Skip to main content

Advertisement

SpringerLink
Log in

Occipital Neuralgia and Cervicogenic Headache: Diagnosis and Management

  • Headache (R. Halker Singh, Section Editor)
  • Published:
Current Neurology and Neuroscience Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Occipital neuralgia (ON) and cervicogenic headache (CGH) are secondary headache disorders with occipital pain as a key feature. Due to significant phenotypic overlap, differentiating ON and CGH from primary headache disorders such as migraine or tension-type headache, or other secondary headache disorders, can be clinically challenging. This article reviews the anatomy, clinical features, unique diagnostic considerations, and management approaches relating to ON and CGH.

Recent Findings

Conservative therapeutic approaches are considered first-line. Anesthetic nerve blocks may have a dual role in both supporting diagnosis and providing pain relief. Newer minimally invasive procedures, such as pulsed radiofrequency (PRF) and occipital nerve stimulation (ONS), represent an exciting therapeutic avenue for severe/refractory cases. Surgical interventions should be reserved for select patient populations who have failed all other conservative and minimally invasive options, to be weighed against potential risk.

Summary

ON and CGH represent an ongoing diagnostic challenge. Further studies are required to consolidate efficacy regarding the comprehensive management of ON and CGH.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Bogduk N. The neck and headaches. Neurol Clin N Am. 2004;22(1):151–71.

    Article  Google Scholar 

  2. Bogduk N. Cervicogenic headache: anatomic basis and pathophysiologic mechanisms. Curr Pain Headache Rep. 2001;5(4):382–6.

    Article  CAS  Google Scholar 

  3. Goadsby PJ, Ratsch T. On the functional neuroanatomy of neck pain. Cephalalgia. 2008;28(suppl 1):1–7.

    Article  Google Scholar 

  4. •• Johnston MM, Jordan SE, Charles AC. Pain referral patterns of the C1 to C3 nerves: implications for headache disorders. Ann Neurol. 2013;74(1):145–8 Insights on the patterns of pain referral from the upper cervical nerves.

    Article  Google Scholar 

  5. • Shimohata K, Hasegawa K, Onodera O, Nishizawa M, Shimohata T. The clinical features, risk factors, and surgical treatment of cervicogenic headache in patients with cervical spine disorders. Headache. 2017;57(7):1109–17 Cross-sectional study describing the clinical features of cervicogenic headache and the prevalence in patients with cervical myelopathy/radiculopathy.

    Article  Google Scholar 

  6. Levin M. Nerve blocks in the treatment of headaches. Neurotherapeutics. 2010;7(2):197–2013.

    Article  Google Scholar 

  7. Shin KJ, Kim HS, Kwon HJ, Yang HM. Anatomical consideration of the occipital cutaneous nerves and artery for the safe treatment of occipital neuralgia. Clin Anat. 2018;31(7):1058–64.

    Article  Google Scholar 

  8. Choi II, Jeon SR. Neuralgias of the head: occipital neuralgia. J Korean Med Sci. 2016;31(4):479–88.

    Article  CAS  Google Scholar 

  9. Koopman JS, Dieleman JP, Huygen FJ, de Mos M, Martin CG, Sturkenboom MC. Incidence of facial pain in the general population. Pain. 2009;147(1–3):122–7.

    Article  Google Scholar 

  10. Sjaastad O, Bakketeig LS. Prevalence of cervicogenic headache: Vaga study of headache epidemiology. Acuta Neurol Scand. 2008;117(3):173–80.

    Article  CAS  Google Scholar 

  11. Knackstedt H, Bansevicius D, Aaseth K, Grande RB, Lundqvist C, Russel MB. Cervicogenic headache in the general population: the Akershus study of chronic headache. Cephalalgia. 2010;30(12):1468–76.

    Article  Google Scholar 

  12. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018 ;38(1):1–211.

  13. Bogduk N, Govind J. Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatments. Lancet Neurol. 2009;8(10):959–68.

    Article  Google Scholar 

  14. •• Ashina S, Bendtsen L, Lyngberg AC, Lipton RB, Hajiyeva N, Jensen R. Prevalence of neck pain in migraine and tension-type headache: A population study. Cephalalgia. 2015;35(3):211–9 Evaluation of the prevalence of coexisting neck pain in primary headache disorders.

    Article  Google Scholar 

  15. Lampl C, Rudolph M, Deligianni CI, Mitsikostas DD. Neck pain in episodic migraine: premonitory symptom or part of the attack? J Headache Pain. 2015;16:566.

    Article  Google Scholar 

  16. Kuhn WF, Kuhn SC, Gilberstadt H. Occipital neuralgias: clinical recognition of a complicated headache. A case series and literature review. J Orofac Pain. 1997;11(2):158–65.

    CAS  Google Scholar 

  17. Blumenfeld A, Siavoshi S. The challenges of cervicogenic headache. Curr Pain Headache Rep. 2008;22(7):47.

    Article  Google Scholar 

  18. Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. Headache. 1998;38(6):442–5.

    Article  CAS  Google Scholar 

  19. Van Suijlekom H, Van Zundert J, Narouze S, Van Kleef M, Mekhail N. Cervicogenic headache. Pain Pract. 2010;10(2):124–30.

    Article  Google Scholar 

  20. • Narouze S. Occipital neuralgia diagnosis and treatment: the role of ultrasound. Headache. 2016;56(4):801–7 Review of occipital neuralgia and the use of ultrasound-guided interventional therapies.

    Article  Google Scholar 

  21. Newman S, Steed L, Mulligan K. Self-management interventions for chronic illness. Lancet. 2004;364(9444):1523–37.

    Article  Google Scholar 

  22. Côté P, Yu H, Shearer HM, Randhawa K, Wong JJ, Mior S, Ameis A, Carroll LJ, Nordin M, Varatharajan S, Sutton D, Southerst D, Jacobs C, Stupar M, Taylor-Vaisey A, Gross DP, Brison RJ, Paulden M, Ammendolia C, Cassidy JD, Loisel P, Marshall S, Bohay RN, Stapleton J, Lacerte M Non-pharmacological Management of Persistent Headaches Associated with neck pain: a clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration. Eur J Pain 2019. doi: https://doi.org/10.1002/ejp.1374.

  23. López-Soto PJ, Bretones-García JM, Arroyo-García V, García-Ruiz M, Sánchez-Ossorio E, Rodríguez-Borrego MA. Occipital Neuralgia: a noninvasive therapeutic approach. Rev Lat Am Enfermagem. 2018;26:e3067.

    Article  Google Scholar 

  24. Haas M, Bronfort G, Evans R, Schulz C, Vavrek D, Takaki L, et al. Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial. Spine J. 2018;18(10):1741–54.

    Article  Google Scholar 

  25. Van Zagten MS, Troost J, Heeres JG. Cervical myelopathy as complication of manual therapy in a patient with a narrow cervical canal. Ned Tijdschr Geneeskd. 1993;137(32):1617–8.

    Google Scholar 

  26. Biller J, Sacco RL, Albuquerque FC, Demaerschalk BM, Fayad P, Long PH, et al. Stroke. Cervical Arterial Dissections and Assoc Cervical Manip Ther: a statement for healthcare professionals from the American Heart Association/American Stroke Association. 2014;45(10):3155–74.

    CAS  Google Scholar 

  27. • Gross A, Langevin P, Burnie SJ, Bédard-Brochu MS, Empey B, Dugas E, et al. Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. Cochrane Database Syst Rev. 2015;23(9):CD004249 Systematic review of mobilisation therapy for neck pain in patients with and without cervicogenic headache.

    Google Scholar 

  28. Chen L, Zhang XL, Ding H, Tao YQ, Zhan HS. Comparative study on effects of manipulation treatment and transcutaneous electrical nerve stimulation on patients with cervicogenic headache. J Chin Integr Med/Zhong Xi Yi. 2007;5(4):403–6.

    Article  Google Scholar 

  29. Ghaly RF, Plesca A, Candido KD, Knezevic NN. Transcutaneous electrical nerve stimulation in treatment of occipital neuralgia: a case report. A A Pract. 2018;11(1):4–7.

    Article  Google Scholar 

  30. Nguyen JP, Nizard J, Kuhn E, Carduner F, Penverne F, Verleysen-Robin MC, et al. A good preoperative response to transcutaneous electrical nerve stimulation predicts a better therapeutic effect of implanted occipital nerve stimulation in pharmacologically intractable headaches. Neurophysiol Clin. 2016;46(1):69–75.

    Article  Google Scholar 

  31. Deyo RA, Walsh NE, Schoenfeld LS, Ramamurthy S. Can trials of physical treatments be blinded? The example of transcutaneous electrical nerve stimulation for chronic pain. Am J Phys Med Rehabil. 1990;69(1):6–10.

    Article  CAS  Google Scholar 

  32. Haldeman S, Dagenais S. Choosing a treatment for cervicogenic headache: when? What? How much? Spine J. 2010;10(2):169–71.

    Article  Google Scholar 

  33. Vanelderen P, Lataster A, Levy R, Mekhail N, Van Kleef M, Van Zundert J. Occipital neuralgia. Pain Pract. 2010;10(2):137–44.

    Article  Google Scholar 

  34. Dougherty C. Occipital Neuralgia. Curr Pain Headache Rep. 2014;18(5):411.

    Article  Google Scholar 

  35. Martelletti P. Inflammatory mechanisms in cervicogenic headache: an integrative view. Curr Pain Headache Rep. 2002;6(4):315–9.

    Article  Google Scholar 

  36. Volcy M, Tepper SJ, Rapoport AM, Sheftell FD, Bigal ME. Botulinum toxin a for the treatment of greater occipital neuralgia and trigeminal neuralgia: a case report with pathophysiological considerations. Cephalalgia. 2006;26:336–40.

    Article  CAS  Google Scholar 

  37. Linde M, Hagen K, Salvesen Ø, Gravdahl GB, Helde G, Stovner LJ. Onabotulinum toxin a treatment of cervicogenic headache: a randomised, double-blind, placebo-controlled crossover study. Cephalalgia. 2001;31(7):797–807.

    Article  Google Scholar 

  38. Langevin P, Peloso PM, Lowcock J, Nolan M, Weber J, Gross A, et al. Botulinum toxin for subacute/chronic neck pain. Cochrane Database Syst Rev 2011;(7):CD008626.

  39. Kapural L, Stillman M, Kapural M, McIntyre P, Guirgius M, Mekhail N. Botulinum toxin occipital nerve block for the treatment of severe occipital neuralgia: a case series. Pain Pract. 2007;7(4):337–40.

    Article  Google Scholar 

  40. Taylor M, Silva S, Cottrell C. Botulinum toxin type-a (BOTOX) in the treatment of occipital neuralgia: a pilot study. Headache. 2008;48(10):1476–81.

    Article  Google Scholar 

  41. Blumenfeld A, Ashkenazi A, Napchan U, Bender SD, Klein BC, Berliner R, et al. Expert consensus recommendations for the performance of peripheral nerve blocks for headaches–a narrative review. Headache. 2013;53(3):437–46.

    Article  Google Scholar 

  42. Ashkenazi A, Blumenfeld A, Napchan U, Narouze S, Grosberg B, Nett R, et al. Peripheral nerve blocks and trigger point injections in headache management: a systematic review and suggestions for future research. Headache. 2010;50(6):943–52.

    Article  Google Scholar 

  43. Naja ZM, El-Rajab M, Al-Tannir MA, Ziade FM, Tawfik OM. Occipital nerve blockade for cervicogenic headache: a double-blind randomized controlled clinical trial. Pain Pract. 2006;6(2):89–95.

    Article  Google Scholar 

  44. Goadsby PJ, Hoskin KL, Knight YE. Stimulation of the greater occipital nerve increases metabolic activity in the trigeminal nucleus caudalis and cervical dorsal horn of the cat. Pain. 1997;73(1):23–8.

    Article  CAS  Google Scholar 

  45. Naja ZM, El-Rajab M, Al-Tannir MA, Ziade FM, Tawfik OM. Repetitive occipital nerve blockade for cervicogenic headache: expanded case report of 47 adults. Pain Pract. 2006;6(4):278–84.

    Article  Google Scholar 

  46. O'Neill F, Nurmikko T, Sommer C. Other facial neuralgias. Cephalalgia. 2017;37(7):658–69.

    Article  Google Scholar 

  47. Zhou L, Hud-Shakoor Z, Hennessey C, Ashkenazi A. Upper cervical facet joint and spinal rami blocks for the treatment of cervicogenic headache. Headache. 2010;50(4):657–63.

    Article  Google Scholar 

  48. Narouze SN, Casanova J, Mekhail N. The longitudinal effectiveness of lateral atlantoaxial intra-articular steroid injection in the treatment of cervicogenic headache. Pain Med. 2007;8(2):184–8.

    Article  Google Scholar 

  49. Byrd D, MacKey S. Pulsed radiofrequency for chronic pain. Curr Pain Headache Rep. 2008;12(1):37–41.

    Article  Google Scholar 

  50. Chua NH, Vissers KC, Sluijter ME. Pulsed radiofrequency treatment in interventional pain management: mechanisms and potential indications- a review. Acta Neurochir. 2011;153(4):763–71.

    Article  Google Scholar 

  51. Choi HJ, Oh IH, Choi SK, Lim YJ. Clinical outcomes of pulsed radiofrequency neuromodulation for the treatment of occipital neuralgia. J Korean Neurosurg Soc. 2012;51(5):281–5.

    Article  Google Scholar 

  52. Huang JHY, Galvagno SM, Hameed M, et al. Occipital nerve pulsed radiofrequency treatment: a multi-center study evaluating predictors of outcome. Pain Med. 2012;13(4):489–97.

    Article  Google Scholar 

  53. Vanelderen P, Rouwette T, De Vooght P, et al. Pulsed radiofrequency for the treatment of occipital neuralgia: a prospective study with six months of follow-up. Reg Anesth Pain Med. 2010;35(2):148–51.

    Article  Google Scholar 

  54. • Grandhi RK, Kaye AD, Abd-Elsayed A. Systematic review of radiofrequency ablation and pulsed radiofrequency for Management of Cervicogenic Headaches. Curr Pain Headache Rep. 2018;22(3):18 Review of radiofrequency ablation and pulsed radiofrequency in the management of cervicogenic headache.

    Article  Google Scholar 

  55. Gabrhelik T, Michalek P, Adamus M. Pulsed radiofrequency therapy versus greater occipital nerve block in the management of refractory cervicogenic headache—a pilot study. Prague Med Rep. 2011;112(4):279–87.

    CAS  Google Scholar 

  56. Halim W, Chua NH, Vissers KC. Long-term pain relief in patients with cervicogenic headaches after pulsed radiofrequency application into the lateral atlantoaxial (C1-2) joint using an anterolateral approach. Pain Pract. 2010;10(4):267–71.

    Article  Google Scholar 

  57. Lord SM, Barnsley L, Wallis B, McDonald G, Bogduk N. Percutaneous radiofrequency neurotomy for chronic cervical zygapophyseal joint pain. N Engl J Med. 1996;335(23):1721–6.

    Article  CAS  Google Scholar 

  58. Govind J, King W, Bailey B, Bogduk N. Radiofrequency neurotomy for the treatment of third occipital headache. J Neurol Neurosurg Psychiatry. 2003;74(1):88–93.

    Article  CAS  Google Scholar 

  59. Hamer JF, Purath TA. Response of cervicogenic headaches and occipital neuralgia to radiofrequency ablation of the C2 dorsal root ganglion and/or third occipital nerve. Headache. 2014;54(3):500–10.

    Article  Google Scholar 

  60. Park SW, Park YS, Nam TK, Cho TG. The effect of radiofrequency neurotomy of lower cervical medial branches on cervicogenic headache. J Korean Neurosurg Soc. 2011;50(6):507–11.

    Article  Google Scholar 

  61. Keifer OP Jr, Diaz A, Campbell M, Bezchlibnyk YB, Boulis NM. Occipital nerve stimulation for the treatment of refractory occipital neuralgia: a case series. World Neurosurg. 2017;105:599–604.

    Article  Google Scholar 

  62. Palmisani S, Al-Kaisy A, Arcioni R, Smith T, Negro A, Lambru G, et al. A six year retrospective review of occipital nerve stimulation practice–controversies and challenges of an emerging technique for treating refractory headache syndromes. J Headache Pain. 2013;14:67.

    Article  Google Scholar 

  63. Johnstone CS, Sundaraj R. Occipital nerve stimulation for the treatment of occipital neuralgia-eight case studies. Neuromodulation. 2006;9(1):41–7.

    Article  Google Scholar 

  64. Slavin KV, Nersesyan H, Wess C. Peripheral neurostimulation for treatment of intractable occipital neuralgia. Neurosurgery. 2006;58(1):112–9.

    Article  Google Scholar 

  65. Melvin EA Jr, Jordan FR, Weiner RL, Primm D. Using peripheral stimulation to reduce the pain of c2-mediated occipital headaches: a preliminary report. Pain Physician. 2007;10(3):453–60.

    Google Scholar 

  66. •• Sweet JA, Mitchell LS, Narouze S, et al. Occipital nerve stimulation for the treatment of patients with medically refractory occipital neuralgia: congress of neurological surgeons systematic review and evidence-based guideline. Neurosurgery. 2015;77(3):332–41 Systematic review and guideline recommendations for the use of occipital nerve stimulation in the management of occipital neuralgia.

    Article  Google Scholar 

  67. Sjaastad O, Fredriksen T, Jorgensen JV. Electrical stimulation in headache treatment. For separate headache(s) or for headache generally? Funct Neurol. 2009;24(1):53–9.

    CAS  Google Scholar 

  68. • Eghtesadi M, Leroux E, Fournier-Gosselin MP, Lespérance P, Marchand L, Pim H, et al. Neurostimulation for refractory Cervicogenic headache: a three-year retrospective study. Neuromodulation. 2018;21(3):302–9 Retrospective review of occipital nerve stimulation in the management of cervicogenic headache.

    Article  Google Scholar 

  69. Rodrigo-Royo MD, Azcona JM, Quero J, Lorente MC, Acin P, Azcona J. Peripheral neurostimulation in the management of cervicogenic headache: four case reports. Neuromodulation. 2005;8(4):241–8.

    Article  Google Scholar 

  70. Jasper JF, Hayek SM. Implanted occipital nerve stimulators. Pain Physician. 2008;11(2):187–200.

    Google Scholar 

  71. Bovim G, Fredriksen TA, Stolt-Nielsen A, Sjaastad O. Neurolysis of the greater occipital nerve in cervicogenic headache. A follow up study. Headache. 1992;32(4):175–9.

    Article  CAS  Google Scholar 

  72. Wilhour D, Nahas S. The neuralgias. Curr Neurology Neurosci Rep. 2018;18(10):69.

    Article  Google Scholar 

  73. Schrot RJ, Mathew JS, Li Y, Beckett L, Bae HW, Kim KD. Headache relief after anterior cervical discectomy: post hoc analysis of randomized investigational device exemption trial: clinical article. J Neurosurg Spine. 2014;21(2):217–22.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Women’s College Hospital Centre for Headache, Division of Neurology, University of Toronto, Toronto, Canada

    Rebecca Barmherzig & William Kingston

  2. The Hospital for Sick Children, Division of Neurology, Department of Pediatrics, Toronto, M5G 1X8, Canada

    Rebecca Barmherzig

Authors
  1. Rebecca Barmherzig
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. William Kingston
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Rebecca Barmherzig.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Headache

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Barmherzig, R., Kingston, W. Occipital Neuralgia and Cervicogenic Headache: Diagnosis and Management. Curr Neurol Neurosci Rep 19, 20 (2019). https://doi.org/10.1007/s11910-019-0937-8

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11910-019-0937-8

Keywords

Search

Navigation