Occipital Neuralgia vs Migraine: When to Reconsider the Diagnosis

A patient was surprised to learn that she had occipital neuralgia when she was originally diagnosed with migraine headaches.

Writing in Reddit’s popular r/migraine community, a social media community, the user said:

“Hey everyone, long time migraine sufferer. Found out it’s not a migraine, it’s occipital neuralgia. I got nerve ablations on the left and right side of my neck at the medial nerve branches. Wow, what a relief after years of being told it’s a migraine. Three neurologists and 4 other docs all said migraines. My PCP sent me to a pain management specialist who knew exactly what it was!” 

Other posters chimed in, wondering if they, too, should revisit their migraine diagnosis after years of unsuccessful treatment. Others echoed the original poster’s experience, saying they also found relief once they were treated for occipital neuralgia. 

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Teshamae Monteith, MD, chief of the headache division at the University of Miami Health System and spokesperson for the American Neurological Association, explained the clear differences between the two conditions to Psychiatrist.com. 

Physiologically, the two are actually quite unique, she said. The exact cause of migraine is unknown, but believed to be the result of abnormal brain activity that temporarily affects nerve signals, chemicals, and with less relevance to changes in blood vessels than previously thought. More women have migraine than men.

Occipital neuralgia, on the other hand, is the result of compressed or irritated nerves that run from the neck, up the back of the head, and into the scalp. Occipital pain is common in both men and women, but true occipital neuralgia is actually quite rare, Monteith pointed out. 

“A very classic presentation of occipital neuralgia is pain at the base of the neck from a few seconds to minutes. It’s severe shooting, paroxysmal pain,” she said. “It can result from injury, pinched or compressed nerves, tight neck muscles, nerve compression, infection, or inflammation.”

“A migraine is not that. Migraine often has associated symptoms like sensitivities, nausea, vomiting, and at the same time, pounding head pain that can be unilateral or bilateral and lasting for up to 72 hours when untreated.”

But the confusion is understandable, Monteith said, because the two conditions do Monteith said, because the two conditions do co-exist and share some similarities such as neck pain that may be common with migraine as well. In either case, a patient might experience a throbbing or burning feeling that first starts at the base of the head and creeps up into the scalp. They might also feel general pain behind the eyes, through the entire length of the neck, and on one or both sides of the head. 

There are unique diagnostic clues that help clinicians make the diagnosis, Monteith said. 

“Most migraine patients report some sort of trigger like changes in sleep patterns, weather, hormones, stress, or the response to a stimulus like flashing lights or strong smells, whereas an occipital neuralgia episode might be set off by a poor sleep position, a bump on the head, or even hair brushing.”  

As for treatment, Montieth said a procedure called a nerve block that targets the nerve in the back of the head (occipital nerve), which may also offer diagnostic information. Medications like anti-depressants and neuropathic medications are also worth consideration. Palliative methods like physical therapy can also help. Radiofrequency ablation performed by pain a specialist may be an intervention as a last resort when nothing else has worked, she added.

Migraine sometimes responds to nerve blocks and antidepressants, but sometimes not. Many patients with migraines start with over the counter or prescription drugs such as triptans or beta blockers and move onto nerve blockers like Botox in the case of chronic migraine, Monteith said. Since treatment response varies so widely, neurologists work with patients to come up with a personal preventive and rescue plan.

Monteith said that because diagnosis is often made through the lens of the specialist with their given training and expertise, this can sometimes lead simultaneously to underdiagnosis and overdiagnosis , especially when symptoms overlap.  

She recommended a full medical history and the appropriate diagnostic testing to make the right call. 

As for migraine patients who aren’t getting any relief after trying numerous remedies over a period of time, she said that it’s worth revisiting the diagnosis to see if they do, in fact, have occipital neuralgia. 

“Consider why treatment is not effective. And could this be something else? It’s worth it to be evaluated, to get a physical exam, and potentially diagnostic testing as well, to assure that there is no other cause.”