Occipital Neuralgia

Occipital Neuralgia (ON) is characterized by recurring, paroxysmal attacks of severe, sharp or stabbing pain in the posterior scalp, typically originating from the occipital nerves. It includes the Greater Occipital Nerve (GON), Lesser Occipital Nerve (LON) or Third Occipital Nerve (TON). Pain episodes last from seconds to minutes and may be accompanied by persistent discomfort between attacks. The condition exhibits clinical variability based on the specific branches of the occipital nerves involved.

Frequency of Nerve Involvement:

• GON: Most commonly involved (up to 90% of cases).
• LON: Less commonly involved.
• TON: Rarely involved.
• GON and LON: Co-involvement seen in 9% of cases.

 

Clinical Presentation

Primary Symptoms

• Sharp, stabbing or electric shock-like pain in the neck.
• Persistent pain with paroxysmal aggravation and variable distribution.
• Pain often radiates from the base of the skull to the scalp and may be perceived in the retro-orbital area plus it can be unilateral or bilateral.
• Tenderness along the greater occipital nerve and lesser occipital nerve, particularly at the base of the skull.
• Possible hypoesthesia, dysesthesia, or numbness in affected areas.
• Scalp sensitivity (allodynia) where light touch or pressure triggers pain.
• Pain triggered by neck movements, head tilting or sustained postures.
• Muscle spasms and tenderness is seen in the neck and upper back muscles.
• Episodic pain with periods of relief in between.
• Typically no fever or other systemic signs unless another condition is involved.

Associated Symptoms

• Vision impairment/ocular pain
• Tinnitus
• Dizziness
• Nausea
• Congested nose
• Sensitivity to light (photophobia) and sound (phonophobia), mimicking migraines.

 

Causes of Occipital Neuralgia

Diagnosing Occipital Neuralgia

Diagnostic Testing for ON:

• Cervical spine X-rays - reveal abnormal anatomy and possible instability, open-mouth views can show arthritis at the second cervical vertebra.
• CT scans - assess degenerative processes and rule out neoplastic pathology.
• MRI scans - detect soft tissue pathologies, including infiltrative lesions.
• Electromyography (EMG) and nerve conduction studies - evaluate for radiculopathy.
• Local anesthetic injections - temporarily relieve pain and aid in diagnosis.
• Ultrasound evaluation of GON - shows increased cross-sectional area and circumference on the symptomatic side in unilateral cases.

Differential Diagnosis

• Tension-type headache
• Migraine
• Cervicogenic headache
• Cluster headache
• Trigeminal neuralgia
• Postherpetic neuralgia
• Giant cell arteritis
• Chiari malformation
• Cervical spondylosis
• Vertebral artery dissection
• Multiple sclerosis
• Myofascial pain syndrome
• Cervical disc herniation
• Temporomandibular joint (TMJ) dysfunction
• Arnold-Chiari malformation
• Paraganglioma of the neck
• Suboccipital muscle spasm
• C2 nerve root irritation
• Occipital bone metastasis
• Atlantoaxial instability

 

Physiotherapy Management of Occipital Neuralgia (ON)

Occipital Neuralgia requires a comprehensive, step-by-step approach integrating conservative and medical strategies. Below is a detailed physiotherapy management plan:

1. Patient Education

• Educate about ON triggers (e.g., poor posture, neck strain, sleeping positions).
• Emphasize activity modification to avoid aggravating factors.
• Stress the importance of adherence to the treatment plan for long-term success.

2. Pain Management

Pain relief is the first goal in treating ON. Physiotherapy can significantly reduce pain through manual techniques, electrotherapy and other non-invasive interventions.

Manual Therapy

• Gentle Occipital Nerve Mobilization: Relieve nerve irritation and improve neural mobility.
• Myofascial Release: Target the upper trapezius, suboccipital muscles, and cervical paraspinals to reduce tension.
• Soft Tissue Mobilization: Focus around the occipital nerve pathway to reduce discomfort.
• Cranial Massage: Relaxes surrounding tissues and enhances blood flow.

Electrotherapy

• TENS (TranscutaneousElectrical Nerve Stimulation): Apply over the occipital region for pain modulation.
• Therapeutic Ultrasound: Utilize for localized inflammation reduction and improved circulation.
• Heat Therapy: Apply to the neck and occipital areas for muscle relaxation and improved circulation.

3. Postural Correction

Chronic poor posture is a significant contributing factor in ON. Physiotherapy aims to correct these issues through education and exercises.

Ergonomic Training

• Optimize desk and workstation setup:
• Monitor height, it should be at eye level.
• Chair position should support the lumbar spine with feet flat on the floor.
• Encourage frequent breaks to avoid sustained forward head posture.

Postural Exercises

• Chin Tucks: Realign cervical spine and strengthen deep neck flexors.
• Scapular Retraction Exercises: Improve upper back strength to reduce muscle strain.

4. Strengthening and Stabilization

Building strength in the cervical and scapular muscles provides support to the neck and improves postural alignment.

Cervical Strengthening

• Begin with isometric neck exercises (e.g., pressing head gently against resistance).
• Progress to dynamic exercises for deep neck flexors and extensors.

Scapular Strengthening

• Strengthen key muscles like the rhomboids, trapezius, and serratus anterior.
• Examples: Rows, scapular squeezes, and wall slides.

5. Stretching and Flexibility

Tight muscles contribute to ON symptoms. Targeted stretching improves flexibility and relieves tension.

Targeted Muscle Stretching

Focus on the following

1. Suboccipital muscles
2. Levator scapulae
3. Upper trapezius
4. Sternocleidomastoid

Nerve Glides

• Gentle mobilization of the occipital nerve to improve neural mobility and reduce pain.

6. Stress and Relaxation Techniques

Stress management is critical as tension often exacerbates ON symptoms.

Relaxation Training

• Teach diaphragmatic breathing to reduce overall muscle tension.
• Incorporate mindfulness exercises or stress management techniques.

Trigger Point Release

• Use manual therapy or tools to release trigger points in cervical and scapular muscles.

7. Cervical Mobility Improvement

Restoring and maintaining cervical spine mobility reduces nerve compression and pain.

Joint Mobilization

• Gentle mobilization of upper cervical joints (C0-C3) for better range of motion.

Range of Motion (ROM) Exercises

Perform controlled neck movements:

1. Flexion
2. Extension
3. Rotation
4. Lateral bending

8. Advanced Therapies

Consider advanced interventions if conservative methods show limited improvement.

Dry Needling/Acupuncture

• Reduces muscle tension and pain in the cervical and occipital regions.
• Benefits are comparable to pharmacological interventions.

Kinesio Taping

• Provides support to cervical muscles.
• Reduces tension and encourages better posture.

9. Home Exercise Program (HEP)

Encourage patients to integrate daily exercises focusing on:

• Cervical and scapular strengthening.
• Stretching tight muscles like the upper trapezius and levator scapulae.
• Postural correction exercises to maintain long-term improvements.

10. Multidisciplinary Integration

For chronic or refractory cases, work alongside other healthcare professionals:

• Address stress and chronic pain coping mechanisms.
• Coordinate with physicians for medication management or advanced procedures like infliximab.

This step-by-step physiotherapy approach aims to comprehensively address the physical, functional, and psychosocial aspects of occipital neuralgia for effective long-term management.