Occipital Neuralgias: Clinical Recognitionof a Complicated Headache. A Case Seriesand Literature Review

Waltet F, Kubn, MDAssistant ProfessorDepartment of Emergency Medicine

Sharon C. Kubn, MDAssistant ProfessorDepartment of Family Medicine

Medical College of GeorgiaAugusta, Geotgia

Huson Gilbetstadt, MDStaff PhysicianEmergency DepartmentSt Vincent's Medical CenterJscksonvilie, Flotida

Correspondence to:Dr Walter F. KuhnDepartment of Emergency MedicineMedical College of Georgia1120 15th Street, AF-1054Augusta, Georgia 30912^007

The objective of this study was to assist clinicians in the diagnosisof the occipital neuralgia syndrome by describing its clinical char-acteristics. Bibliographies and clinical descriptions of occipitalneuralgia syndrome were identified through a review of literaturepublished between 1966 and 1993. A prospective case series wasperformed by the authors in a university emergency departmentduring a 1 -year period. Patients with unilateral aching pain of thehead, coupled with pain in the distribution of the occipital nerve,Tinel's sign, and relief of pain after local anesthetic injection, wereincluded. Fatients rated pain relief on a 10-point scale. Twelvepatients met the criteria for occipital neuralgia and were includedin the study. All patients reported at ¡east 80% decrease of painafter injection, and 42% had complete relief. Clinical features,other than headache, that were common in patients included tinni-tus in 33%; scalp paresthesia, 33%; nausea, 42%; dizziness, 50%;and visual disturbances, 67%. Occipital neuralgia is a benignextracranial cause of headache, and it may be confused with othermore serious headache syndromes. Recognition depends on anunderstanding of the symptoms along with a careful history andphysical examination. Local anesthetic injections produce signifi-cant relief of the headaches and can aid in the diagnosis of the syn-drome..1 OROFACIAL PAIN 1997:11;158-165,

key words: headache, neuralgia, occipital neuralgia

Neuralgia involving the greater or lesser occipital nerves is abenign, extracranial cause of headache seen in outpatientpractice, and it has been described only several times in

the literature, tti 1949, Hunter and Mayfield' described a group ofpatients with occipital neuralgia who reported sudden, recurrenthemicranial pain that was "often associated with tearing of theeye, flushing of the face, alteration of the sweat and at times occlu-sion of the nasal passage on the side involved,"^ Although theheadache is often mistaken for a tension-type, cluster, migraine, or"thunderclap" headache,^ as in suharachnoid hemorrhage, distinc-tive clinical features are present. The key to che diagnosis is thetypical description of "neuralgia" pain, which is similar to thequality of tbe pain of trigeminal neuralgia.'

"Neuralgia" pain is generally described as a brief, sbarp, lanci-nating pain in tbe distribution of tbe relevant tierve, and it usuallylasts several seconds. Tbere may also be a continuous aching com-ponent that may be present for days or weeks in the area of theaffected nerve. Tbe Headacbc Classification Committee of the

158 Voiume 11, Number 2, 1997

Kuhn el al

International Headache Society described occipitalneuralgia as "a paroxysmal jabbing pain in the dis-tribution of the greater or lesser occipital nerves,accompanied by diminished sensarion or dysaes-thesia in the affected area. It is commonly associ-ated with tenderness over the nerve concerned."''The International Headache Society's diagnosticcriteria include "pain in the distribution of thegreater or lesser occipital nerve; pain that is stab-bing in quality, although aching may persistbetween paroxysms; affected nerve is tender topalpation; and condition is eased temporarily bylocal anesthetic block of the appropriate nerve.'"'Hypesthesia or dysesrhesia during or after the clin-ical episode, coupled with the presence of repro-ducible extracranial tenderness or Tinei's sign overthe nerve, are hallmark features of rhe occipitalneuralgias,̂ Resolution of pain rhrough anesrhetichlock of rhe grearer occipiral nerve can be used roconfirm the diagnosis of occipital neuralgia,'' Theaim of the present study was to report a literaturereview of the occipital neuralgias along with a caseseries of 12 patients to aid rhe emergency physi-cian in the recognition of this clinical syndrome.

Literature Review

A MEDLINE bibliographic database search ofEnglish language literature was undertaken for allpublications related ro the topic and publishedduring the period 1966 througb June 1993.Additional articles were idenrified from the bibli-ographies of articles retrieved and from the bibli-ographies of chapters of textbooks on neurologyand headache. Articles and letters (1949 through1993) dealing wirh occipiral neuralgia, auricularneuralgia, craniofacial pain, or headache producedby lesions in the upper cervical roors wereobtained. Arricies were critically assessed indepen-dently by rhe aurhors. No controlled srudies deal-ing with the treatment of occipital neuralgia werefound. Mosr of the published arricies on occipiralneuralgia are case reports or case series srudies.

Materials and Methods

A 10-year rerrospecrive chart review of outpatientsand inpatients seen at the Medical College ofGeorgia (MCG), Augusta, GA, a large tertiaryreferral center and teaching hospital, yielded onlythree patients with occipital neuralgia. Because ofthis small number, the retrospective approach wasabandoned. Instead, a prospective identification

and case series of patienrs who presented withheadache to the MCG emergency department fromNovember 1992 rhrough Octoher 1993 (12months) was undertaken. Permission was grantedfor the study hy the Human Assurance Committee.The emergency deparrment ar MCG examinesapproximately 40,000 patients per year and is areferral resource for most of the state of Georgia.All patients presenting to the emergency depart-ment with the complaint of headache had a gen-eral review of systems and a general physicalexamination with special focus on neurologicsymptoms and the neurologic examinarion. Aheadache history was also obtained. Patients pre-senring with a neuralgia-type headache were exam-ined for tenderness over the occipital nerve,Patienrs meeting crireria for occipital neuralgiawere examined by one of rhe authors. The aurhorsinterviewed each patient and recorded a generalheadache history. Special attention was paid to ahistory of any minor or ma|Or head or necktrauma. "Occipiral neuralgia" was diagnosed byrhe authors if the patients had a history consistentwith neuralgia-type pain, along with tendernessover the related nerves; Tinei's sign, causing wors-ening of the headache; and prompt relief of theheadache wirh local anesrhetic block of the greateror lesser occipital nerves using 1 to 3 mL of 0,5%bupivacaine hydrochloride with epinephrine overthe area where the nerve rravels over rhe occipitalproruberance. No attempt was made to blind orcontrol these injections. All patients were referredto rhe MCG neurology clinic for follow-up care. InDecember 1993, all parients were telephoned rodiscover if they had sought follow-up care, hadpersistenr headaches, or had heen involved in addi-rional diagnostic studies. The charts on patientswho attended follow-up visits in the neurologyclinic were rerrospectively pulled; the original diag-noses were compared wirh the final diagnosesfrom tbe neurology clinic. No attempt was madeto reexamine the patients whose symptoms hadresolved.

Results

The authors prospectively identified 12 patientswho met the aforementioned criteria for the diag-nosis of occipiral neuralgia and who presented tothe emergency deparrment during a 1-year period,tnformarion on hisrory and demographics wasgathered at the time of presentation. Follow-uptelephone calls were made to all patients; it waspossible for 10 of the 12 to be contacted to check

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Kuhn et a

Table 1

Parient

1234567a9101112

Initial Symproms in Parients With Occipital Neuralgia

Age

(y)

2327252649

48495144

21S830

Sex

FFFFFMFMMMMF

Duration

3.5 h5 d3 d2 h1 wk3 m3 d4 d3 ma2 wk2 wk4 5 d

Traumahistury

NoNoNoYesVesNoNoNoNoYesNoNo

Pares-tKesia

NoNoNoNoNoNoNoYesYesYesYesNo

Tinnitus

NoNoNoNoNoNoYesYesYesYesNoNo

Nasalsymptoms

NoNoNoNoNoNo

NoNoYesNoYesNo

Visualsymptoms

YesYesYesNoNoYesYesNoYesYes

YesNo

Dizziness/vertigo

NoNoNoYesNoYesYesNo

YesYesNoYes

Nausea

No

NoNoYesNo

YesYesNo

NoYesNoYes

Tinel's

sign

YesYesYes

YesYesYes

YesYesYes

YesYesYes

the validity of the initial information and to dis-cover whether the headache had persisted orreturned and whether they had sought follow-upcare. Several patients returned to the emergencydepartment with persistent headaches and werereexamined by the authors. The information thatwas gathered is presetited in Table 1,

Of the 12 patients identified, 50% were white,50% were black, and 60% were female. The dura-tion of the headache ranged from several hours to 3months. One third of the patients reported scalpparesthesia, and one tiiird had tinnitus (Table 2).Seventeen percent (2/12) had nasal symptoms, usu-ally congestion or "stuffiness" with the headache.Two thirds (67%) of the patients reported ocularsymptoms: either blurnng of vision or ocular pain.Half of the patients (6/12) reported symptoms ofdizziness or vertigo. Twenty-five percent were foundto have a history of trauma to the head or neck thatpreceded the onset of the headache by days ormonths. None of these were considered seriousinjuries; most related a minor head injury or "cervi-cal strain" from a fall or motor vehicle accident inthe distant past. Slightly less than half (42%) of thepatients reported nausea with their headaches. Allhad Tinel's sign over the occipital nerve, which wasa criterion for the diagnosis of occipital neuralgia.

Nearly one third of the patients had seen otherphysicians before presenting to the emergencydepartment. Prior to presentation co the authors ofthe present study, one patient had made five visitsand another had made four visits to multiplephystctans without recognition or diagnosis ofoccipital neuralgia.

Although the intention of the study was not toreport on the efficacy of local anesthetic injectionover the occipital nerve, all of the patients had sig-

Table 2 Frequency of Symproms Identified

Patients (n =

Scalp paresthesiaTinnitusNasal congestionVisual blurring, ocoular painVertigo/dizzinessNauseaTinel's sign over occipital nerve

Nutnber

4

4286

512

Percent

33331767

5042

100

nificant, immediate, and sometimes dratnatic relief(within 20 minutes) of their headache followinginjection of 0.5% bupivacaine hydrochloride andepinephrine over the nerve. Patients who obtainedrelief from the local anesthetic, thus confirmingthe diagnosis of occipital neuralgia, were given acorticosteroid injection at the site. Patients ratedthis relief on a 10-point numerical scale, with"10" being the worst headache of their hves and"0" representing absence of any headache or headpain. All patients reported a minimum of 80%relief of acute pain after injection, and several had100% relief. No patients required the acuteadministration of narcotics for their headachesafter the local injection.

From the 10 of 12 successful follow-up phonecalls it was found that two patients had no returnof their headaches after initial presentation (Tahle3). The other eight patients reported return of theheadache 3 ro 28 days after their visit: all reportedthat the recurrence of the headache (rated on a 10-point numerical scale) was milder than the originalheadache for which they had sought care in theemergency department. None of the patients con-

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Kuhn et al

Table 3 Results After Injection With Local Anesthetic, Steroid Combination

Patietit1

3345

6

78910

1112

Degree (%) of headacherelief 20 minutes after

injection {based onnurtierical score)

100

100 (7 to 0)100 (10 to 0)80(10 to 2)90

1O08080

100100

100ao ( 10 to 2)

Time after iniection untilheadache returned

Not availableNo return at 2.5 months2 weeks1 week1 week1 vueek1 month

2 weeks2 weeks3 daysNo return at 4 months

Not available

Does patient havechronic, persistentheadaches arfollow-up?

NA

NoNoNoNo

YesYesYesYesNoNoNA

tacted reported any significant relief of iheirheadaches with medication, including ihtiprofen,which had been prescribed by the authors, or nar-cotic analgesics, which had been prescribed byother physiciatis.

Discussion

Several authors have described the clinical syn-drome of occipital neuralgia. Occipital neuralgia isnot an uncommon cause of protracted or severeintractable headache. It occurs more frequently inwomen/ and unlike many other types of head-ache, it is not related to menstruation, emotionalfaaors, physical fatigue, change in weather, alco-hol, tobacco, or food allergies'*; it is often presenton awakentng in rhe morning with no prodrome.The frequency of an attack can vary from weeks tomonths, and the duration of a headaches can varyfrotn days to weeks,^ The pain is true neuralgiawith intermittent, brief episodes of excruciating,sharp, lancinating pain, which is sometimesaccompanied hy a dull, persistent ache in the der-matomal area of the nerve. Scalp and neck tender-ness or paresthesia in the distrtbutton of the sec-ond cervical dermatome are usually present duringpainful episodes.^ Often the pain is exacerbated byflexion of the neck.̂ However, in occipital neural-gia, there is no limitation of or resistance to pas-sive neck movements, no changes in neck musclecontour, and no abnormal tenderness of neck mus-culature as in cervicogenic headaches.'' The attackis not terminated by sleep, ergot compounds, orsedatives. Blurred vision, retro-orbital pain, lacri-mation, and facial flushing is a frequent complaintand may lead the patient to consult an ophthal-

mologist,^'" Dizziness and occasional tinnitus arealso described as well as nasal congestion not associ-ated with nasal or sinus pathology,

Pascual-Leone and Pascual-Leone Pascua^described 12 patients with occipital neuralgia. All ofthe patients had nausea, vomiting, and photophobia,tnimicking migraine headache. Eleven had blurryvision, seven had vertigo or dizziness, and five hadnasal congestion wtth their headaches. Sevenpatients had complete relief of their symptoms 30mitiutes after nerve block with 1% iidocaine, andthe others had significant but incomplete relief,̂Auricular netiralgia shares many of the same charac-teristics with occipital neuralgia but also involvespain referral to the ear, cheek,, side of face, and, insome instances, wtthtn the ear canal itself and areaof the temporomandibuiar joint, mimicking pathol-og)' of the ear or temporomandibuiar disorders,'"

The neuroanatomy of the occipital nerves helpdefine the clinical syndrome associated with theseneuralgias. The greater and lesser occipital nervesare a continuation of the second and/or third cervi-cal roots. The roots receive branches from the spinalaccessory nerve and the superior sympathetic gan-glion. There is also cotnmunication between theroots and the trigeminal ganglion and probably theacoustic and vestibular nerves, which may explainsome of the confusing symptoms seen with occipitalneuralgia (blurred vision, nasal stuffiness, tinnitus,and dizziness)." The greater occipital nerve passesbackward between the atlas and the axis in thespace between the inferior oblique capitis and thesemispinalis muscle (Fig 1), The nerve pierces thesetntspinahs muscle and passes through a small aper-ture in the aponeurosis of the trapezius muscle toetnerge over the occiput as the greater occipitalnerve.-'

Journal of Orsfacial Pain 161

Kuhn et al

Lesser occipital nerve

External occipitalprotiuberance

Greater occipital nerve'

Nuchal ligament-

Trapezius muscle

Fig 1 Anatomy of occipital nerves.

The occipital nerve supplies setisory distributionto rhe posterior aspect of the scalp, the side of theneck, the shoulders, and portiotis of the face,̂ Thegreat auricular nerve produces sensory disrributionof rhe remporomandibular ¡oint; external mcarus;tympanic membrane; superior half of rhe pinna;and the skin and fascia uf rhe check, remple, andscalp.'^ Because these nerves are quire superficialas they exit from the posterior cervical muscula-rure ro enter rhe scalp tissues, rhey are readilysimulated by palpation." Tenderness of the lesseroccipital nerve may be elicited by manual pressurein the depression that lies about 3 cm superomedi-ally ro rhe rip of the mastoid process. Tendernessof the greater occipiral nerve may be elicired overthe occipiral proruberance or by digiral pressure inrhe depression just lareral ro the inseition of thetrapezius muscle into the occipital bone.̂ "* Coxand Cocks^ reporred the resection of rhe occipitalnerve in 95 patients seen for chronic pain. Manyof these nerves showed pathologic changes (79%),including "neuromata, scarring around the nerve,neural fibrosis and densely adherent occipitallymph nodes-" They also noted that "the aperture

through whieh rhe nerve passes ar the tendinousupper end of the trapezius muscle was frequentlyfound to be compressing the nerve at rhar point."^

It is important to consider other causes of occip-ital pain when diagnosuig occipital neuralgia.'''Migraine and cluster headaches as well as diseasein the cervical spine, especially diseases thatinvolve the C-1, C-2, and C-3 nerve roots, mayeasily be confused with occipital neuralgia. Othersources of pain in and around the vertebral col-umn proper may include the apophyseal ¡oinrs andthe synovial joinrs of the occipiroatlanto andatlantoaxial junctions; the annulus fibrosus of theintervertebral discs; the ligaments of rhe spinal col-umn and rhe periosteum of the vertebral bodies;rhe cervical muscles {including myofascial rriggerpomrs'''] and their attachments to bone; the cervi-cal nerve roots and nerves; and the vertebral arter-ies.'* The pain-sensitive structures may be stimu-lated by a variety of pathologic processes,including osteoarthritis, rhcumaroid arthritis, tem-poral arteritis,^' trauma, abnormal posrure,^ infec-tion, rumor and Paget's disease. Causes of occipiralpain that may mimic occipital neuralgia include

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Kuhn et al

Cl-2 arthrosis'^"; direct trauma to the occiput;inflammations, such as herpes zoster or postzosterneuralgia; compression between the atlas and theaxis, as in traumatic byperextension of the neck oratlantoaxial dislocation; entrapment between trau-matized muscles; compression from caudally dis-placed tonsils of the cerebellum, as in tbe Arnold-Chiari malformations'"; primary and metastatictumors, especially of tbe posterior fossa; mastoidand intraspinal infections; and metabolic disor-ders, including diabetes and gout,

Edmeads'^ listed seven features of headachethat suggest a cervical origin and necessitate athorough radiologie examination of the cervicalspine and craniovertehral junction. Radiologieevaluation ,should be considered for patients with-out a typical history of neuralgia-type pain, ten-derness over the nerve, and relief of headachewith local anesthetic injection or with persistentor recurrent pain after local anesthetic injection.Edmeads' criteria'^ for radiologie evaluationinclude (1) headaches with a persistent occipitalor suboccipital component, especially unilateral,(2) reproduction or alteration of tbe beadachewith movement of the neck, (3) abnormal postureof the head and neck, (4) suboccipital or nuchaltenderness, (5) abnormal motility at the craniocer-vical junction, (6) significant and painful limita-tion of neck movements, and (7) signs and symp-toms referable to the lower medulla, uppercervical cord, or upper cervical nerve roots. Forinterpretation of the radiographs, it should beremembered tbat certain findings, including lossof lordosis, osteopbytes, narrowed disc space,foraminal narrowing, and even disc protrusionsshown on myelograms or magnetic resonanceimaging scans are common m people older thanage 40^^ and may not indicate the cause of thesymptomatology. In 1947, Perelson''' describedpalpable tenderness of the occipital nerves withmultiple organic beadache etiologies. The presenceof any associated focal neurologic finding otherthan hypesthesia over the occipital nerve requiresa more extensive evaluation, including computer-ized tomographic scanning or magnetic resonanceimaging. Occlusion of the vertebral arterial systemin the neck has been suspected to he a source ofoccipital headache in patients witb vcrtebrobasilarinsufficiency. The vertebral arteries arc closelyassociated with the first six cervical vertebrae,rendering them susceptible to compression fromtrauma, including direct blows, attempted stran-gulation, or aggressive cervical manipulation,"* Ifa bruit is present, consideration should he given tovertebral angiograpby,^'

Because there are no specific laboratory orradiologie findings to confirm the diagnosis ofoccipital neuralgia, tbe diagnosis and treatmentrests on a cateful and accurate history and physi-cal examination. The hest method of confirma-tion remains tenderness of the associated nerves,along with the characteristic pain syndrome andrelief of tbe symptoms witti local anestheticblockade of the associated nerve. Blockade of thegreater or lesser occipital nerve with local anes-thetic should provide prompt and sometimes sus-tained relief from the beadache. Because thesenerves do not supply intracranial structures,headaches that are relieved following nerve blockare considered to be caused by extracranial fac-tors,^ witb the possible exceptions of pain reliefon the hasis of either a placebo effect or a tempo-rary redistribution of the anesthetic to the centralnervous system,̂ ^

Once the diagnosis of occipital neuralgia isconfirmed, several modes of therapy may proveuseful. Initial therapy should consist of reassur-ance and symptomatic treatment with deep heat,physical therapy, restriction of activities, and amild analgesic.-' The nonstetoidal anti-inflamma-tory medicines, such as indomethacin, may beuseful in some patients, Baclofen has also beenadvocated hy some autbors. It bas been addition-ally noted that some patients may respond torranscutaneous electrical nerve stimulation(TENS),'"-".24 Cervical traction is not belpfuland is not indicated. Tbe apphcation of cervicalcollars is controversial. Some autbors advocatecollars for pain relief. Others state that theyshould be avoided because tbey may exacerbatetbe pam by compression of the occipital nerve asIt travels over the superior nuchal line,̂ ^ Whenpain IS refractory to the above measures, a localblock of the occipital nerve with a long-actinglocal anesthetic, sucb as bupivacaine hydrochlo-ride with epinephrine, in combination with a cor-ticosteroid (methylprednisolone acetate) oftenresults in significant temporary or even pro-tracted relief of the pain,̂ ** Some authors recom-mend that this he done repeatedly.̂ -^ The treat-ment of recalcitrant pain is controversial. Severalauthors '̂-^-* have advocated alcohol block of thenerve, nerve section, avulsion, or decompressionof the nerve. Other authors '̂̂ ^-^ '̂̂ ^- '̂' have sug-gested that these procedures do not work in alarge majority of instances, and they may lead topermanent pain and significant disability fromdenervatioii dysesthesia, Carbama7,epine is thedrug of choice for other forms of neuralgia andmay be tried in occipital neuralgia.'** The initial

Joumsl of Otafacial Pain 163

Kuhn et al

dose of 100 mg per day can be given, and this isgradually increased to 800 mg per day in divideddoses. Some patients may respond to lower dosesof carbamazepine, and orhers may require more.However, mosr of the literature is anecdotal andnone of the above drugs have been rigorouslystudied in patients with occipital neuralgia.

Conclusion

Occipital neuralgia is a clinical entity that may beencountered in patients presenting to an emer-gency department. The diagnosis is often straight-forward from the history and clinical examinationif it is considered by the examining physician. Theheadache frequently has two components, arecurrent, brief, lancinating component and achronic, dull ache over the area of the nerve dis-tribution. Only patienrs wirh rypical neuralgiapain, tenderness over the nerve, Tinei's sign, andrelief of pain with injection of local anestheticwere selected for the present study. The 12patients were similar to those previouslydescribed in the literature in relation to type ofheadache and associated symptoms. Associatedsymptoms, beside headache, that were presenr inseveral of the patients included paresthesia in thedistribution of the nerve, tinnitus, nasal conges-tion, visual symptoms, dizziness/vertigo, and nau-sea. There are no ancillary tests thar can be usedto aid in the diagnosis, except symptom relieffrom local anesthetic injection over the occipitalnerve. All of the patients reported significant tem-porary relief of their symptoms within minutes ofa local anesthetic injection, and several had long-lasting relief. Although other more serious dis-eases may mimic the occipiral neuralgias, a care-ful history evaluation and physical examinationcan usually exclude these if strict diagnostic crite-ria are followed, if any of the components ofoccipital neuralgia is not present, radiologie eval-uation and referral is indicated. Because theseneuralgias are often chronic, follow-up should beassured by someone knowledgeable in rhe care ofthese disorders. There have been no controlledstudies deahng with the various options for paincontrol in patients wirh occipital neuralgia. Well-controlled studies are needed to evaluate the effi-cacy of various treatment options for parientswith this disorder because the pain can be chronicand disabling. It is hoped that with increasedawareness of the syndrome by clinicians, morepatients with this problem can be recognized andtreatment modalities can be evaluated.

Acknowledgments

ThL- aulhors wisli to thank Morton A, Winner, DDS. /or hi?encouragement, and Robert Cux, MD, PhD, for his helpful bug-ges rions.

References

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2, Pascual-Leo ne A, Pascual-Leone Pascual A, Occipital neu.ralgia; Another benign cause of 'thunderclap' headachif, JNeurol Neurosurg Psychiacry ] 9 9 2 ; 5 5 Í 4 1 1 .

3, Solomon 5, Liptdn RB, Facial pain. Headache 1990Í8;913-928,

4, Headache Classification Committee of the InternationalHeadache Society. Classification and diagnostic criteriafor headache disorders, cranial neuralgias and facial pain,Cephalalgia 1988;8(7):él-71

5, Smith DL, Lucas LM, Kumar KL. Greater occipiral neu.ralgia: An unusual presentitig feature of neurosyphilis.Headache 1987;27;552-554,

6, Couch JR, Treatment of facial and scalp neuralgias. In:Gallagher RM (ed). Drug Therapy for Headache, NewYork: Marcd Dekker, 1991:255-273.

7, Con CL |r. Cocks GR. Occipital neuralgia, J Med AssocState Ala 1979;48{7):23-27,

8, Chouret EE, The greater occipital neuralgia headache.Headache 19é7;7i33-34.

9, Dugan MC, Locke S, Gallagher JR, Occipital neuralgia inadolescents and young adults, N EngI J Med 1962;267:1166-1172,

10, Diamond S, Cervical spine disease and muscle contractionheadache. In: Dalcssio DJ (ed), Wolffs Headache andOther Head Pain, ed 5. New York: Oxford UniversityPress, 1987:182-186,

11, Damarjian E. Auriculû-temporal neuralgia—An originaldiagnostic and therapeutic approach. RI Med J 1970;53:100-101,

12, Kcrr FWL. Mechanisms, diagnosis and management ofsome cranial and facial pain syndromes, Sury Clin NorthAm 1963;43:951-9Ê1,

13, Pawl RP. Headache, cervical spondylosis and anteriorcervical fusion. In: Nyhus LM (scries ed), Surg Annu

14, Perelson HN, Occipital nerve tenderness: A sign ofheadache. South Med J 1947;40:653-656,

15, Graff-Radford SB, Jaeger B, Reeves JL, Myofascial painmay present clinically as occipital neuralgia,Neurosurgery 19S6;19:610-613,

IE, Edmeads J, Headaches and head pains associated withdiseases of the cervical spine. Med Clin North Am 1978;62:533-544,

17, Jundt JW, Mock D, Temporal arteritis with normal ery-throcyte sedimentation rates presenting as occipital neu-ralgia. Arthritis Rheum 1991;34:217-219,

18. Ehni G, Benner B, Occipital neuralgia and C1-C2 arthro-sis, N EngI J Med 19S4;310:127,

19, Ehni G, Benner B, Occipital neuralgia and the Cl-2arthrosis syndrome, J Neurosurg 1984;61:961-965,

20. Scott M. Occipiral neuralgia, Penn Med 196Sí71(iaii85-88,

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21, Bullard DE, Nashold BS, The surgical trearment of headand neck pain. In: Dalessio DJ (ed). Wolffs Headache andOther Head Pain, ed 5. New York: Oxford UniversityPre55, 1987:366,

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Resumen

Neuralgias occipitales: El reconocimiento clínico de unacefalea complicada. Series de casos y revisión de liter-atura

El propósito de este estudio fue el de asistir 3 los clínicos en eldiagnóstico del síndrome de la neuralgia occipital, por rnedio de ladescripción de sus caracten'sticas clínicas. Se identificó la bibli-ograHa y ias descripciones clínicas del sindrome de la neuralgiaoccipital a través de una revisión de la literatura publicada entre1966 y 1993 Los autores revisaron series prospectivas de casosen un departamento de urgencias universitario, durante 1 año.Se incluyeron pacientes que presentaban dolor de cabeza unilat-eral, junto con dolor en la distribución del nervio occipital, signode Tinel. y alivio del dolor después de la inyección de unanestésico locai Los pacientes evaluaron el alivio dei dolor enuna escala de i O puntos Diez pacientes cayeron en la clasifi-cación de ia neuralgia occipital y fueron incluidos en el estudio.Todos los pacientes reportaron que el dolor había disminuido porla menos en un 80% después de la inyección, y el alivio total enun 42% de los pacientes. Los rasgos clínicos, fuera de la cefalea,que experimentaron connúnmente los pacientes incluyeron el tin-nitus en un 33%; parestesia del cuero cabelludo en un 33%;nausea en un 42%; vértigo, en un 50%: y disturbios visuales enun 75%. La neuralgia occipital es una causa extracraneal benignade la cefalea, y puede ser confundida con otros síndromes decefaleas mas serios. El reconocimiento depende del entendí,miento de los síntomas junto con la e|ecuciÓn de una historia y unexamen físico cuidadosos. Las inyecciones con anestesia localproducen un alivio significativo de las cefaleas y pueden ayudaren el diagnóstico del síndrome.

Zusammenfassung

Okzipitalneuralgieri: klinische Erkennung eines kom-plizierten Kopfschmerzes. Ein Fallbericht undLiteraturnJckblick

Das Ziel dieser Studie war es, dem Kliniker in der Diagnose desokzipitalen Neuralgiesyndroms zu helfen, indem ihre klinischenMerkmale beschrieben werden. Bibliographien und klinischeBeschreibungen des okzipitalen Neuraigiesyndroms wurden durcheinen Rückbiick der Literatur erhaiten, weche iwischen 1966 und1993 herausgegeben wurde. Ein prospektiver Fallbericht wurdevon den Autoren m einer Universitätsnotfallabteilung währendeiner 1-Jahresperiode durchgeführt. Eingeschlossen wurdenPatienten mit einseitigem Kopfschmerz, gepaart mit Schmerzen inder Verbreitung des Nervus occipitalis, Tinel's Zeichen undAbnahme der Schmerzen nach Injektion eines LokalanästhetikasDie Patienten schätzten die Schmerziinderung auf einer 1Û Punkte-Skala ein Zwölf Patienten wiesen die Kritenen für eine Okïipital-neuralgie auf und wurden m die Studie aufgenommen. AllePatienten berichteten über zumindest 80% Schmerzabnahme nachInjektion, und 42% hatten eine vollständige Abnahme. KlinischeMerkmale ausser Kopfschmerzen, welche die Patienten gerreinhatten, waren Tinnitus in 33%; Parästhesien der Kopfhaut, 33%:Nausea, 42%. Schwindel, 50%: sowie Sehstönjngen, 75%, DieOkzipitalneuralgie ist eine gutartige extrakraniale Ursache fürKopfschmerzen, und sie kann vermischt sein mit anderen ern-sthafteren Kopfschmerzsyndromen, Die Erkennung hängt vomVerständnis der Symptome zusammen mit einer sorgfältigenAnamnese und Untersuchung ab Injektionen eines Lokal-anästhetikas bewirken eine signifikante Abnahme der Kopfs-chmerzen und können bei der Diagnose des Syndroms helfen.

Journal of Orafacial Pain 165