HEADACHE CURRENTS
Headache Currents
Occipital Neuralgia Diagnosis and Treatment:
The Role of Ultrasound
Samer Narouze, MD, PhD
Background.—Occipital neuralgia is a form of neuropathic
type of pain in the distribution of the greater, lesser, or third
occipital nerves. Patients with intractable occipital neuralgia do
not respond well to conservative treatment modalities. This
group of patients represents a significant therapeutic challenge
and may require interventional or invasive therapeutic
approaches.
Purpose.—Occipital neuralgia frequently occurs as a result
of nerve entrapment or irritation by a tight muscle or vascular
structure, or nerve trauma during whiplash injury.
Although the entrapment theory is most commonly accepted,
it lacks strong clinical evidence to support it. Accordingly, the
available interventional approaches have been targeting the
accessible part of the occipital nerve rather than the entrapped
part.
Conclusion.—Bedside sonography is an excellent imaging
modality for soft tissue structures. Ultrasound not only allows
distinguishing normal from abnormal entrapped occipital
nerves, it can identify the level and the cause of entrapment as
well. Ultrasound guidance allows precise occipital nerve blocks
and interventions at the level of the “specific” entrapment
location rather than into the site of “presumed” entrapment.
Key words: occipital neuralgia, diagnostic ultrasound, entrapment
neuropathy
INTRODUCTION
Occipital neuralgia is defined as a unilateral or bilateral
paroxysmal, shooting, or stabbing pain in the posterior
part of the scalp, in the distribution of the greater, lesser,
or third occipital nerves. It is commonly associated with
tenderness over the involved nerve and sometimes accom-
panied by diminished sensation or dysesthesia in the
affected area.1 The pain of occipital neuralgia may be
referred to the fronto-orbital area through the trigemino-
cervical interneuronal connections in the trigeminal spinal
nucleus (Table 1).
Address all correspondence to Samer Narouze, MD, PhD, Clinical Professor of Anesthesiol-
ogy and Pain Management, Ohio University; Clinical Professor of Neurological Surgery,
Ohio State University; Chairman, Center for Pain Medicine; Western Reserve Hospital,
1900 23rd St, Cuyahoga Falls, OH 44223, USA.
Accepted for publication February 8, 2016.
.............
Headache
C 2016 American Headache Society
V Conflict of Interest: Advisory board; SJM.
801
ETIOLOGY OF OCCIPITAL NEURALGIA
Most cases of occipital neuralgia are idiopathic with no defi-
nite structural etiology. Possible etiologies are listed below.
 Occipital nerve entrapment: The greater occipital
nerve (GON) arises from the C2 dorsal ramus with
minor contribution from C3 and can follow a very
variable anatomic course.2–5 It curves around the
inferior border of the inferior oblique muscle to
ascend on its superficial surface. Then it penetrates
the semispinalis capitis and invariably the splenius
muscle to end subcutaneously near the nuchal line by
penetrating the trapezius muscle or the fascia. The
GON can be entrapped anywhere from its origin at
the C2 nerve root until it becomes subcutaneous at
the trapezius apponeurosis.
 Postoperative: especially after Arnold-Chiari malfor-
mation surgery or other craniocervical junction sur-
geries. Occipital neuralgia and neuritis have been
reported after radiofrequency ablation (RFA) and
cryoablation.6
 Atlanto-axial joint (AAJ) rheumatoid arthritis and
subluxation as the C2 dorsal root ganglion lies poste-
riorly to the medial aspect of the joint.
 C2 nerve root and dorsal root ganglion (DRG)
lesions: for example, meningioma, vascular
malformation.
 Trauma, infection, space occupying lesions, and
tumors.
DIFFERENTIAL DIAGNOSIS OF OCCIPITAL
NEURALGIA
Occipital neuralgia must be distinguished from primary and
secondary headache disorders as well as tender trigger points
in the suboccipital and upper neck muscles.
Occipital pain can be referred pain arising from the atlanto-
occipital, atlanto-axial, or upper cervical zygapophyseal (facet)
joints. Clinically, this can be differentiated from the typical
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Headache Currents

Table 1.—ICHD-3 Beta Diagnostic Criteria of Occipital

Neuralgia†
A. Unilateral or bilateral pain fulfilling criteria B-E
B. Pain is located in the distribution of the greater, lesser and/or third
occipital nerves
C. Pain has two of the following three characteristics:
1. recurring in paroxysmal attacks lasting from a few seconds to
minutes
2. severe intensity
3. shooting, stabbing or sharp in quality
D. Pain is associated with both of the following:
1. dysesthesia and/or allodynia apparent during innocuous stimulation
of the scalp and/or hair
2. either or both of the following:
(a) tenderness over the affected nerve branches
(b) trigger points at the emergence of the greater occipital nerve or in
the area of distribution of C2
E. Pain is eased temporarily by local anesthetic block of the affected Fig. 2.—Short axis sonogram at C1-2 level showing a normal
nerve greater occipital nerve (arrows) as it runs between the inferior
F. Not better accounted for by another ICHD-3 diagnosis. oblique muscle (IOM) and the semispinalis capitis (SSC). Trap,
trapezius muscle; Spl, splenius muscle.

neuropathic pain of occipital neuralgia, as the pain will be
aggravated with movement of the affected joint.
Figure 1 illustrates a proposed algorithm to guide appropri-
ate diagnosis and treatment for occipital pain.7
THE ROLE OF ULTRASOUND IN DIAGNOSIS
THE ETIOLOGY OF OCCIPITAL NEURALGIA
Diagnostic Ultrasound
The GON can be traced with ultrasound from its origin at
C2 nerve root all the way until it becomes subcutaneous at
the trapezius aponeurosis.
1. Diagnosis of occipital nerve entrapment: by demon-
strating enlarged, abnormal, swollen nerve8 (Figs. 2
and 3). The normative sonographic data indicate
that the GON cross-sectional area is 2.0 6 0.1 mm2
at C1-2 level. The size of the GON typically
remains the same until it branches in the occipital
area. The mean GON cross-sectional area in
symptomatic patients following entrapment was
4.1 6 2.6 mm2.8,9

Fig. 3.—Short axis sonogram at C1-2 level showing a swollen

greater occipital nerve with edema surrounding the nerve
Fig. 1.—Occipital headache algorithm. *There is lack of evidence (arrows) as it runs between the inferior oblique muscle (IOM)
supporting the use of BoNT for tension type headache (TTH). and the semispinalis capitis (SSC).
803 | Headache | April 2016
Fig. 4A.—Short axis sonogram at C1-2 level showing the greater
occipital nerve (arrows) as it runs between the inferior oblique
muscle (IOM) and the semispinalis capitis (SSC). Trap, trapezius
muscle; Spl, splenius muscle.
Fig. 4B.—Short axis sonogram at C1 level showing the greater
occipital nerve (arrows) entrapped within the belly of the semi-
spinalis capitis (SSC). Trap, trapezius muscle; Spl, splenius mus-
cle; IOM, inferior oblique muscle. Notice the enlarged nerve with
enhanced fascicular pattern.
Headache Currents
Fig. 4C.—Short axis sonogram at the occipital level showing the
greater occipital nerve (arrows) as it pierces the trapezius muscle
(Trap). Occ, occiput. Notice the swollen enlarged nerve.
2. Diagnosis of the cause of entrapment:
 entrapment within the suboccipital muscles
(Fig. 4A-C)
 impingement by arterial vessels (Fig. 5)
 impingement by venous aneurysms/malformations
(Fig. 6)
 muscle space occupying lesion (Fig. 7)
3. Lesions at the level of the C2 nerve root and dorsal
root ganglion (DRG) may be identified as well (Fig. 8).
THE ROLE OF ULTRASOUND IN THE
TREATMENT OF OCCIPITAL NEURALGIA
Interventional Modalities
1. Ultrasound guided occipital nerve block
The procedure can be performed either distally at the
nuchal line (Fig. 9, position A) or more proximally
between C1 and C2 (Fig. 9, position B).10 I prefer block-
ing the GON at C1-2 level where it runs between the infe-
rior oblique muscle (IOM) and the semispinalis capitis
muscle (SSC). The GON is well identified here and can
be easily targeted rather than trying to identify the termi-
nal subcutaneous branches at the nuchal line. However, it
should be noted that are no available studies directly com-
paring blocking the neve at these two locations.
804 | Headache | April 2016
Fig. 5.—Short axis sonogram at C1-2 level showing an abnormal
artery (A) impinging the greater occipital nerve (arrow) as it runs
between the inferior oblique muscle (IOM) and the semispinalis
capitis (SSC).
The procedure can be performed with the patient either
in the prone or sitting position. A high-frequency ultra-
sound transducer is usually used (low-frequency trans-
ducer may be used depending on body habitus). First, a
transverse short axis view is obtained by applying the
transducer in the midline over the occiput and then
scanning caudally to identify C1 and C2 levels. C1 lacks a
spinous process, and the first bifid spinous process
encountered is C2 (Fig. 10). Then, the transducer is moved
Fig. 6.—Short axis sonogram at C1-2 level showing an abnormal
vein impinging the greater occipital nerve (arrows) as it runs
between the inferior oblique muscle and the semispinalis capitis.
Headache Currents
Fig. 7.—Short axis sonogram at C1-2 level showing a cyst
(arrows) within the semispinalis capitis (SSC). IOM, inferior
oblique muscle.
laterally until the suboccipital muscles are seen in the
view. To better differentiate the IOM from the SSC, the
lateral end of the transducer is tilted cephalad to be in line
with the orientation of the IOM as it stretches between C1
and C2. By changing the transducer orientation in this
manner, the sonogram will show the IOM in its long axis,
while obtaining a short axis view of the SSC and thus
clearly differentiating the two muscles and the fascial
plane in between where the GON can be searched for.
Fig. 8.—Short axis sonogram at C2 level showing the C2 dorsal
root ganglion (DRG), the vertebral artery (VA), and the greater
occipital nerve (GON) between the inferior oblique muscle
(IOM) and the semispinalis capitis (SSC).
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Fig. 9.—The position and orientation of the ultrasound transducer
for greater occipital nerve block. A: nuchal line; B: C1-2 level.
The American Headache Society Special Interest
Group expert consensus and systematic reviews on occipi-
tal and other nerve blocks, published in 2010 and 2013,
addressed other considerations for the blocks, including
the frequency of injections, as well as the type of injectate,
Fig. 10.—Short axis sonogram at C2 level. Note the bifid spinous
process of C2 (arrows). Trap, trapezius muscle; SSC, semispinalis
capitis muscle; IOM, inferior oblique muscle.
Headache Currents
Fig. 11.—Short axis sonogram at C1 level showing the lead
(arrow heads) placed subcutaneously superficial to the semispina-
lis capitis muscle (SSC) and the inferior oblique muscle (IOM).
SC, subcutaneous.
and whether the blocks should be done with local anes-
thetic alone or with steroids. Different recommendations
were made for different headache disorders, including
occipital neuralgia, migraine, and cluster headache.11,12
2. Ultrasound guided botulinum toxin type-A injec-
tions
Recent studies have shown that injection of onabotu-
linumtoxinA into the “presumable” sites of GON
entrapment may provide some short-term relief in
symptomatic patients.13,14
Fig. 12.—Short axis sonogram at C1 level showing the lead
(arrow heads) placed between the semispinalis capitis muscle
(SSC) and the inferior oblique muscle (IOM). Med, medial; lat,
lateral.
806 | Headache | April 2016
Our observations indicate that botulinum toxin may
provide sustained relief in patients with occipital neu-
ralgia when injected into a “specific” entrapment loca-
tion (rather than into the site of potential or
“presumed” entrapment). The appropriate site for
injection may be identified with bedside ultrasound
imaging. The normalization of biomechanics after the
release of the occipital nerve is likely the source of the
long-term recovery, rather than prolonged action of the
botulinum toxin itself.8
3. Ultrasound guided occipital peripheral nerve
pulsed radiofrequency
There is an interest in pulsed radiofrequency (PRF)
as a minimally invasive percutaneous treatment for
intractable occipital neuralgia. At the time of this writ-
ing in February 2016, there are 2 prospective studies
and one retrospective multicenter study with promising
results.15–17 However, the lack of randomized controlled
studies and the variation in the technique with land-
mark versus imaging guidance limit the wide applica-
tion of this treatment modality.
4. Ultrasound guided occipital peripheral nerve
stimulation
Occipital neurostimulation (ONS) or greater occipi-
tal peripheral nerve stimulation offers the potential for
a minimally invasive, relatively low risk, nerve preserv-
ing, and reversible approach to managing intractable
occipital neuralgia as well as other headache disorders.
There is a growing body of literature regarding the
efficacy and safety occipital nerve stimulation, and the
Congress of Neurological Surgeons released a state-
ment in 2015 supporting the use of ONS for the treat-
ment of intractable occipital neuralgia, however
demanding more research and a unified improved
technical approach.18
The level and depth of lead placement are very cru-
cial for successful ONS results. Traditionally, the lead
is placed with fluoroscopy, and if the lead is too
superficial patients may experience unpleasant dysthe-
sias in the overlying skin area. If the lead is placed
deep, it may penetrate the occipital muscles, which
usually leads to painful muscle spasms upon stimula-
tion.19 As ultrasound is a great tool in visualizing soft
Headache Currents
tissue structures, ultrasound-guided technique will ena-
ble the lead to be placed subcutaneously superficially
to the occipital muscles (Fig. 11). The GON can also
be recognized, and the lead can alternatively be
placed intentionally between the inferior oblique and
semispinalis muscle (where the nerve runs) at the C1-
2 level (Fig. 12).20 In this latter case, the GON can be
stimulated with minimal settings, which can save the
life of the battery.
Acknowledgment: All figures are printed with permis-
sion from Ohio Pain and Headache Institute; Samer Nar-
ouze, MD, PhD.
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