Occipital neuralgia is paroxysmal pain in the occipital–parietal region of the head, which is caused by irritation of the large / small occipital nerves. Pathology occurs with degenerative changes in the cervical vertebrae, compression of nerve structures by muscles or dilated venous vessels. The condition is manifested by painful paroxysms that last for several minutes and are repeated many times during the day. For the diagnosis of occipital neuralgia, radiography and CT of the spine, neuroimaging studies, Dopplerography of the cervical vessels are performed. Treatment includes drug blockades, physiotherapy, manual therapy.
General information
The relationship between headaches and pathologies of the cervical zone was first identified in 1926, after another 14 years, a complete clinical picture of occipital neuralgia was described. Occipital nerve neuralgia (occipital neuralgia) is included in the 3rd edition of the International Classification of Headaches. It belongs to the subsection “painful cranial neuropathies”. The proportion of this pathology among patients with chronic cervicalgia reaches 40%. Given the high prevalence and complexity of pharmacocorrection, the disease is a serious problem for clinical neurology.
Causes
The triggering factor of neuralgia is called mechanical damage to the occipital nerves. This is due to the anatomical features of the formation of these nerve structures: they are poorly protected by the integumentary tissues and are subject to traumatization. Given the interconnection of nerve, muscle, bone and cartilage structures, several etiological factors are often combined in one patient. The most common causes of occipital neuralgia:
- Arthrosis of the intervertebral joints. Joint injuries are observed in osteochondrosis, rheumatoid arthritis and other degenerative processes in the cervical vertebrae. The condition is aggravated by inadequate loads on the neck, whiplash injury, scoliosis.
- Myofascial syndrome. Compression of the occipital nerves occurs with painful tension of the cervical muscles that occurs during prolonged stay in an uncomfortable position. This problem is typical for office workers, employees of conveyor lines, seamstresses and other masters of manual labor.
- Vascular disorders. Against the background of atherosclerosis of the main arteries of the head, venous fullness develops. Constantly dilated veins compress neural structures, causing transient occipital pain.
- Neoplasms. Any bulky formations in the spine and occiput cause mechanical compression of nerves and provoke paroxysms of headaches.
Pathogenesis
The great occipital nerve is formed from the posterior branch of the 2nd cervical spinal nerve. It contains mixed fibers: short motor branches that innervate the belt muscles, the peninsular muscle of the head, the long neck muscle and long branches that provide sensitivity to the skin of the occipital region of the head. The small occipital nerve is the cutaneous branch of the cervical plexus, which innervates the lateral parts of the occiput and the posterior surface of the auricle.
There are 2 phases in the pathogenesis of cervicalgia: acute occurs according to the type of nociceptive disorders, chronic is characterized by neurotic pain. This is accompanied by sensitive disorders in the occipital nerves, the phenomena of hypalgesia in the outer bracket of the Zelder. The possibility of short-term relief from pain attacks by pressor action is also described, since the receptors of tactile fibers block nociceptive afferentation.
Symptoms
The main complaint of the patient is sharp headaches that occur on one side of the head or all over the back of the head. Unpleasant sensations develop suddenly by the type of lumbago or electric discharge, some people note pulsating cervicalgia. The pains reach maximum intensity, last from a few seconds to a couple of minutes, after which they also suddenly disappear. Symptoms are accompanied by photophobia, acustophobia, lacrimation.
During an attack, the patient tries to maintain maximum immobility, since any movement increases the painful symptoms. Some people slightly pull their head back and to the side in order to ease their suffering with the help of a pose, but such actions do not give the expected effect. From one to several dozen seizures develop per day. Their triggers can be awkward head turns, shaking in transport, sneezing and coughing.
Headaches practically do not occur between attacks of occipital nerve neuralgia. Occasionally, patients complain of unpleasant sensations of burning, tingling, crawling goosebumps on the back of the head. A decrease in the skin sensitivity of the parietal and occipital areas is also determined, up to numbness. At the same time, the trigger points of the nerves remain painful, an accidental touch to them can cause a new paroxysm of neuralgia.
Complications
Regular headaches worsen the quality of life, increase anxiety and depressive moods, and occasionally cause carcinophobia. Frequent pain paroxysms are associated with a decrease in performance, especially among professions that require increased concentration of attention. Neurological disorders are accompanied by disorders of blood supply and trophic tissues, therefore, in patients with long-term neuralgia, the hair on the back of the head falls out.
Diagnostics
If occipital neuralgia is suspected, an examination by a neurologist is indicated. Valuable information is obtained during a physical examination, which reveals areas of reduced or increased sensitivity, trigger points at the exit points of the occipital nerves, violations of reflex activity. With a typical clinical picture, it is not difficult to determine occipital neuralgia. To clarify its causes , the following methods are assigned:
- Spine x-ray. An X-ray allows you to detect signs of degenerative changes in bone and cartilage structures, anterior osteophytes, scoliosis and other disorders of the normal anatomy of the cervical vertebrae. It is possible to clarify the degree of damage to the spine according to MRI or CT of the cervical spine.
- Ultrasound of the vessels of the neck. The study is prescribed to determine atherosclerotic lesions of the arteries, and is carried out as part of a comprehensive diagnosis for patients with frequent headaches. According to the indications, the examination is supplemented with rheoencephalography to assess blood flow in the brain.
- MRI of the brain. Neuroimaging is used to exclude other neurological causes of cervicalgia, in particular, if an Arnold-Chiari anomaly is suspected. To clarify the neurological diagnosis, electroencephalography, echoencephalography, CT of the brain are prescribed.
- Laboratory complex. To assess the somatic status of the patient, the results of a hemogram, a biochemical blood test with determination of the lipid spectrum, and a general urinalysis are required. In case of concomitant cardiac pathology, a study of the blood coagulation system is recommended.
Differential diagnosis
Differential diagnosis is carried out with migraine, arterial hypertension, cluster pain. When making a diagnosis, it is necessary to distinguish the neuralgia of the occipital nerve from the reflected pain in lesions of the atlantoaxial and facet joints of the cervical vertebrae. In a comprehensive assessment of the neurological status, occipital cervicalgia is differentiated with the presence of sensitive trigger points of the cervical muscles or their attachment sites.
Treatment
Conservative therapy
Blockades with solutions of local anesthetics are recognized as the most effective method of correction of occipital nerve neuralgia. Manipulation is initially carried out for diagnostic purposes, after which, when confirming the diagnosis, the patient is prescribed therapeutic blockades. After the introduction of anesthetics into the trigger zone, the frequency of seizures is reduced, the importance of provoking factors that cause the appearance of new paroxysms of pain decreases.
The use of oral painkillers does not have a significant therapeutic effect. At the same time, non-drug methods are widely used in patients with occipital neuralgia. Manual therapy has a positive effect on the course of the disease, which restores the physiological volume of movements in the cervical region and normalizes muscle tone. Acupuncture and electrical stimulation are used as auxiliary methods of therapy.
Surgical treatment
In the absence of the effect of conservative methods of therapy, additional examination and treatment of patients in the department of neurosurgery is indicated. To relieve the pain syndrome, an isolated C2 neurectomy or ganglionectomy is performed. In severe forms of arthropathy of the facet joints, neurosurgical fusion of C1-2 is possible. Surgical treatment options have a limited range of indications.
Prognosis and prevention
Occipital nerve neuralgia refers to polyethological conditions with a chronic course, which complicates its effective therapy. With complex treatment, pain paroxysms are reduced, but it is not always possible to completely rid the patient of symptoms. Prevention of neuropathy consists in the prevention and timely detection of diseases of the cervical zone, which are typical causes of mechanical compression of nerves.