What are the common causes of occipital headaches?

Common Causes of Occipital Headaches

The most common causes of occipital headaches include cervical strain, occipital neuralgia, migraine with occipital predominance, and tension-type headache. 1, 2

Primary Causes

1. Cervical Strain

• Characterized by:
  • Neck pain and stiffness
  • Persistent headache (often occipital/suboccipital in location)
  • Neck or upper extremity weakness
  • Pain with cervical motion
  • Tenderness in cervical spine, paraspinal and suboccipital muscles 1
• Mechanism: Injury to neck structures leads to somatosensory dysfunction and aberrant signaling along cervical afferent pathways 1
• Clinical signs:
  • Pain/tenderness on midline palpation of cervical spine
  • Weakness with paracervical strength testing
  • Limitation of cervical motion
  • Pain/paresthesia in occipital region with palpation or head movement 1

2. Occipital Neuralgia

• Characterized by:
  • Paroxysmal lancinating pain in the distribution of greater, lesser, or third occipital nerves
  • Sharp, stinging, or electric shock-like pain 3, 4
• Diagnostic confirmation: Greater occipital nerve blockade with anesthetics/corticosteroids 4
• Treatment options:
  • Greater occipital nerve block (first-line minimally invasive intervention) 3
  • Physical therapy and preventive medications (antiepileptics, tricyclic antidepressants) 4
  • Refractory cases: pulsed radiofrequency, occipital nerve stimulation 1, 4
  • Acupuncture may provide relief in some cases 5

3. Migraine with Occipital Predominance

• Characterized by:
  • Unilateral location (often)
  • Throbbing character
  • Moderate to severe intensity
  • Worsening with routine activity
  • Associated symptoms: nausea, vomiting, photophobia, phonophobia 1
• May include prodromal symptoms like visual distortions, scotomas, food cravings, heightened sensory perceptions 1
• Can be triggered by hormonal changes, certain foods, sensory stimuli, missed meals, or stress relief 1

4. Tension-Type Headache

• Characterized by:
  • Pressing, tightening, non-pulsatile character
  • Mild to moderate intensity
  • Bilateral location
  • No aggravation with routine activity
  • No nausea/vomiting (may have anorexia)
  • No photophobia and phonophobia (or only one) 1
• Treatment options:
  • Ibuprofen (400 mg) or acetaminophen (1000 mg) for short-term treatment 1
  • Amitriptyline for prevention of chronic tension-type headache 1
  • Physical therapy 1
  • Aerobic exercise or progressive strength training 1

Secondary Causes (Less Common)

1. Intracranial Hypotension

• Characterized by orthostatic headache that:
  • Is absent or mild when lying flat
  • Occurs within 2 hours of becoming upright
  • Improves >50% within 2 hours of lying flat 1
• May be accompanied by neck stiffness, tinnitus, hearing changes, and other symptoms 1

2. Structural Abnormalities

• Potential causes include:
  • C1-2 arthrosis syndrome
  • Atlantoaxial lateral mass osteoarthritis
  • Hypertrophic cervical pachymeningitis
  • Cervical cord tumor
  • Chiari malformation 6

3. Trauma-Related

• Direct injury to occipital nerves
• Fracture of the atlas
• Compression of the C-2 nerve root 6

Diagnostic Approach

Red Flags Requiring Further Evaluation

• Abnormal neurological examination findings
• Papilledema or optic disc changes
• Worsening pattern of headache frequency or severity
• Headache that awakens patient from sleep
• Abrupt onset of severe headache
• Marked change in headache pattern 2, 1

Neuroimaging Considerations

• Not routinely recommended for patients with typical primary headache features and normal neurological examination 2
• Diagnostic yield is very low (approximately 1%) 2
• Consider for atypical headache patterns or neurologic signs 1

Treatment Considerations

For Occipital Neuralgia

• Greater occipital nerve block is suggested for short-term treatment of occipital pain 1, 3
• Physical therapy to alleviate muscle tension and improve posture 3
• Occipital nerve stimulation for medically refractory cases 1

For Cervical Strain

• Physical therapy is suggested for management of cervicogenic headache 1
• Address underlying neck pathology

For Migraine with Occipital Predominance

• Standard acute and preventive migraine treatments 2
• Consider greater occipital nerve block 7

Clinical Pitfalls to Avoid

• Misdiagnosing occipital neuralgia as migraine or vice versa (approximately 48% of patients diagnosed with migraine may have headaches due to greater occipital nerve irritation) 7
• Relying solely on response to nerve blocks for diagnosis (can be positive in multiple headache types) 4
• Failing to recognize cervical strain as a cause of occipital headache, which requires specific physical therapy interventions 1
• Overlooking cranial autonomic symptoms that can be present in primary headaches 2