Occipital Neuralgia Mimics: What Your Doctor May Be Missing

At the Miami Headache and Pain Clinic, we frequently evaluate patients referred for posterior-head pain attributed to Occipital Neuralgia. However, “true” occipital neuralgia is surprisingly rare, and a variety of conditions often masquerade as it. Understanding these mimics is key to correct diagnosis and appropriate treatment.

What is Occipital Neuralgia?

Occipital neuralgia (ON) refers to pain originating from the occipital nerves: the three nerve pairs in the back of the head — the greater, lesser and the third (or “third occipital”) nerves. These nerves generally arise from the upper cervical spine (primarily C2, C3 nerve roots) and travel along the posterior scalp, providing sensory innervation of the back and lateral aspects of the head. 

The term neuralgia implies a pathology in the nerve itself: typically sharp, electric or stabbing pain, occurring in brief (seconds) repetitive attacks, and strictly following the anatomical course of the affected nerve. This is analogous to Trigeminal Neuralgia in the trigeminal distribution. 

In full transparency: although occipital neuralgia is quite well described, it is an uncommon diagnosis — especially when contrasted with more frequent headache disorders that involve the posterior scalp. 

Why Mimics Matter

Because the posterior scalp is an intersection of multiple pain pathways (cervical, cranial nerves, musculoskeletal, vascular), many disorders may present with head-and-neck pain in the region of the occipital nerves. These can be misdiagnosed as ON, delaying targeted therapy (nerve blocks, interventional procedures) and leading to suboptimal outcomes. Indeed, major headache‐pain reviews emphasise the importance of ruling out mimics when diagnosing ON. 

Below are some of the common and important mimics to consider.

1. Migraine

Migraine is fundamentally a disorder of sensory hypersensitivity. Patients often experience photophobia, phonophobia, dizziness with neck movement, smell intolerance, and skin sensitivity (scalp allodynia). Since the occipital nerves supply much of the posterior scalp, it’s not surprising that patients with migraine frequently report tenderness or pain over the occipital nerve distribution. This can lead to the erroneous label of occipital neuralgia when the underlying mechanism is migrainous.

Moreover, just as migraine patients may have tenderness in the temples, or the forehead, where the auriculotemporal, and supraorbital nerves are, occipital nerve-area pain shouldn’t automatically mean occipital neuralgia.

2. Cervical Facet / Cervicogenic Headache

The upper cervical spinal structures (C1–C3) and their associated joints/muscles are intimately related to the occipital nerves. For example, the C2 nerve gives rise to the greater occipital nerve. Joint inflammation (facet joints), arthritic changes, muscle‐ligament strain in the neck can irritate adjacent nerve roots or soft tissues and refer pain to the occipital region.

In fact, it is liklely that many of the patients diagnosed with occipital neuralgia are suffering in reality from cervicogenic headache.

This is becoming more relevant in this age due to the long hours spent in front of screens in positions that may not be ideal for neck health, such as with stooped head.
Cervicogenic headache is also the usual suspect behind occipital headache that are due to car accidents; as whiplash injuries commonly affect upper cervical joints.

3. Chiari Malformation

Structural lesions of the posterior fossa/cervical junction may present with posterior-head pain that mimics occipital neuralgia. For example, Chiari malformation; which happens when the posterior portion of the brain (known as the cerebellum) migrates downward through the opening separating the brain from the spinal cord. As a result, a headache can be frequently felt in the posterior part of the head while the pressure is, which can be mistaken for occipital neuralgia. This pressure typically worsens with deep breathing or exertion. 

4. Multiple Sclerosis (and other demyelinating/neuropathic conditions)

Though rare, demyelinating conditions such as MS may involve upper cervical nerve roots or dorsal ganglia, potentially producing pain in the occipital nerve distribution, in a similar way it can cause trigeminal neuralgia. 

5. Intracranial Hypotension / CSF Leak

Our central nervous system (the brain and spinal cord) does not directly touch the inner surfaces of the skull or vertebral column. Instead, it is suspended in a cushioning fluid known as cerebrospinal fluid (CSF), which surrounds and protects it. This fluid is continuously produced and absorbed, maintaining a relatively stable volume and pressure under normal conditions.

However, if a leak occurs—such as from a bone spur or a small tear in the dura—the pressure within the system drops, allowing the brain to sag slightly under the influence of gravity. Similar to a Chiari malformation, this downward shift can cause the posterior part of the brain to become compressed at the opening that separates the brain from the spinal cord. The resulting traction often leads to an intense occipital headache. This headache typically worsens when the patient stands up and improves when lying down.

Conclusion

While occipital neuralgia is a well-recognized entity, true neuralgia of the occipital nerves is relatively uncommon compared to its mimics. Conditions such as migraine (with posterior scalp involvement), cervicogenic headache (from upper cervical spine pathology), structural lesions (Chiari malformation, CSF leak), and other neuropathic disorders must always be considered in the differential diagnosis. A careful history, focused examination, appropriate imaging, and judicious use of diagnostic nerve blocks are critical to avoid misdiagnosis.

For clinicians in headache and pain practice — including at the Miami Headache and Pain Clinic — recognising these mimics is essential to direct patients toward the right interventional or medical treatment path. Whether it is an occipital nerve block, cervical facet intervention, or migraine infusion therapy, aligning the mechanism with the therapy improves outcomes.

If you or someone you know suffers from persistent posterior-head pain that has been labelled “occipital neuralgia” but has not responded to typical treatments, a thorough re-evaluation may be warranted. At the Miami Headache and Pain Clinic, we specialise in headache disorders, interventional pain techniques, and infusion therapies and are well-equipped to undertake this nuanced differentiation.