Causes of Nape Pain Radiating to the Occipital Area
Primary Etiologies
The most common cause of nape pain radiating to the occipital area is cervical strain with associated occipital neuralgia, followed by cervicogenic headache and post-traumatic cervical injury. 1
Cervical Strain and Occipital Neuralgia
Cervical strain causes occipital/suboccipital headache through injury to neck structures leading to somatosensory dysfunction and aberrant signaling along cervical afferent pathways. 1
The greater occipital nerve (GON) is particularly vulnerable due to its long course through mobile neck structures and potential compression by fibrosis, surrounding anatomic structures, or osseous pathology such as bone spurs or hypertrophic atlanto-epistropic ligament. 2
Clinical signs include pain/tenderness in the cervical spine with midline palpation, paraspinal and suboccipital muscle tenderness, limitation of cervical motion, and pain/paresthesia in the occipital region with palpation or head movement. 1
The pain is typically characterized as sharp, stabbing, or shooting in nature, originating in the suboccipital region and radiating over the vertex in the distribution of the greater, lesser, and/or third occipital nerves. 3, 4
Post-Concussion Cervical Strain
Head injury resulting in neck pain, neck stiffness, and persistent occipital/suboccipital headache represents a distinct concussion-associated condition. 1
Dysfunction in cervical afferent pathways disrupts coordination of cervical and vestibular reflexes, leading to the characteristic pain pattern. 1
Differentiating isolated cervical strain from concomitant whiplash-associated disorder is critical for appropriate management. 1
Cervicogenic Headache
Cervicogenic headache presents with occipital pain that may be referred from cervical spine pathology, including facet arthropathy, degenerative disc disease, or atlantoaxial instability. 2
Physical examination reveals tenderness over the greater and lesser occipital nerves, with pain reproduction on cervical motion. 3
Secondary and Referred Causes
Temporomandibular Joint (TMJ) Syndrome
TMJ dysfunction commonly causes referred otalgia and pain radiating to the periauricular area, temple, or neck, which can mimic occipital pain patterns. 1
Patients typically have a history of gum chewing, bruxism, or recent dental procedures with subsequent malocclusion, and demonstrate tenderness over the affected TMJ with associated crepitus. 1
Vascular and Neurologic Causes
Vascular etiologies should be considered in the differential diagnosis of cervical pain, particularly when "red flags" are present. 1
Constitutional symptoms (fever, weight loss), elevated inflammatory markers (WBC, ESR, CRP), or signs suggesting infection, malignancy, or inflammatory arthritis warrant urgent evaluation. 1
Important Clinical Pitfalls
Most cases of occipital neuralgia are idiopathic, with no identifiable structural cause found on imaging. 5
Migraine headache can present with occipital pain and responds to occipital nerve blocks, potentially leading to misdiagnosis of occipital neuralgia. 6
Bilateral pain can occur in occipital neuralgia, though unilateral presentation is more common, and pain can radiate to the frontal region and face. 3
Imaging studies (MRI of the cervical spine) are necessary to exclude underlying pathological conditions such as tumors, infection, or structural abnormalities before confirming a diagnosis of primary occipital neuralgia. 4