Occipital neuralgia: symptoms, causes and treatment

Treatment is stepped, starting with simple measures and moving to specialist options if the pain does not settle. A UK private hospital group describes anti-inflammatory medication as something that can often relieve the symptoms, and says physiotherapy and massage can also relieve the pain.

An occipital nerve block is the next step for many people. An NHS trust pain-management leaflet explains that it is an injection of local anaesthetic and steroid into a group of nerves at the back of the head. Both medicines act to block the pain signals sent to the brain, and the steroid also reduces swelling and inflammation around the nerves.

The leaflet says the procedure takes 10 to 15 minutes, is done while you are awake (sedation may be offered), may use ultrasound for guidance and is usually followed by about 30 minutes of observation before you go home. It also says you do not have to have a nerve block and that you can carry on with painkillers instead if you prefer.

If blocks and medicines are not enough, specialist centres may offer occipital nerve stimulation. The hospital group describes electrodes placed against the nerves through a small operation, with a battery-powered generator under the skin of the chest that sends mild electric currents to the back of the head to block pain signals.

Neuralgia means pain along the course of a nerve. The occipital nerves run from the top of the spine up the back of the scalp, so the pain is felt at the back of the head and can be mistaken for other headaches. A UK private hospital group lists these symptoms. Not everyone has all of them.

• Episodes of stabbing pain that last from seconds to minutes.

• Pain on one side of the head.

• Strange sensations along the scalp, the back of the head and the neck.

• An area of scalp that feels extremely tender.

• A dull ache between attacks.

• Attacks set off by ordinary things such as brushing the hair or resting your head on a pillow.

The same hospital group page says occipital neuralgia is often caused when the occipital nerve, which travels along the neck and up to the base of the skull, becomes trapped. It names arthritis between the first and second vertebrae (neck bones) as one way the nerve can be trapped and cause pain.

The sources used for this page do not give a fuller list of causes, so the likely cause in your own case is best discussed with the clinician who assesses you.

The NHS notes that routine headaches have many common triggers, such as stress, poor posture, dehydration, missed meals, too much alcohol and taking too many painkillers. A headache diary can help work out what sets your headaches off.

There is no home treatment that replaces a proper diagnosis, but general headache self-care from the NHS and NHS inform can help while you wait to be seen. These tips are written for headaches in general, not for occipital neuralgia specifically.

• Drink plenty of water, get plenty of rest and try to relax, because stress can make headaches worse.

• Take paracetamol or ibuprofen, but keep to the dose on the packet. The NHS lists taking too many painkillers as a cause of headache in itself.

• NHS inform says you should not normally take painkillers on more than 10 days every month, because frequent use can cause medication overuse headache.

• Do not skip meals, and avoid looking at a screen for a long time or drinking alcohol.

• Keep a headache diary of when attacks happen and what you were doing; the NHS says this can help work out triggers.

• If hair brushing or a pillow sets off an attack, note it in the diary and mention it to the clinician.

A single attack is short. The hospital group page describes stabbing episodes that last from seconds to minutes, with a dull ache in between. The NHS says that ordinary headaches can last from 30 minutes to several hours, or sometimes several days, which is a different pattern.

None of the UK sources used here says how many weeks or years the condition itself lasts, and it is not possible to give a reliable figure. What the sources do say is that a nerve block can relieve pain for a few weeks or months, and that further treatment plans are based on how you respond to the injection. Some people need repeat injections.

There is no single blood test for occipital neuralgia. A consultant discusses your symptoms to make a diagnosis, and the hospital group page says CT scans of the spine and an MRI scan may be ordered to look at the area in more detail.

Assessment of any headache starts with the pattern of pain and any red flags. NICE Clinical Knowledge Summaries tells GPs to ask about red flags, when the pain began, how long and how often it comes, where it is and what it feels like, associated symptoms, triggers and medicines. It says investigations are generally not needed to diagnose a primary headache, and that a headache diary kept for at least 8 weeks can help when the diagnosis is uncertain.

Ruling out other causes is a big part of the assessment, particularly if you have any of the red-flag features below or the pattern of your headaches has changed.

Most headaches are not serious, but some features should never be put down to a nerve problem without assessment.

The NHS says to call 999 or go to A&E if a headache starts suddenly and is extremely painful, or you or a child have a headache with any of the following. Do not drive yourself to A&E.

• A head injury within the last 3 months.

• A seizure (fit).

• Numbness or weakness in the body or face.

• Difficulty speaking, balancing, walking or remembering things.

• Drowsiness or confusion, or loss of vision.

• A rash that does not fade when a glass is rolled over it.

• A very high temperature, a stiff neck, or bright lights bothering you.

The NHS says to ask for an urgent GP appointment or get help from NHS 111 if a headache comes with vision or eye problems, is triggered or made worse by coughing, sneezing, bending down or exercising, comes with being sick, or comes with jaw pain when eating or a sore or tender scalp.

NHS inform adds that a sore scalp or jaw pain while chewing in someone over 50 is a reason to contact the GP practice urgently, as are a headache if you are pregnant or have just given birth, and a headache that is new or getting worse with dizziness, vomiting or weakness. It says to contact the GP practice for a headache that wakes you from sleep, or if you have or have had cancer.

Scalp tenderness is also a feature of occipital neuralgia, which is why new scalp tenderness with jaw pain when eating should be assessed promptly rather than assumed to be nerve pain. The NHS says to see a GP if headaches are not getting better with self-care, are getting worse or are frequent.

Several conditions can cause pain in the head and face, and the pattern is what helps tell them apart. This table summarises what the NHS, NHS inform and the hospital group page say.

A GP is the usual starting point on the NHS. If the diagnosis is unclear or the pain is not settling, they can refer you on to a specialist service such as neurology or a pain clinic, where nerve blocks are carried out. Waiting times for specialist appointments vary by area.

Private neurology and pain services offer similar assessments, scans and injections, often with more flexible appointment times. The procedure and its risks are broadly the same whichever route you take. Whichever you choose, ask who will explain the results and what the plan is if the injection helps only for a short time.