Occipital Neuralgia

http://www.dizziness-and-balance.com/disorders/central/migraine/images/FIG3-MG.jpg

What is it?
Irritation to the greater or lesser occipital nerves

How does it present?
I. sudden onset stabbing/shooting/shock-like/electric pain that starts in the nuchal region and spreads
II. patient can complain of diminished sensation when not feeling

How can you diagnose?
The International Classification of Headache Disorders-2 definition:
A. paroxysmal stabbing pain, with or without persistent aching between paroxysms, in the distribution of the greater, lesser, and/or third occipital nerves
B. tenderness over the affected area
C. pain is eased temporarily by local anesthetic block of the nerve.

This being said, it is important to make sure the pain isn't coming from the neck. Palpate and range the neckHow to treat?

Nerve block!! Here are the key points:
Great occipital nerve: Identify the inion (it's the bony part of the back of the skull). The greater occipital nerve runs 2cm lateral to this bony prominence.

Lesser occipital nerve: Runs close to the mastoid process, just medial to it

http://www.ankoorclinic.com/images/OccipitalNeuralgia.jpg

Medicine: 0.5% Marcaine (1.7ml) + 40mg/ml methyprednisolone (0.3ml). Or 2% Lidocaine (1.7ml) + 10mg triamcinolone (0.3ml).

Technique: Have patient flex neck, chin to chest. Inject and spread. Make sure you aspirate to avoid a superficial artery. Infiltrate at the point of maximal tenderness and surrounding areas. Then wait 10-15min.

PEARL: Alleviation of symptoms by nerve block is both therapeutic and diagnostic!


Practical Pain Management offers a nice tutorial with cool skull pictures:

References:
Garza, I. Occipital Neuralgia. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013.

Ward, JB.(2003). Greater Occipital Nerve Block. Seminars in Neurology 23(1):59-61