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Case Studies in Headache: Occipital Headache

By Christy Jackson, M.D.
Director, Dalessio Headache Center at Scripps Clinic, La Jolla, California

Headaches that originate in the area where the base of the skull and the neck join – called the occipital region – may have numerous causes. Structures in both the junction of the skull and the cervical vertebrae have regions that generate pain, including the lining of the cervical spine, the joints, ligaments, cervical nerve roots and vertebral arteries that pass through the cervical vertebrae.

One form of occipital headache is known as cervicogenic headache. This disorder originates from the cervical (neck) spine. The following cases illustrate how it is diagnosed and treated.

CASE 1
Ann had suffered from lifelong migraine. She had been under the treatment of headache specialists and over the years had significant success decreasing the frequency and severity of her headaches. However, she still had daily pain that spread from the occipital region to the angle of the jaw on the right side of her face. She also experienced pain behind the right eye.

An MRI and CT of her brain were normal as was the neurological exam. Ann did have tenderness below the occipital region on the right, diminished range of motion of her neck and a significant amount of spasm in the neck and shoulder musculature.

An occipital nerve block using a steroid and local analgesic was performed on the right side and Ann noted a decrease in the amount of pain after about five minutes. A physical therapist then identified postural issues that were contributing to her muscular spasm. With a home exercise program, the headaches have resolved.

CASE 2
A 61-year-old man named Juan, who had a history of migraine that had gone into remission, came to see me about pain above his left eye that had been ongoing for several years. It was different from his migraines, as it only occurred on the left side and primarily above his left eye.

Juan described how the headache would begin at the left occipital ridge and spread up over the top of his head to the region above his left eye. No triggering event could be discovered. The headache lasted all day, every day, and was often worse in the morning when he arose from sleep. He also had a normal neurological exam and MRI. But an exam of Juan’s spine revealed a mild curvature of the thoracic (upper back) spine and an elevated shoulder on his right. Point tenderness was found at the left occipital ridge, which reproduced a portion of his pain.

An occipital nerve block was delivered to the left occipital nerve and Juan was pain-free for over a month. A spinal x-ray revealed a very mild scoliosis of his thoracic spine. Juan is currently in a physical therapy program to strengthen the shoulder and neck musculature and has remained headache-free for over four months.

DISCUSSION
Headaches that originate in the occipital regions that are coupled with limited range of motion, and can be reproduced with positional maneuvers and relieved with a diagnostic occipital nerve block, may be cervicogenic headache. The concept of cervicogenic headache is somewhat controversial, with different criteria for diagnosis among the International Headache Society and the Cervicogenic Headache International Study Group. Both societies agree that headaches can result from pathology in the neck region because of the pain sensitive structures there.

A local anesthetic block may help in the diagnosis if the patient’s headaches resolve from the block, further diagnostic studies are then indicated to search for significant muscle, joint or nerve involvement, such as spasm, arthritis or disc degeneration in the upper cervical region or spine. A course of aggressive physical therapy along with postural changes and home exercise programs can provide patients with significant relief.

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