone earset or bookstand. It is also important to determine whether patients are using bifocal glasses and whether adjusting the neck to use these glasses is contributing to the condition.Postural training and relaxation exercises should be incorporated into the exercise regimen. Principles of ergonomics should be addressed if work site activity is limited by pain exacerbations (e.g., use of a telephone headset, document holder). Cervicaltraction ormanual therapy, including spinal manipulation and spinal mobilization, has been used to treat patients with cervicogenicheadaches. Any spinal manipulation should be done with caution because there are serious risks if it is improperly performed. Blockade of the greater or lesser occipital nerve with a local anesthetic is diagnostic and therapeutic. Pain relief can vary from hours to months. Dorsal rhizotomy of C1, C2, C3, and C4 has been described; about 71% to 77% of patients report significant benefit.Pulsed radiofrequency to the culprit occipital nerve was shown to improve symptoms for 6 months or more.One should consider surgical treatment after conservative therapy has failed. A variety of surgical procedures for occipital neuralgia have been proposed, such as neurostimulation,neurectomy, C1-C2 decompression, C2 ganglionectomy, occipital nerve stimulation andsurgical release of the inferior oblique muscles