Occipital Headache Causes
Primary Causes
Occipital neuralgia is characterized by paroxysmal lancinating pain in the distribution of the greater, lesser, or third occipital nerves, but cervicogenic headache and migraine are far more common causes of occipital pain. 1
Occipital Neuralgia
- Paroxysmal, sharp, shooting pain in the distribution of occipital nerves (greater, lesser, or third occipital nerve) 1
- Tenderness or positive Tinel sign over the occipital nerve on physical examination 2
- Triggered by specific movements or sustained head positions 3
- Digital pressure over the upper nuchal area reproduces the pain pattern 3
Cervicogenic Headache
- Unilateral pain spreading from the back of the head to frontal and temporal regions 3
- Triggered by certain neck movements or sustained provocative head positions 3
- Associated with cervical facet arthropathy or upper cervical pathology 4
- Pain referred from the neck structures 4
Migraine with Occipital Features
- Migraine can present with occipital pain and may be misdiagnosed as occipital neuralgia 2
- Cervical trigger factors can induce migraine in some patients 3
- Overlapping symptoms make differentiation challenging 2
Secondary Causes (Red Flags)
Structural Abnormalities
- Chiari I malformation: cerebellar tonsillar herniation through foramen magnum, with headache worsened by Valsalva maneuver in children >3 years 5
- Cervical cord tumor 6
- C1-2 arthrosis syndrome or atlantoaxial lateral mass osteoarthritis 6
- Fracture of the atlas 6
Vascular Causes
- Arterial dissection: requires urgent CTA of head and neck if strongly suspected 5
- Venous sinus thrombosis: evaluate with MRV or CTV if venous outflow obstruction suspected 5
- Subarachnoid hemorrhage, especially with arterial aneurysm 5
Inflammatory/Infectious
- Meningeal infiltration or enhancement (evaluate with MRI with contrast) 5
- Hypertrophic cervical pachymeningitis 6
- Neurosyphilis 6
Trauma-Related
- Whiplash injuries producing cervicogenic headache-like symptoms 3
- Compression of the C-2 nerve root 6
- Fibrositis or myositis 6
Diagnostic Pitfalls
In children, isolated occipital and cervical pain are not characteristic of any primary headache group and warrant diagnostic caution. 5
- Misdiagnosis is common: patients with standing diagnoses of migraine may actually have occipital neuralgia or cervicogenic headache as contributing factors 2
- Greater occipital nerve blocks can be falsely positive in migraine patients, as they are effective for both conditions 1
- Meningeal enhancement on MRI after lumbar puncture should not be confused with pathology 5
- Mixed mechanisms (neurovascular, neuropathic, myofascial, cervicogenic) may all contribute simultaneously 2
Imaging Considerations
- MRI of the brain with and without contrast is preferred for evaluating secondary causes, including Chiari malformation, tumors, and meningeal pathology 5
- Sagittal T2-weighted sequence of the craniocervical junction for suspected Chiari I deformity 5
- CTA or MRA for suspected arterial dissection 5
- MRV preferred over CTV in children for venous sinus thrombosis evaluation 5