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Occipital neuralgia and cervicogenic headache

Some headaches begin in the neck. Occipital neuralgia arises from the occipital nerves at the back of the head; cervicogenic headache arises from the upper neck joints. Both can be tested directly with diagnostic blocks, and treated at their source where confirmed.

Headache medicine and neck pain medicine overlap at the top of the spine. The upper cervical joints and the occipital nerves both refer pain over the back and side of the head — sometimes to the temple or behind the eye — producing headaches that are frequently labelled migraine or tension-type for years before the neck is properly examined. The distinguishing feature of this group is that the source can be tested directly.

Occipital neuralgia arises from the greater and lesser occipital nerves, which climb from the upper neck over the back of the skull. Irritation produces sharp, shooting or electric pain from the skull base over the scalp, often one-sided, typically with marked tenderness at one point and sometimes altered scalp sensation. It can follow injury or arise without one.

Cervicogenic headache is referred from the upper cervical facet joints and related structures. Clues include headache that starts in the neck and spreads forward, provocation by neck movement or sustained postures, reduced neck movement, and a history of whiplash or other neck injury. The headache is real head pain — but its generator is in the neck.

Why the distinction matters. Migraine is managed with migraine treatments. Occipital and cervicogenic headache can be treated at their source — and the test is direct. An occipital nerve block that abolishes the headache during the anaesthetic window implicates the nerve; medial branch blocks of the upper cervical joints test the joints the same way. A negative result matters too: it redirects attention to migraine or another primary headache, and away from procedures that would not have helped.

Treatment where a source is confirmed. For occipital neuralgia: nerve blocks, which are sometimes therapeutic as well as diagnostic, and radiofrequency treatment. For cervicogenic headache: radiofrequency neurotomy of the responsible upper cervical joints, which in well-selected patients can substantially reduce headache for months at a time, alongside neck rehabilitation. Where migraine coexists — common — both problems are named and both are treated, in coordination with your GP or neurologist.

Assessment first. Not all headache at the back of the head is occipital or cervicogenic, and headache with new or unusual features needs proper evaluation before any injection. Assessment here covers the pattern, triggers, medication history — including medication overuse headache, which mimics and worsens other headache types — and neurological examination, with onward referral where the picture points elsewhere.

Sources: International Association for the Study of Pain; International Headache Society classification; Healthdirect Australia.