Differential Diagnosis of Occipital Headache

The differential diagnosis for occipital headache can be categorized into several groups based on the likelihood and potential impact of missing the diagnosis.

• Single Most Likely Diagnosis

  • Tension headache: This is the most common type of headache and often presents with bilateral occipital pain, typically described as a band or a squeezing sensation around the head. The pain is usually mild to moderate and can be associated with stress, poor posture, or muscle tension.

• Other Likely Diagnoses

  • Cervicogenic headache: Originates from the cervical spine and is referred to the occipital region. It is often unilateral and can be exacerbated by specific neck movements or positions.
  • Occipital neuralgia: Characterized by sharp, stabbing pain in the occipital region, usually unilateral, and can be accompanied by tenderness over the affected nerve.
  • Migraine: Although typically associated with unilateral frontal or temporal pain, migraines can occasionally present with occipital headache, especially in the early stages or in certain variants like the "occipital migraine."

• Do Not Miss Diagnoses

  • Subarachnoid hemorrhage: A life-threatening condition that can present with a sudden, severe headache, often described as "the worst headache of my life." Although the pain can be diffuse, it may initially be localized to the occipital region.
  • Meningitis: Inflammation of the meninges can cause severe headache, fever, and neck stiffness. The headache can be occipital in nature and is a medical emergency.
  • Cervical spine fracture or instability: Especially in the context of trauma, an unstable cervical spine fracture can present with occipital pain and is critical to diagnose promptly to avoid further injury.

• Rare Diagnoses

  • Giant cell arteritis: An inflammatory condition affecting the blood vessels, which can cause headache, typically temporal but occasionally occipital, along with other symptoms like jaw claudication and visual disturbances.
  • Chiari malformation: A structural defect in the cerebellum that can cause occipital headache, especially with coughing or straining, due to herniation of the cerebellar tonsils into the spinal canal.
  • Occipital condyle syndrome: A rare condition characterized by sharp pain in the occipital region, often associated with trauma or inflammation of the occipital condyles.