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.
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.
The phenotype is stable and no urgent secondary cause is suspected.
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.
GabapentinUse the current BNF neuropathic-pain schedule with low initiation, gradual titration and renal dose adjustment rather than copying a fixed maximum.