Synopsis
Recognise occipital-nerve pain without turning a descriptive tenderness finding into a diagnosis, exclude dangerous posterior headache causes, and coordinate rehabilitation, diagnostic block and specialist intervention proportionately.
- Occipital neuralgia is recurrent unilateral or bilateral shooting, stabbing or sharp pain in the distribution of the greater, lesser or third occipital nerves, usually lasting seconds to minutes.
- Pain begins in the upper neck or posterior scalp and can radiate toward the vertex or behind the eye through trigeminocervical convergence; radiation alone does not establish migraine.
- Scalp dysaesthesia, allodynia and tenderness over the affected nerve are supportive, particularly when pressure reproduces the familiar paroxysm rather than generic muscular discomfort.
- Diagnostic criteria include temporary improvement after local-anaesthetic block, but a block is not perfectly specific and should be interpreted alongside the complete phenotype.
- Cervicogenic headache is typically provoked by neck movement with restricted range and referred pain, while migraine more often has hours-long attacks, nausea, sensory sensitivity and activity aggravation.
- Examine the scalp, cervical spine, neurological system and fundi where indicated; occipital tenderness can accompany migraine, whiplash, myofascial pain and upper-cervical joint disease.
- Imaging is not automatic in a stable classic presentation, but red flags, abnormal examination, recent trauma, malignancy, infection risk or an atypical progressive pattern justify targeted brain or cervical imaging.
- Initial care commonly combines explanation, avoidance of repeated pressure, sleep and ergonomic adjustment, physiotherapy and a time-limited neuropathic-pain medicine trial selected for the individual.
- An ultrasound-guided or landmark occipital-nerve block may support diagnosis and provide temporary relief; consent must cover local-anaesthetic toxicity, bleeding, infection, alopecia or steroid effects where relevant.
- Persistent disability belongs in headache, pain or neurology services; radiofrequency, peripheral nerve stimulation and decompressive surgery have selected roles but limited evidence and require multidisciplinary selection.
Key red flags
Progression, constitutional symptoms, neurological deficit, papilloedema, cancer, immunosuppression or a major change after trauma should displace the benign working diagnosis.
Investigation priorities
Determine whether the pain has a nerve-territory paroxysmal phenotype.
Management branches
A patient presents with posterior scalp or upper-neck pain.
- Establish whether attacks are brief, shooting and nerve-distributed, then ask about thunderclap onset, fever, trauma, cancer, immunosuppression, visual change and focal neurological symptoms.
- Examine scalp and nerve emergence points, cervical movement, cranial nerves, limbs and gait, adding fundoscopy and vascular assessment where the differential requires them.
- Escalate any secondary-headache feature immediately; otherwise explain the provisional diagnosis and acknowledge overlapping migraine or mechanical pain when present.
The phenotype is stable and no urgent secondary cause is suspected.
- Identify repeated pressure, sleep position, sustained neck posture and movement restriction, then agree feasible ergonomic adjustments without prescribing rigid immobilisation.
- Refer for physiotherapy when cervical dysfunction contributes, using graded mobility, posture and strengthening rather than forceful high-velocity manipulation near vascular structures.
- Consider a time-limited neuropathic-pain medicine trial with a pre-agreed functional target, adverse-effect review and stopping plan if benefit is not meaningful.
Key medicines
AmitriptylineFor neuropathic pain, a typical oral start is 10 mg at night with slow titration under the current BNF and local formulary; lower starts may suit frailty.Anticholinergic burden, postural hypotension, sedation, cardiac disease, glaucoma, urinary retention and overdose toxicity limit use; review driving and do not continue without measurable benefit.
GabapentinUse the current BNF neuropathic-pain schedule with low initiation, gradual titration and renal dose adjustment rather than copying a fixed maximum.Dizziness, somnolence, falls, oedema, misuse and respiratory depression with opioids require review; taper rather than stop abruptly after sustained exposure.