Learning Objectives
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Develop an understanding of the causes of occipital neuralgia.
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Learn the clinical presentation of occipital neuralgia.
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Learn how to use physical examination to help diagnose occipital neuralgia.
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Learn to distinguish occipital neuralgia from tension-type headache.
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Learn the important anatomic structures in occipital neuralgia.
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Develop an understanding of the treatment options for occipital neuralgia.
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Learn the appropriate testing options to help diagnose occipital neuralgia.
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Learn to identify red flags in patients who present with occipital neuralgia.
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Develop an understanding of the role in interventional pain management in the treatment of occipital neuralgia.
Amy Lin
“Doctor, you know that husband of mine, Joe, is always getting hurt? Well, this time he decided to take it out on me.” Amy went on to say that about 3 weeks ago, she wanted to knock down a bird’s nest that was in the gutter over her patio door, so she asked Joe to get the ladder out for her. She was walking behind Joe as he carried the ladder, and when he suddenly turned, the ladder hit Amy squarely on the back of her head. “Doc, he really rang my bell! I saw stars, and it brought tears to my eyes. I gave him what-for and grabbed the ladder away from him before he killed me with it. I got the bird’s nest down, but for the past 3 weeks, the back of my head has been killing me. I’ve tried to tough it out. I tried all the usual stuff: tea tree oil, Motrin, the heating pad. Joe wanted me to go to the chiropractor, but I was afraid it might make my head worse. I think it’s about time to trade Joe in on a new and improved model.” I could tell that Amy was getting really wound up about Joe, so I reassured her that she had done everything right, except perhaps letting Joe carry the ladder. I asked her if she had ever had headaches before and she shook her head no. “So, no loss of consciousness?” and again she shook her head no. I suggested that we look her over to figure out what was wrong and what we could do to make it better.
I asked Amy to point with one finger where it hurt the most. Amy pointed to her left occipital region, and then pointed up toward the vertex of her scalp. “Is there any numbness?” I asked. Amy replied that the left side of her head felt like it was asleep. “You know, Doctor, that weird pins-and-needles feeling that you get when your foot goes to sleep.”
“Are you having any visual problems, or is there anything else that I need to know about?” I asked.
“Nothing but my husband, Joe. He means well, but he is always an accident waiting to happen.”
“Let’s put you in a gown and take a look,” I said.
On physical examination, Amy was afebrile and her respirations were 16. Her pulse was 74 and regular, her blood pressure a nice 110/68. Palpation of her cranium revealed no mass or other abnormality. Her head, eyes, ears, nose, throat (HEENT) exam, including fundoscopic examination, was normal, as was her cardiopulmonary examination. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Palpation over the left greater and lesser occipital nerves elicited a shocklike pain that radiated from the nuchal ridge to the top of her head on the left. Her neurologic examination was otherwise within normal limits. There were no pathologic reflexes.
Given the history of trauma, I ordered a magnetic resonance imaging (MRI) of the brain to rule out any occult pathology.
Key Clinical Points—What’s Important and What’s Not
The History
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History of acute trauma to the left occiput when hit with a ladder
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No loss of consciousness
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No history of previous headache
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Headache is located primarily in the left occipital region with pain radiating to vertex of the scalp
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A pins-and-needles sensation in the distribution of the pain
The Physical Examination
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Patient is afebrile
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Tenderness over the greater and lesser occipital nerve
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Deep palpation over the greater and lesser occipital nerve reproduces the neuritic pain that radiates to the vertex of the scalp
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Normal fundoscopic examination
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Normal neurologic examination, upper extremity motor and sensory examination
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No pathologic reflexes
Other Findings Of Note
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Normal HEENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
What Tests Would You Like to Order?
The following tests were ordered:
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MRI of the brain
Test Results
The MRI of the brain was normal.
Clinical Correlation—Putting It All Together
What is the diagnosis?
Occipital neuralgia
The Science Behind the Diagnosis
Clinical Syndrome
Occipital neuralgia is usually the result of blunt trauma to the greater and lesser occipital nerves ( Fig. 8.1 ). The greater occipital nerve arises from fibers of the dorsal primary ramus of the second cervical nerve and, to a lesser extent, from fibers of the third cervical nerve. The greater occipital nerve pierces the fascia just below the superior nuchal ridge, along with the occipital artery. It supplies the medial portion of the posterior scalp as far anterior as the vertex (see Fig. 8.1 ). The lesser occipital nerve arises from the ventral primary rami of the second and third cervical nerves. The lesser occipital nerve passes superiorly along the posterior border of the sternocleidomastoid muscle and divides into cutaneous branches that innervate the lateral portion of the posterior scalp and the cranial surface of the pinna of the ear ( Fig. 8.2 ).
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