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The curious example of occipital neuralgia

 •  • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of PainScience.com: a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

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I mentioned occipital neuralgia in a recent post as a useful example of a headache that is really about the neck. A little more detail on that today…

Occipital neuralgia is the pain caused by a distressed C2 spinal nerve. It blasts the back of the head with “lancinating” pain. It is certainly one kind of headache, but it is more of a vicious head stabbing than aching.

Occipital neuralgia has a more common and famous evil twin: trigeminal neuralgia, which causes a very similar kind of pain in the face. I’ve had some mild trigeminal neuralgia over the years, and I pray I never have it worse.

Both conditions are classic examples of particularly vicious chronic pain conditions. They are dramatic neuropathies: pain that arises from damage to the nervous system itself. The quality of the pain is often stabbing, electrical, or burning, but nearly any quality of pain is possible. Unfortunately, it’s also more likely to lead to chronic pain: nerves don’t heal well.

So occipital neuralgia is a head pain with a cause that is unambiguously in the neck. And if that’s the case … doesn’t that constitute proof that there is such a thing as “cervicogenic headache”? Can it put that debate to rest?

No. It’s certainly a useful example of the idea of cervicogenic headache … but no, it’s not proof or even evidence of the kind of headache that the debate is about. It is considered a bit of a special case, and for good reason.

Bogduk explains that occipital neuralgia and other C2 issues “are distinguished from common, or idiopathic, cervicogenic headache, by their unique, clinical features and pathology.” In short, we know exactly what’s going on there, and, yes, it’s crappy and “cervicogenic” … but it’s also clearly different from much more common kinds of headache that may also be cervicogenic (or might not be).

Bogduk also notes that occipital neuralgia was a popular but poorly defined diagnosis for decades, often carelessly applied to more ordinary headaches, in much the same way a lot of severe non-migraine headaches are still casually called “migraines” just to make them sound as awful as they feel. “Some cases in the past may have been instances of C2 neuralgia before that entity was defined,” he writes, while other cases misdiagnosed as occipital neuralgia actually might “have been examples of referred pain from upper cervical skeletal structures.”

All this diagnostic/naming confusion has boosted the idea that occipital neuralgia is a sub-type of cervicogenic headache, but it’s truly not what the cervicogenic headache debate is about.

I’ve updated the PainSci headache guide with this information, so this post is now a free excerpt from that book. Just giving it away. To show you how good the whole thing is!