Case of the Month #20: Neck Pain and Headache by Dr Kerry Bosworth

Published: 30/09/2022


Occipital neuralgia is a rare cause of pain in the head and neck [1, 2]. The pain can be unilateral or bilateral and is severe in intensity with a shooting or stabbing character. The patient will typically have paroxysmal attacks of pain that last from a few seconds to a few minutes. It is caused by damage or irritation of the greater, lesser and/or third occipital nerves.

The differential diagnoses include primary headaches, such as migraine and tension-type headaches, and secondary headaches including tumour and cervical disc disease. Blood tests and imaging should be performed to rule out causes of secondary headaches.

Management can include relaxation, cognitive behavioural therapy, massage, acupressure and acupuncture [3, 4, 5, 6]. NSAIDs, anti-neuropathics and muscle relaxants may be helpful [2]. Occipital nerve blocks and pulsed radiofrequency can be offered [2]. Botulinum toxin type-A injections may also be beneficial [2, 7]. If the pain is refractory to other treatments, subcutaneous occipital nerve stimulation can be considered [2].

Autofusion of the spine may occur after trauma, infection or degenerative disc disease [8, 9, 10]. It may also be part of a disease process such as ankylosing spondylitis. It can cause spondylotic myelopathy and severe pain. Other musculoskeletal conditions such as diffuse idiopathic skeletal hyperostosis (DISH) may give similar presentations [11].