Occipital neuralgia and Suboccipital headache – C2 neuralgia treatments without nerve block or surgery

Ross A. Hauser, MD.

Occipital neuralgia – C2 neuralgia treatments without nerve block or surgery

Patients who write to us often describe a condition of hopelessness from a diagnosis of Occipital neuralgia or C2 neuralgia. They tell us about unrelenting headaches, pain and even swelling in the back of the head and neck. They will tell us about large doses of medications they take, some later to be found inappropriate or ineffective. They will even describe the problem of not getting enough medications. Such is the seeming hopelessness of their situation.

Generally, patients who are diagnosed with occipital neuralgia or entrapment neuropathy of the greater or lesser occipital nerve have already undergone occipital nerve blocks, radiofrequency, and or decompressive surgery for the occipital nerve. Some of the surgeries include C2 gangliotomy, C2 ganglionectomy, C2 to C3 rhizotomy, C2 to C3 root decompression, neurectomy, and neurolysis with or without sectioning of the inferior oblique muscle.

A February 2022 paper in the journal Pain Medicine (1) wrote: “The pathophysiology and underlying mechanism of occipital neuralgia remain unclear; occipital neuralgia can be a challenging diagnosis to make, as its symptoms can overlap with other common pain syndromes. Because of the difficulty in diagnosis, its true incidence and prevalence remain poorly defined.” In other words, there is a problem with diagnosis and a problem then of understanding a proper treatment path. In this paper, temporary, percutaneous peripheral nerve stimulation was the focus. We will discuss this treatment below.

Discussion points of this article:

  • “My big problem is my MRI, MRA, and CT Scan show nothing. So all I get is pain medications for Occipital neuralgia and Suboccipital headache.
  • Occipital release, muscle relaxants, NSAIDs, and massages for Occipital neuralgia and Suboccipital headache.
  • A further explanation of vision and headache problems because of cervical spine compression.
  • How upper cervical instability can impact the brainstem.
  • The path to treatment using regenerative medicine injections and DMX imaging studies to restore cervical neck stability.

When is it a headache and when is it Occipital neuralgia?

  • When is it a headache and when is it Occipital neuralgia? This may be a confusing question for some. Isn’t Occipital neuralgia a headache?
    • Occipital neuralgia and migraines are different problems and while similar in symptoms are vastly different in treatment needs. Or are they?
    • Your doctor may think you have Occipital neuralgia because your migraine medications are not working.
  • Symptoms, headache, strange vibration in the upper lip, deep pain at the base of the skull, or severe pain between the eyebrows. Sometimes all of them.
  • When the occiput bone smashes against the C1 vertebra.
  • “The clinical implications of distinguishing occipital neuralgia and migraine headache and isolated occipital neuralgia include differences in the treatment regimen, avoidance of inappropriate use of medical resources, and differences in long-term outcomes.”

Nerve blocks

  • Desperate for answers, doctors start the slow turn away from nerve blocks and towards cervical ligament repair and treating the muscle spasms of the suboccipital region.
    Suboccipital muscle spasm and the path toward nerve blocks.
  • A brief explanation of cervical ligament injury and headaches.
    • Suboccipital headache Moving away from nerve blocks and getting results from ligament repair.
      The desperation of pain relief – patients opt for high-dose nerve blocks.
    • The treatment of overstretched cervical neck ligaments as an alternative to High-Volume Anesthetic Suboccipital Nerve Blocks
  • Botox injections are not disease-altering – they do not fix what is causing the muscle spasms – cervical instability.

The role of cervical instability in occipital neuralgia

  • A noisy neck is a clue to cervical neck instability being the underlying cause of Occipital neuralgia and headaches.
  • A discussion of surgery and other treatments for Occipital neuralgia and Suboccipital headache.
  • Rewards and risk of surgery – “Clinicians should bear in mind the risk that destructive procedures carry, which include the possibility of the development of painful neuroma or causalgia (severe burning pain), conditions that may be even harder to control than the original complaint.”
  • Other treatment options: Is freezing the nerve better than burning the nerve?
  • Dry Needling as opposed to acupuncture for Occipital neuralgia and Suboccipital headache.
  • The role of cervical instability in occipital neuralgia. Focus on the cervical neck ligaments.
  • Treatment: Occipital neuralgia is a whole-body disorder.
  • Spasms and tension in the cervical muscle fixes.
  • Prolotherapy for Suboccipital headache.

Introduction

In the video, Ross Hauser, MD discusses diagnosis and non-surgical treatment options for Occipital neuralgia.

Dr. Hauser’s learning points from the video.

  • If you have chronic occipital headaches and have been diagnosed with occipital neuralgia and none of the traditional treatments that you have been offered have worked,  it may be possible to find your problem in upper cervical instability. Upper cervical instability is a very loose neck that allows the cervical vertebrae to wander and irritate the C2 nerve and that’s what’s causing your occipital neuralgia.

The interwoven nature of the C1 and C2 nerve roots through the vertebrae is seen in the image below. If the vertebrae are wandering, they rub, compress, and irritate the nerves. The path of the C2 nerve which branches and becomes the occipital nerve, is shown resting tightly between the C1 and C2 vertebrae.

C1 AND C2 NERVE ROOTS

“My big problem is my MRI, MRA, and CT Scan show nothing. So all I get is pain medications”

The probable accurate diagnosis of occipital neuralgia is well documented. Sometimes when there is no clear diagnosis of occipital neuralgia, but nerve pain is suspected, pain medications will be the main treatment recommendation.

A typical patient history will describe that: one day, I had a headache, and it never went away. I have had this headache for years. Some days it is bad, other days it is a dull throbbing that I can manage along with ice and NSAIDs. My biggest problem is that when I finally get an MRI, an MRA, or CT Scan, they show nothing. My doctors are confused, I am confused and I am back on pain medications because there is nothing else that they can do.

Compounding this frustration is the reach for answers these patients are getting from healthcare providers and specialists who are seemingly guessing at what their problem is. Is it a pinched nerve? Is it muscle inflammation? Is it nerve inflammation? Further, as the headaches increase, other symptoms develop including hearing problems, vision problems, and dizziness.

In their search for answers, few are told that their problems may be related to cervical spine and neck instability. This, despite clear and mounting evidence that cervical spine and neck instability is a primary causative factor in the diagnosis of occipital neuralgia. BUT, without clear evidence on MRI, MRA, or CT Scan, there can be no diagnosis of cervical spine problems, neck instability, or cervical facet joint syndrome if the images offer no appearance of degenerative or traumatic injury to the C1-C2 area.

For some of you, this article may represent the first time you are exploring an in-depth discussion and research that cervical spine and neck instability may be the root of your problem. In many patients we see, a discussion with their health care providers have continued to singularly focus on symptom suppression and dealing with their neuralgia, their nerve pain, as the case of their base of the skull pain and painful range of motion, and headache problems.


Occipital release, muscle relaxants, NSAIDs, and massages

For some people, a conservative care regimen of NSAIDs, muscle relaxants and massage will be all they need to get pain relief and a good night’s sleep.  Some patients will report that they initially had great results from a massage of “Occipital release” that helped with their painful muscle spasms. However, these pain relief advances they were getting soon became less effective and they were in fact “back to square one.”

At square one, new treatments were brought in or “upped,” and continued.

  • more nerve blocks that did not work,
  • cortisone injections whose remarkable pain relief effects quickly went away in a matter of hours or days or sometimes weeks,
  • Thermal Radiofrequency Ablation that burned out nerves,
  • an aggressive Botox injection campaign to relax the muscles in the occipital region,
  • chiropractic manipulations that helped or hurt them and,
  • acupuncture and other forms of “alternative” medicine. In the end, these people are still looking for help that they are not getting.
The location and relation between the suboccipital muscles to the C1 vertebra - the Atlas, and the C2 vertebra - the Axis and the path of the occipital nerve. Upper cervical spine instability at C1-C2 can cause pressure in the area resulting in the contraction and spasm of the muscle contraction
The location and relation between the suboccipital muscles to the C1 vertebra – the Atlas, and the C2 vertebra – the Axis and the path of the occipital nerve are illustrated. Upper cervical spine instability at C1-C2 can cause pressure on the base of the spine resulting in the contraction and spasm of the suboccipital muscle. This can cause headaches, migraines, and occipital neuralgia.

A further explanation of vision and headache problems because of cervical spine compression

To better understand how upper cervical instability is associated with visual symptoms, it is important to reiterate the anatomy. The upper cervical spine protects the lower medulla oblongata as it goes through the foramen magnum and emerges as the spinal cord. Thus the medulla and the cervical cord are closely related to the highly mobile parts of the cervical spine, especially the suboccipital region. The suboccipital region is the most mobile area of the spine and the area of maximal mechanical activity. The brainstem has been shown to stretch with neck flexion and extension. This has been documented in numerous studies, especially those surrounding head trauma and whiplash injury. This stretch can enough to interfere with nerve impulses.

Another common finding is sensitivity to a friction-type “to and fro” motion at the base of the scalp. This is called allodynia, a generic term for a normally non-painful stimulus that has become very painful. This sign suggests neuropathy and is most commonly from occipital nerve irritation from upper cervical instability. Neuropathy or neuralgia is pain in one or more nerves caused by compression and/or irritation of the peripheral nerve structures. In this case, it is the lesser or greater occipital nerves. When a headache sufferer has extreme sensitivity on a particular part of the face or head, they most likely have a neuropathy or neuralgia of the nerve that supplies that part of the skin with sensation.

There are many types of cranial neuralgias that are associated with headaches, the most common of which are occipital, glossopharyngeal, and trigeminal. Upper cervical instability is associated with changes in the C0-C2 angle and altered mechanoreceptor sensory input and nerve root irritations can cause or be associated with the cranial neuralgias. It is interesting that cervical intramuscular anesthetic injections in an emergency for severe facial and head pain had the following results: a 65% cure rate of the headache including migraines; an overall response rate of 85%; associated signs and symptoms such as nausea, vomiting, photophobia, phonophobia were relieved; and there was rapid relief of palpable scalp or facial tenderness (mechanical hyperalgesia and allodynia pain). This is pointed out in the research of Garry Mellick, DO, and Larry Mellick MD. (2,3) Again more evidence that the cause of headaches, migraines, and facial or scalp neuropathic symptoms is actually from the neck. Of further interest is that besides the relief of severe facial pain, the intramuscular cervical injections produce rapid relief of palpable scalp or facial tenderness (mechanical hyperalgesia and allodynia pain).

What are we seeing in this image? How upper cervical instability can impact the brainstem.

The vast array of neurologic-like, vascular, and cardiovascular-like symptoms suffered by patients in whiplash-related or cervicomedullary junction degeneration of injury can be explained by examining the position of the brain stem in the cervical spine and how instability at the C1 or C2 levels can cause these bones to start wandering around and compressing nerves, arteries, and veins.

The vast array of neurologic-like, vascular and cardiovascular-like symptoms suffered by patients in whiplash related or cervicomedullary junction degeneration of injury can be explained by examining the position of the brain stem in the cervical spine and how instability at the C1 or C2 levels can cause these bones to start wandering around and compressing nerves, arteries and veins. 

There is communication between the occipital nerve (C2) and the trigeminal nerve via the medulla (the lowest portion of the brain stem). This is why pain that begins at the C2 level often starts in the suboccipital region and radiates up to the vertex and forward behind the ipsilateral eye. Often patients feel pain as if the eyeball were torn from the socket. The headache is similar to a migraine and often accompanied by nausea, vomiting, and blurred vision. This greater occipital-trigeminal syndrome simulates occipital neuralgia and hemicranial attacks as occur with cluster headaches. This connection is confirmed as hyperosmotic saline injections into the suboccipital neck muscles refer to pain in the trigeminal region and likewise, administration of local anesthetic into the same region relieved the pain of referred eye or orbital pain. Local anesthetics injected into the suboccipital muscles could also cause ataxia, dizziness, and nystagmus in humans. The cervical spine can also induce eye position changes and visual illusory movements. This confirms that proprioceptive information from the neck plays a role in regulating eye position in determining gaze direction. The suboccipital muscles also have been shown to have a significant influence on proprioception (whole-body balance) and head-on-body orientation. It is easy to understand then how cervical instability can dramatically alter balance and give many different head, face, and eye symptoms.

The path to treatment using regenerative medicine injections and DMX imaging studies to restore cervical neck stability

We are very hopeful that this article will be a journey of understanding for you. What we hope to present is good evidence that the challenges of occipital neuralgia can be overcome, not with sedation in the form of stronger pain medications, or the constant treatment of symptoms with short-term treatments that may or may not work or may make the situation worse. We are going to present evidence that simple dextrose injections can fix a very complicated problem. Below we will also discuss another imaging type, the use of DMX or Digital Motion X-ray that helps uncover “hidden,” cervical spine and neck instability. The difference with DMX images is that it takes a movie of your cervical spine moving through various motions.

When is it a headache and when is it Occipital neuralgia? This may be a confusing question for some. Isn’t Occipital neuralgia a headache?

In our clinic, we see many patients with a chief complaint of headaches. The obvious challenges of these people’s headaches are first, obtaining pain relief, and secondly, finding the source of what is causing them their headaches and stopping future occurrences.

But when is it a headache and when is it Occipital neuralgia?

This may be a confusing question for some. Isn’t Occipital neuralgia a headache?

This is the description provided by The National Institute of Neurological Disorders and Stroke (4)

  • “Occipital neuralgia is a distinct type of headache characterized by piercing, throbbing, or electric-shock-like chronic pain in the upper neck, back of the head, and behind the ears, usually on one side of the head.  Typically, the pain of occipital neuralgia begins in the neck and then spreads upwards.  . . .  In many cases, however, no cause (for Occipital neuralgia) can be found.  A positive response (relief from pain) after an anesthetic nerve block will confirm the diagnosis.”

This definition may confirm your worst fears, nothing can be done for you other than nerve blocks and increasingly heavier doses of medication.

Occipital neuralgia and migraines are different problems and while similar in symptoms are vastly different in treatment needs. Or are they?

In your research on headaches, you may have come upon many websites that suggest that:

  • Occipital neuralgia is a “headache” pain.
  • Occipital neuralgia is not a “headache” pain but a nerve-related pain.
  • Occipital neuralgia and migraine headaches share the same symptoms.
  • Occipital neuralgia and migraines require different treatments as one is nerve pain and one is “chemical” related imbalances caused by many problems. In our peer-reviewed published research, we documented in the journal Practical Pain Management (5) numerous risk factors, often labeled “triggers,” that may result in a migraine-eliciting environment. These include skipped meals, sleep deprivation, hormonal changes, alcohol consumption, and acute stress, among others. Individuals may also report pain sensations in areas innervated by the trigeminal system—notably nasal and neck regions, which can then lead to misdiagnosis of sinus or tension headaches.

Your doctor may think you have Occipital neuralgia because your migraine medications are not working

For many patients, it is common to go through a long medical history that is in reality a process of elimination. Often Occipital neuralgia will be diagnosed on a basis of a medication or treatment that is not working.

In The Journal of Head and Face Pain, (6) researchers at the Department of Neurology, the University of Southern California, Keck School of Medicine, conducted a study to identify differences in patient symptoms with a diagnosed isolated occipital neuralgia and patients with occipital neuralgia who also had a migraine headache.

The doctors of this study were trying to sort through the confusion. Here is what they said:

  • “Occipital neuralgia is an uncommon cause of headaches. Very little is known about the pain characteristics and associated features of patients with occipital neuralgia and migraine headache and whether these pain characteristics differ from those of patients with isolated occipital neuralgia.”

Note: We want to point out here that the term “uncommon,” suggests a rarely diagnosed cause.

Symptoms, headache, strange vibration in the upper lip, deep pain at the base of the skull, or severe pain between the eyebrows. Sometimes all of them.

In this video Ross Hauser, MD. discusses C0-C1 instability and the problems it creates on C1 nerve root compression. The highlights and summary transcript are below.

The Occiput bone smashes against the C1 vertebra

At 0:50 video – the patient’s Digital Motion X-Ray demonstrates that their occiput is violently colliding with their C1 vertebra every time they move their head forward and their chin juts out.

IIn this still fame from the video, Dr. Hauser points to the back of the patient's skull, the occiput bone as it smashes into the patient's C1 vertebrae every time they move their head forward and their chin juts out, as in reaching out for something, looking upwards, etc. When this happens the patient's C1 nerve root and vertebral artery are compressed. This compression would lead to headaches, facial pain, and vibrating sensations in the upper lip.
In this still frame from the video, Dr. Hauser points to the back of the patient’s skull, the occiput bone as it smashes into the patient’s C1 vertebrae every time they move their head forward and their chin juts out, as in reaching out for something, looking upwards, etc. When this happens the patient’s C1 nerve root and vertebral artery are compressed. This compression would lead to headaches, facial pain, and vibrating sensations in the upper lip.

“The clinical implications of distinguishing occipital neuralgia and migraine headache and isolated occipital neuralgia include differences in the treatment regimen, avoidance of inappropriate use of medical resources, and differences in long-term outcomes.”

So to answer this challenge, the researchers looked at 35  patients all diagnosed with occipital neuralgia

  • Twenty patients had occipital neuralgia and migraine headache and 15 had isolated occipital neuralgia.
  • Patients with occipital neuralgia and migraine headache had significantly more complaints of pain traveling to the scalp and the presence of scalp tenderness and tingling compared with patients with isolated occipital neuralgia.
  • 25% of patients in the occipital neuralgia and migraine headache group described the pain as “dull” whereas none of the isolated occipital neuralgia group reported this characteristic.
  • There was a higher use of chiropractors and massage therapy in patients from occipital neuralgia and migraine headache groups than from isolated occipital neuralgia.

The findings of this study were offered to help doctors identify differences in pain characteristics for patients with occipital neuralgia and migraine headache and those for patients with isolated occipital neuralgia. The main learning point of this research is that patients with migraines should also be screened for symptoms of occipital neuralgia. Why?

  • The clinical implications of distinguishing occipital neuralgia and migraine headache and isolated occipital neuralgia include differences in the treatment regimen, avoidance of inappropriate use of medical resources, and differences in long-term outcomes.”

What we see here is that migraine and occipital neuralgia are difficult to understand and that makes it difficult to get at the root of their cause and apply appropriate treatments.

Ross Hauser, MD. Cause of occipital neuralgia and migraines seen on DMX and resolved with Prolotherapy

In this video, Ross Hauser, MD offers a brief introduction to the causes and diagnosis of occipital neuralgia and migraines treated with the aid of DMX (Digital Motion X-Ray and simple dextrose Prolotherapy cervical spine injections.

Summary highlights of the video:

  • One of the most common conditions that we see here at Caring Medical is migraine headaches. Another common condition is occipital neuralgia.
  • Much of the confusion surrounding the diagnosis of these two conditions is that a root cause, upper cervical spine instability (at C1-C2) is common to both problems and rarely looked for initially.
  • Dr. Hauser demonstrates that the occiput (the main portion of the back and lower part of the skull), sits on the Axis (C1) which sits on the Axis (c2).
  • Dr. Hauser focuses on the Facet joint at C1-C2. On the back of this joint is the C2 nerve root. If the patient has upper cervical instability at C1-C2, the C1 vertebrae can hit, damage, and compress the C2 nerve root. The occipital nerve is an offshoot of the C2 nerve. The cause of occipital neuralgia and the trigger of the structural cause of migraine headaches is the instability of the C1 – C2 facet joint.
  • The way we documented upper cervical instability in our offices is by digital motion x-ray or DMX. A brief demonstration is shown of the digital motion X-ray of one of our patients who had their occipital neuralgia successfully treated with dextrose Prolotherapy cervical spine injections.
  • To see the C1-C2 facet joint – the x-ray is taken from the front of the face and with an open mouth. Then what we are looking for is a misalignment, is there an overhang of the C1-C2 vertebrae when the person bends their head to the side?
  • At 2:08 of the video, the x-ray takes a film of the patient’s neck in motion, demonstrating the C1-C2 overhang or misalignment. So the structural cause of migraine headaches is actually looseness of the facet joint at C1 C2.
  • Prolotherapy cervical spine injections address this looseness by strengthening the connective tissue structures that are designed to prevent this looseness. These are the cervical spine ligaments of the neck.  Normally it takes anywhere from 4 to 5 treatment sessions to resolve this instability and thereby the symptoms. The treatment and research are explained below.

Desperate for answers, doctors start the slow turn away from nerve blocks and towards cervical ligament repair and treating the muscle spasms of the suboccipital region

  • University researchers are helping to confirm that cervical sympathetic syndromes (pain and functional problems) caused by instability in the neck are real problems and related to weakness of neck ligaments and muscles. 
  • This acknowledgment is featured in research in the Journal of Physical Therapy Science, (7) which states a suboccipital headache is caused by muscle fatigue.
  • In this research, a Korean university team focused on muscle fatigue.
  • In Caring Medical research, we focus on cervical ligament weakness. Muscles get fatigued because they are in spasms from trying to stabilize an unstable neck. An unstable neck gets that way because of ligament weakness and damage. A result of ligament weakness causing muscle spasms is a suboccipital headache.

Treating muscle spasms with manipulation

Another study (December 2017) in the Journal of Manipulative and Physiological Therapeutics (8) brings together observations from previous studies and clinical outcomes to suggest that cervical spinal manipulations that help “unfreeze,” or move the neck about, would help eliminate pressure in the muscles and neck and thereby reduce or alleviate Suboccipital headache.

As we have documented in our research and discussed in our articles on Over Manipulation Syndrome, when the ligaments are exposed to continued stress, they will slowly stretch. Repeated stretching such as from excessive high-velocity manipulations will cause them to elongate and deform. The stretched-out cervical and capsular ligaments of the spine will cause instability of the spine. When this goes on for too long, the ligaments stretch to the point of no return and are unable to hold the vertebrae in place. The vertebrae shift and start to cause pain and other symptoms of spinal instability.

You can see how this could lead to a pattern of even more manipulations because the vertebrae are now shifting more frequently. But manipulations at this point will only make things worse. The attempt at realignment with manipulations will not hold but will stretch the ligaments further, potentiating the symptoms of the over-manipulation syndrome.

This image shows the occipital muscles at the base of the skull. The muscles include the rectus capitis posterior major, rectus capitis posterior minor, the obliquus capitis, inferior and obliquus, and capitis superior
This image shows the occipital muscles at the base of the skull. The muscles include the rectus capitis posterior major, rectus capitis posterior minor, the obliquus capitis, inferior and obliquus and capitis superior

Suboccipital muscle spasm and the path toward nerve blocks

When a patient comes in with headache and neck pain related to the base of the skull we see on examination the hallmark finding of tenderness in the suboccipital muscles.

The function of the suboccipital muscles is underrated, which is confusing because these four fine-tuning muscles are vital in stabilizing the position of the head by helping provide stability in the upper cervical region.

The four muscles are the:

  • rectus capitis posterior major
  • rectus capitis posterior minor
  • the obliquus capitis inferior and
  • obliquus capitis superior.

Two terms to quickly identify before we move on:

  • Flexion – this is the motion of the neck forward where your chin can touch your chest.
  • Extension is the opposite motion where your chin will point straight in the air.
  • The atlantooccipital joint (the joint between the Atlas and Axis (C0-C1) is responsible for 50% of flexion and extension)
  • The atlantoaxial joint (the joint between the first and second cervical vertebrae C1-C2) is responsible for 50% of the neck’s rotation.

Because of its location, the obliquus capitis inferior plays an important role in the static and dynamic stability of the atlantoaxial joint (the joint between the first and second cervical vertebrae C1-C2), especially when there is upper cervical ligament laxity. When cervical neck instability is present the obliquus capitis inferior muscle pulls back the transverse process of the atlas (C0 vertebrae), pulling the atlas back or in extension.

When all four muscles contract on one side, they pull on the neck to that side. When they contract on both sides, they extend the head on the upper cervical spine; this extension is produced at both the atlantooccipital and atlantoaxial joints. The forward head posture position causes the cervical spine to straighten or go into a kyphotic position, which puts more strain on the structures of the upper cervical spine to hold the top two vertebrae, thus the head goes into extension.

  • Over time, the upper cervical ligaments stretch too far, recruiting the suboccipital muscles to tighten.
  • Once fatigued, they also become a source of significant pain. Suboccipital muscle tension or headache is one of the major symptoms of someone having upper cervical instability.

Damage of soft tissue and increase of tension in the neck limits stationary contraction of deep cervical muscle, posing difficulty in sustaining upright neck posture. With this process, cervical pain and cervicogenic headache occur, and as pain occurs or aggravates from the motion of returning to normal posture.

A brief explanation of cervical ligament injury and headaches

In this video, Ross Hauser, MD, explains the mechanisms of cervical ligament injury and headaches.

Transcript summary:

  • Chronic headaches are caused by ligament injury. Because of our modern lifestyle, we’re all hunched over computers and smartphones, when we are hunched over we are getting the slow stretching of the cervical ligaments that connect the bones in the cervical spine. Whiplash injury also causes ligament injury. When these ligaments are injured they can no longer do their intended job, keeping the cervical spine stable.
  • Ligament injury can cause headaches by multiple mechanisms. The most common mechanism of headache is muscle spasms. The muscle spasms try to limit the extra motion of bones so the vertebrae won’t compress nerves or pinch nerves or block cerebral spinal fluid. The person with chronic muscle tension headaches actually has an underlying cervical ligament injury.
  • Cervical ligament injury can also cause activation of nerves and ligaments that can refer pain in the forehead and other parts of the head to give headaches

The desperation of pain relief – patients opt for high-dose nerve blocks

This is a story we often hear. A patient will tell us that following a diagnosis of occipital neuralgia and non-responsiveness to treatments, they will be moved onto a bilateral nerve block. Many will tell us that nerve blocks are limited in their effectiveness. What is limited effectiveness? Usually, it means progressive symptoms that may include: Continued headaches, burning or shoot pain continues along the occipital nerve paths and into the neck mouth, and teeth. Some will report vision problems and blurred vision in one or both eyes, others will have photophobia that comes and goes. Others describe twitching or facial tics, acute ear pain that can last for seconds. Brain fog, signs of radiculopathy such as numbness in the limbs.

Here is a study from the Mayo Clinic that appeared in the August 24th, 2018 edition of The Journal of Head and Face Pain. (9)

When all else fails in helping patients with their symptoms, doctors turn towards High-Volume Anesthetic Suboccipital Nerve Blocks. Let’s see what happened to the patients.

  • In this study, 10 patients suffering from chronic cluster headaches, headaches that could last from weeks to months to years were seen at a dedicated headache clinic over a 7-year time period. These patients were considered difficult to treat as seen in their 7-year medical history of treatment at a dedicated headache clinic.
  • These 10 patients had, at least on 2 occasions analysis received High-Volume Anesthetic Suboccipital Nerve Blocks of 9 mL 1% lidocaine and 1 mL triamcinolone 40 mg/mL injected on the side of the cluster headaches.

RESULTS:

  • Nine of the ten patients received pain relief –
    • 1 and a half weeks the minimal relief, 2 patients made it to 44 weeks of pain relief, the 1 patient received no relief.
    • The cumulative average relief time record was about 10 weeks
  • Serial injections in some patients
    • Five patients were injected serially for 2-4 years (30 injections, 17 injections, 15 injections, 10 injections, and 3 injections, respectively) with consistent pain relief.
    • The person who had 30 injections had a typical relief of 6 weeks
    • The person who had 17 injections had a typical relief of 4 weeks
    • The person who had 15 injections had a typical relief of 12 weeks
    • The person who had 10 injections had a typical relief of 4 weeks
    • The person who had 3 injections had a typical relief of 31 weeks

The person who had the 30 injections developed avascular necrosis of the hip

The result of this study is clear, for the desperate patient, High-Volume Anesthetic Suboccipital Nerve Blocks can provide pain relief.  In our research, we believe we can show similar results without the threat of bone damage.

The treatment of overstretched cervical neck ligaments as an alternative to High-Volume Anesthetic Suboccipital Nerve Blocks

Back to the Korean study at the top of this article

According to the researchers, this study was conducted to compare and analyze the influence of craniocervical flexion and suboccipital relaxation in cervicogenic headache patients on their cervical muscular fatigue, tone, and headache intensity.

In a discussion of their research, the Korean team cited:

  • Most cervicogenic headache patients take a forward neck posture
  • Damage of soft tissue and increase of tension in the neck limits stationary contraction of deep cervical muscle, posing difficulty in sustaining upright neck posture.
  • With this process, cervical pain and cervicogenic headache occur, and as pain occurs or aggravates from the motion of returning to normal posture.
  • Suboccipital muscles receive overactive tension due to Upper-Cross Syndrome (as identified by Dr. Vladimir Janda).
    • Upper Cross Syndrome is characterized by rounded shoulders and the forward position of the shoulder blade. More obvious is the forward-pointed chin.

Cervicogenic headache patient with forward neck posture has high muscle tone and fatigue in superficial muscles to keep the unstable head from gravity, which easily induces postural disorder and pain. Consequently, an effort to keep an upright posture is necessary and exercise intervention is most crucial.

Botox injections are not disease-altering – they do not fix what is causing the muscle spasms – cervical instability

A study in the January 23, 2019 edition of Military Medicine, (10) sought to fix the problem of misdiagnosis or inappropriate treatment by treating both occipital neuralgia and migraine together.

In this study, doctors working with post-9/11 combat veterans addressed the problems of chronic migraine in veterans with a history of traumatic brain injury. To help these veterans, the doctors tried to offer the “best,” migraine treatment and the “best” occipital neuralgia treatments together.

The doctors documented studies that have shown that medications such as oral topiramate or intramuscular injections of onabotulinum toxin A (Botox) and occipital blocks to be helpful in treating occipital neuralgia and provide short-term relief of chronic migraine. This study wanted to see what happened when both treatments were employed in a more aggressive treatment campaign.

The veterans in this study reported that the month before treatments they suffered a headache on average for 24 days of that month. Following 6 months of combined nerve block/botox treatment, the patients reported an average of about 13 days a month where they suffered from headaches. The researchers and doctors while noting this was good success, still acknowledged that the results only reflected one-month post-treatment, longer-term studies were needed.

Comment: What did the doctors find here? Botox reduced muscle spasms by acting as a muscle relaxant. In our treatments we have found dextrose injections can reduce muscle spasms by strengthening the cervical neck ligaments, thereby reducing the need for the muscle to spasm in the first place. We will show that dextrose injections can be long-lasting as well.

It is clear that the main attribute of Botox injections is the reduction of pain through the management of painful muscle spasms. This is symptom suppression. It should be noted that botulinum toxin injections (Botox®) are not disease-altering, meaning they do not fix what is causing the muscle spasms.

In December 2017, researchers in Portugal published in The Cochrane Database of Systematic Reviews (11)

Despite good results with Botox, these researchers wrote of the following concerns: 

  • There are no data from randomized control trials evaluating the effectiveness and safety of repeated botulinum toxin type A injection cycles.
  • There is no evidence from randomized control trials to allow us to draw definitive conclusions on the optimal treatment intervals and doses, the usefulness of guidance techniques for injection, the impact on the quality of life, or the duration of treatment effect.

A February 2022 study (12) from Brazilian doctors assessed twenty-nine patients (28 females, 1 male) treated for greater occipital nerve neuralgia with onabotulinum toxin type A and suggested onabotulinum toxin type A is a safe and effective treatment alternative for patients suffering from refractory greater occipital nerve neuralgia.

Occipital nerve stimulation

In the January 2023 update of the article Occipital nerve stimulation in the medical publication Stat Pearls, (13) Stat Pearls is a publication of the National Center for Biotechnology Information, U.S. National Library of Medicine, researchers offer a brief explanation of the treatment: “Occipital nerve stimulation is a neuromodulation technique aimed at the treatment of different types of neuralgia. This minimally invasive adjustable, and reversible approach provides an implantable device composed of a subcutaneous regional electrode and a pulse generator.  . .  possible indications of Occipital nerve stimulation have expanded to various primary and secondary headache disorders not responsive to other therapies, including drugs for neuropathic pain, infiltrations (e.g., corticosteroids), radiofrequency rhizolysis, acupuncture, psychobehavioral approaches, and different multidisciplinary strategies.”

A March 2023 review paper in the journal Frontiers in pain research (14) examined the use of occipital nerve stimulation as a potential treatment for disabling headaches. The study authors write: “(occipital nerve stimulation) has shown promise for disorders such as chronic migraine and cluster headache. Long-term outcomes stratified by headache subtype have had limited exploration, and literature on outcomes of this neuromodulatory intervention spanning 2 or more years is scarce.” Basically what the researchers were looking for is which type of headache occipital nerve stimulation offer good benefit for and do these treatments last.

To get these answers the researchers examined previously published studies on “occipital neuralgia, chronic migraine, cluster headache, cervicogenic headache, short-lasting unilateral neuralgiform headache attacks (SUNHA), and paroxysmal hemicrania.” Here are their findings: ” With the evidence available, the response to occipital nerve stimulation was sustained in the majority of patients with cluster headache (patients with cluster headaches showed the best response) with low rates of loss of (effectiveness) in this patient population.” Further: “There was a high number 313/439 (71%) of adverse events per total number of patients in the studies including lead migration, requirements of revision surgery, allergy to surgical materials, infection and intolerable paresthesias (numbness, tingling).”

A noisy neck is a clue to cervical neck instability being the underlying cause of Occipital neuralgia and headaches

When we listen to patients diagnosed with occipital neuralgia and migraine headache, who come to their first visit in our clinic, we are listening not only to what they are saying, but we are listening to their neck. Their necks are often the loudest “talker” in the room. When these people gently turn their heads to the side, you can easily hear the chronic popping, cracking, and grinding sounds coming from the neck. If your neck were part of a machine, the repair person would listen and likely say, “It sounds like something is loose.” In our clinic, we often find people have something loose in their neck, and that something is cervical neck ligaments.

If headaches are the main symptom you are suffering from, please see our companion articles:

A discussion of surgery and other treatments

People with occipital neuralgia are offered a vast array of treatments, some of which we have already discussed. In this section, we will begin our discussions of the surgical options.

Rewards and risk of surgery – “Clinicians should bear in mind the risk that destructive procedures carry, which include the possibility of the development of painful neuroma or causalgia (severe burning pain), conditions that may be even harder to control than the original complaint.”

In July 2018 The Journal of Craniofacial Surgery (15) doctors tested the effectiveness of greater occipital nerve decompression, the freeing up of the nerve from surrounding soft tissue or bone which may compress or squeeze the nerve and cause pain.

  • Eleven patients with medical refractory (difficult to treat) occipital neuralgia were enrolled in the study.
  • All of them underwent surgical decompression of the greater occipital nerve at the level of semispinalis capitis and trapezial tunnel. (Behind the ear in the C3-C4 region).
    • Three patients reported complete elimination of pain after surgery while 6 patients reported significant relief of their symptoms.
    • Two patients failed to notice any significant improvement.
    • Surgical decompression of the greater occipital nerve is a simple and viable treatment modality for the management of occipital neuralgia.

Like most surgical procedures, some will benefit greatly, some will benefit to more or lessening degrees, and some will not benefit at all.

A combined study from the Departments of Neurological Surgery at the University of Hallym and the University of Ulsan College of Medicine in South Korea published these observations on the surgical management of occipital neuralgia in the Journal of Korean Medical Science. (16)

Surgical treatment of occipital neuralgia can be considered when a patient does not respond adequately to medical therapies, such as repeated injections, or minimally invasive procedures, such as PRF treatment.

  • Neurolysis (destruction or burning) of the occipital nerve (with or without sectioning of the inferior oblique muscle), C2 gangliotomy or ganglionectomy (the removal of the nerve bundles), C2 to C3 rhizotomy (destroying the nerve roots at the spinal cord), C2 to C3 root decompression (removing materials that may be pressing on the nerve root at C2-C3), and neurectomy (surgical removal of the nerve) were historically introduced for medically refractory patients However, the results were variable.
  • There have been a few positive reports on peripheral nerve stimulation surgery (the permanent placement of electrodes, a less invasive surgery, of the greater occipital nerve or lesser occipital nerve.
  • Of these approaches, both occipital neurolysis and occipital nerve stimulation (ONS) have been used commonly in the clinical field, recently. In selective cases, these methods have shown good outcomes
  • HOWEVER, Clinicians should bear in mind the risk that destructive (nerve burning and surgery) procedures carry, which include the possibility of the development of painful neuroma or causalgia (severe burning pain), conditions that may be even harder to control than the original complaint.

Posterior view of upper cervical region

As stated, surgery can be successful for many patients. A January 2022 paper in the Journal of neurological surgery (17) examined the impact of greater occipital nerve decompression on symptoms of occipital neuralgia. A one-year follow-up study of greater occipital nerve decompression was conducted on 11 patients with typical occipital nerve and 39 chronic occipital headaches due to greater occipital nerve entrapment patients.

Other treatment options: Is freezing the nerve better than burning the nerve?

A French research team examined the feasibility of cryoneurolysis (freezing) of the greater occipital nerve in the management of occipital neuralgia. They published their finding in the Journal of Neuroradiology. (18)

Here are the learning points:

  • Six patients suffering from unilateral refractory (one side non-responsive to treatment) greater occipital neuralgia underwent 7 cryoneurolysis treatments.
  • Technical feasibility (you can perform the procedure without great risk) was 100% as cryoneurolysis could be performed in all 7 cases with accurate sensitive nerve stimulation prior to the freezing cycle.
  • One patient benefited from a second session after the failure of the first session. More than 50% pain reduction was achieved at day 7 in all cases, and 5 of 6 cases at one and three months follow-up.
  • Initial results are promising as 5/7 cases benefited from a 3-month pain alleviation period.

Dry Needling as opposed to acupuncture

A case history was presented in The Journal of the Canadian Chiropractic Association (19) by the Department of Physical Therapy, University of Saint Mary, Kansas. This is the introduction to this case history:

  • This case report is to outline the diagnosis, intervention, and clinical outcome of a patient presenting with occipital neuralgia. Upon initial presentation, the patient described a four-year history of stabbing neck pain and headaches.
  • The patient underwent a total of four dry needling sessions over a two-week duration. During each of the treatment sessions, needles were inserted into the trapezii and suboccipital muscles.
  • Post-intervention, the patient reported meaningful improvement in her neck pain and headaches.
  • The researchers noted: “To the best of our knowledge, this is the first case report describing Dry Needling to successfully improve clinical outcomes in a patient diagnosed with occipital neuralgia.”

The role of cervical instability in occipital neuralgia. Focus on the cervical neck ligaments

Do weakened ligaments in the neck cause an unnatural head posture which can cause occipital neuralgia? Can strengthening these neck ligaments resolve the problem of occipital neuralgia by resolving the problem of cervical instability?

In our decades of practice, we rarely find a problem of the cervical spine to be isolated. The problem of occipital neuralgia is not different. The problems of occipital neuralgia revolve around compression to the occipital nerve and how to resolve that problem. In many patients, we see, weakened cervical ligaments, the structures that hold the vertebrae in proper alignment, have become weakened through wear and tear or traumatic injury.

In our 2014 research led by Danielle R. Steilen-Matias, MMS, PA-C, and published in The Open Orthopaedics Journal (20) our research team was able to demonstrate that when the neck ligaments are injured, they become elongated and loose, which causes excessive movement of the cervical vertebrae. In the upper cervical spine (C0-C2), this can cause a number of other symptoms including, but not limited to, nerve irritation, vertebrobasilar insufficiency with associated vertigo and dizziness, tinnitus, facial pain, arm pain, and migraine headaches.

Treatment: Occipital neuralgia is a whole-body disorder

In our many years of practice, we have always found that chronic, degenerative problems are not problems that sit in isolation of themselves. In other words, the problem of occipital neuralgia may not be limited to the area at the base of the skull. It could be a problem of posture as well and not a problem exclusive to the cervical neck region.

University researchers in Spain published an interesting study in the Latin American Journal of Nursing (21) that helps illustrate this point. The medical team embarked on a four-year study of occipital neuralgia patients where the treatment program consisted of postural modification using personalized plantar orthoses (shoe inserts) and osteopathy (massage and manipulation).

These are the results they found:

“The application of customized orthoses, and in some cases osteopathy, substantially improves the postural alignment (acromion-clavicular (shoulder), trochanter (hip) and external malleolus (ankle) and as a consequence, the symptomatology of occipital neuralgia. It is possible to conclude that after the noninvasive intervention, the level of neuropathic pain decreased significantly. . . Clinicians should consider that invasive (including chiropractic) and/or surgical techniques may trigger less controllable clinical conditions than the underlying entity.”

The suggestion here is to align the posture. In our clinic, we align the posture and keep it aligned through the use of dextrose Prolotherapy injections and sometimes  Caring Cervical Realignment Therapy (CCRT).  To fix the problems related to the cervical spine, you need to restore the natural curvature of the neck. This is part of our Caring Cervical Realignment Therapy (CCRT) developed by Ross Hauser, M.D. This program was the evolutionary product of decades of treating patients with neck disorders, including cervical instability and degenerative disc disease, to provide long-term solutions to cervical neck instability-related symptoms. CCRT combines individualized protocols to objectively document spinal instability, strengthen weakened ligament tissue that connects vertebrae, re-establish normal biomechanics, and encourage the restoration of lordosis.

The challenges of occipital neuralgia are many. Fixing cervical neck instability is not something that can be treated simply or easily, it takes a comprehensive non-surgical program to get the patient’s instability stabilized and the symptoms abated. We believe that if you have been going from clinician to clinician, practitioner to practitioner, doctor to doctor, there is a good likelihood that you have problems of cervical neck instability coming from weakness and damage to the cervical ligaments.

Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, and reliable alternative to surgical and non-effective conservative care treatments. In most cases, it is the injection of the simple sugar dextrose.

Spasms and tension in the cervical muscle fixes

What we see in the medical literature is a clear understanding that these headaches are caused by spasms and tension in the suboccipital muscles and the upper trapezius muscles that extend from mid-back to the base of the skull.

This was discussed in a study by Korean medical university doctors. In this research, the doctors found that the tone and stiffness of the suboccipital muscles and upper trapezius were higher in patients with cervicogenic headaches than in healthy subjects. Here muscle tone refers to the degree of tension in relaxed skeletal muscle, and the most significant factor affecting the level of tone is muscle contraction (spasm) even in a resting state. (22)

Prolotherapy for Suboccipital headache

In 1993, Caring Medical opened its doors, and among our first patients were people who suffered from chronic headaches. Sixteen years later we were able to document our experience in treating patients with headaches:

In 2009 we published research in the journal Practical Pain Management (5) cited above, that showed weak or loose neck ligaments and/or tendons may act as headache triggers in some people.

  • In our study, patients received Prolotherapy injections with a 15% dextrose and 0.2% lidocaine solution (as demonstrated in the video) No other therapies were used. The patients were asked to reduce or stop other pain medications and therapies they were using as much as the pain would allow.

Our findings strongly suggest that Prolotherapy injections can play a role in decreasing intensity level, frequency, duration, number of associated symptoms, and light sensitivity in patients with headache and migraine pain.

  • One hundred percent of patients reported they were at least somewhat better after receiving Prolotherapy, with
    • 39% of these patients reported 100% improvement.
    • 47% of patients stated the intensity of their pain was almost not noticeable after receiving treatment.
    • Notable improvements in the duration of time they suffered from headache pain were also experienced after treatment.
    • Seventy-three percent of patients reported a decreased sensitivity to light during a headache.
    • Symptoms associated with tension and migraine headaches decreased in 80% of the patients in this study.

It should be pointed out we did not report any cases of avascular necrosis of the hip from the treatments.

Prolotherapy heals the way the body heals

  • Prolotherapy solutions are injected into painful areas to repair damaged tissue.
  • The injections create a localized inflammation triggering the immune system to create the building blocks of ligaments, tendons, cartilage, and bone.

An introduction to the treatment is best observed in the video below. A patient with cervical neck instability is treated with Prolotherapy using a Digital Motion X-ray machine.

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

We invite you to continue your research with our article Dynamic Structural Medicine Ross Hauser MD Review of Treatments for Cervical Spine Instability where a discussion is offered on distorted spinal alignment and movement causing neurologic structures that travel through the neck to be put at risk and causing the conditions and symptoms described above. This article offers testing and diagnostic assessment explanations.

We hope you found this article informative and that it helped answer many of the questions you may have surrounding your neck pain. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

References

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This article was updated March 19, 2022

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