Occipital neuralgia

The occipital neuralgia (formerly called Arnold’s neuralgia) is a primary headache, which must be distinguished from the migraine.
The main symptom is an electric, burning and invalidating pain (generally different from the migraine), of which the origin is just below the occipital protuberance and which radiates anteriorly to the vertex of the skull. The patients describes the location of the pain at a superficial level on the scalp. The pain increases by combing the hairs or pressing the head on the pillow.
The great and\or the lesser occipital nerves are involved.
Clinically, the pain and tingling are reproduced by the palpation of nerves next to the occipital bone (Tinel’s sign).
Pain mechanisms are not completely understood. Nerves are probably compressed somewhere by the oblique and the trapeze muscles.
Indeed, the diagnosis seems confirmed by the disappearance of the pain by an anesthetic nerve block. In rare cases the nerve irritation is secondary to vascular malformations, infectious or inflammatory diseases (eg myelitis and multiple sclerosis), vasculitis and arteritis (such as Horton’s disease in the elderly)  or compression of the C2 root, which is at the origin of the occipital nerve, at the vertebral level. A herpetic infection of the C2 root may mimic occipital neuralgia (but in this case we must search for the herpetic vesicular lesions on the scalp). Sometimes neuralgia occurs after cervical spinal surgery.
In suspicion of infiltrative or structural lesions, it is advisable to perform a brain / cervical MRI exam.
Pharmacological treatments (NSAIDs, pregabalin, muscle relaxants) can be initiated. Nevertheless, as symptoms are often excruciating, we perform already at the beginning, the anesthetic block of the nerve by Lidocaine (without corticosteroids) or a local treatment of mesotherapy (Lidocaine+Amytriptyline).
The latest resources for chronic pain which is refractory to standard therapies are pulsed radiofrequency, implantation of an occipital nerve stimulator, and botulinum toxin infiltrations.

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