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Beruto and Ramus first described occipital neuralgia in 1821.1 In the beginning of the 1900’s, Luff2 as well as Osler and McRae3 emphasized occipital neuralgia as a cause of occipital pain and headaches. Most patients with primary headache syndromes who have frequent attacks of pain have tenderness in the suboccipital region.4 Neural blockade of the greater, lesser, and third occipital nerves are interventions employed in the diagnosis and treatment of upper neck pain and headache believed to be caused by pathology in the superior cervical spine. In the clinical setting, neck pain and headache are common complaints, so, when evaluating such patients, the clinician will be well served by eliciting as precise a history as possible and seeking any past cervical spine or head trauma.


The medical terms occipital neuralgia and cervicogenic headache describe a syndrome of neck and head pain primarily referred to the occiput, as well as in the temporal area, forehead and retrobulbar areas, that may arise some distance away, in the upper cervical spine. This occurs because the first three cervical spinal nerve segments (C1-C3) that make up the occipital nerves share a relay-station in the brainstem that continues into the upper cervical spinal cord with the trigeminal cell bodies (the cervico-trigeminal nucleus), and the pain of occipital neuralgia and cervicogenic headaches is referred to structures innervated by the branches of the trigeminal nerve, namely, the forehead, temples, and eyes (Figure 19-1). Neuralgia of C2 (occipital neuralgia) is typically described as a deep or dull pain that usually radiates from the occipital to parietal, temporal, frontal, and periorbital regions. A paroxysmal sharp or shock-like pain is often superimposed over the constant pain. Ipsilateral eye lacrimation and conjunctival injection are common associated signs.5

Indications for occipital nerve blocks therefore include:

  • Neck pain felt in the upper back of the neck, potentially referring to the occiput, temporal, forehead and retrobulbar regions of the head.

  • A history of whiplash injury or similar trauma.

  • The presence of a migraine-like headache syndrome not responding to pharmacologic treatment alone.

Figure 19-1.

Cervico-trigeminal nucleus. (Used with permission from Dr. David Schultz.)


  • Infection of the scalp.

  • Coagulopathy.

  • Cervical instability or acute fracture.

  • Arnold-Chiari syndrome.

  • Inability to lie in the prone or sitting position.

  • Inability to provide informed consent.


The suboccipital nerve (the dorsal ramus of C1) innervates the atlanto-occipital (AO) joint (C0-1), and thus can refer pain to the back of the head, mistakenly attributed to the occipital nerve. The C2 dorsal root ganglion and nerve root innervate the capsule of the atlanto-axial (AA) joint (C1-2) as well as the C2-3 facet, so that trauma to these joints will also refer ...

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