No, it’s not a Migraine


Breaking down the head pain of Occipital Neuralgia.



This is not an academic review on headaches, but rather an attempt to bring awareness to a condition often unrecognized and misdiagnosed, and therefore untreated. Occipital Neuralgia (ON) is a type of head pain that offers a great combination of easy diagnosis, and effective and rewarding treatment. [1,2] Many cases of ON are treated as “migraine,” even by specialists. ED treatment is typically a migraine cocktail “Band-Aid” that sedates and dulls pain for a few hours, only to relapse. Botox has some success in “treating migraine”— is it possible that what is actually treated is occipital neuralgia?

Otherwise, how do we expect a subcutaneous injection to affect the mechanism of migraine, a vascular headache, within minutes that, to the best of our knowledge, originates deep in the cerebral arteries?

The Greater Occipital Nerve (GON) is the longest sensory nerve in the body. Its trajectory takes it through a multitude of anatomical elements that can lead to entrapment. ON is unilateral or bilateral pain along the distribution of one or a combination of the greater, lesser and/or third occipital nerves. ON pain is usually described as dull, gripping, protracted or unrelenting, often severe and usually lasting several hours to days.


It is often accentuated by pressure on the site by headwear such as hair bands, caps, or just pressing the involved side against a pillow when in bed or even with eyeglasses, particularly those with long temples that rest on the occiput. Dysesthesia and/or allodynia present on palpation of the scalp. On physical exam, point tenderness can be located at the occipital notches or along the base of the skull.

Procedure: Local nerve blockade is a safe, quick, and efficacious procedure that is both diagnostic and therapeutic for patients with occipital neuralgia.[3]

Explain to the patient that this is not a brain surgery, it is rather a very small needle barely penetrating the skin. We usually have them look up the process on their cell phone to see the images. As we know, the internet is often more “credible” than us!

Materials needed include:


  1. Local anesthetic such as Lidocaine 1% or Bupivacaine 0.25%.
  2. Steroids such as Dexamethasone 10 mg vial.
  3. 27 gauge 1 ½ or 5/8 inch needle for injection, 10 ml syringe.
  4. Alcohol pads or chlorhexidine scrub and gloves.

It is important to discuss risks (albeit rare and should not deter the treating provider) involved with procedure including medication reaction, infection, injury to occipital nerve such as  prolonged numbness to involved area, bleeding and hematoma (particularly if the patient is on anticoagulant or antiplatelet medications).

Occipital Neuralgia

With the patient sitting over the edge of the bed, locate the occiput and mastoid processes. The occipital nerve and artery will usually bisect these two points as seen in Figure 1. [4] Next palpate for the area(s) of maximum tenderness. Once landmarks are identified, insert the needle first into the GON area and draw back to ensure there is no inadvertent intravascular access.

Then inject a small amount of anesthetic and continue in a fan like pattern. If the lesser occipital nerve is also tender, pull back while still inserted and direct the needle laterally to the point of tenderness and again aspirate and inject anesthetic.

After completion, have the patient hold pressure with gauze. Then return to reevaluate. When the procedure is successful, diagnosis is confirmed.

The addition of steroids to the local nerve block with steroid can result in long lasting analgesia and headache remission. Refer patients to neurologists or pain management specialists who can perform repeated procedures as needed.

*HCA Disclaimer

“This research was supported (in whole or part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this presentation represent those of the author and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.”


Leonard Hamera, is a third year resident of IM program at CMH. Inverness, FL.

Anwar Hamami, MD, is the Associate Medical Director at CMH Emergency Department, Inverness, FL.

Sally Hamami, is a medical student.

Jeffrey Jordan, MD, is the IM Residency Program Director at CMH.


  1. Thanks for the helpful review, and as a former Pain Medicine PA, I think I’m qualified to say that is also a nice procedure “recipe”, but let’s remember to get informed consent first, please!


  2. Nerve block only gave me a week’s worth of relief, but after having this for a decade a week’s vacation was heaven. Insurance covers nerve blocks, but not occipital. I hope that changes.

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