Occipital neuralgia – C2 neuralgia
Ross Hauser, MD | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Katherine L. Worsnick, MPAS, PA-C | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Occipital neuralgia – C2 neuralgia
Patients who write to us often describe a condition of hopelessness from a diagnosis of Occipital neuralgia or C2 neuralgia. They tell us about unrelenting headaches, pain and even swelling in the back of the head and neck. They will tell us about large doses of medications they take, some later to be found inappropriate or ineffective. They will even describe a problem of not getting enough medications. Such is the seemingly hopelessness of their situation.
They continue on with their medical histories that included nerve blocks that did not work, Thermal Radiofrequency Ablation that burned out nerves, an aggressive Botox injection campaign to relax the muscles in the occipital region, chiropractic manipulations that helped or hurt them and acupuncture and other forms of “alternative” medicine. In the end, these people are still looking for help that they are not getting.
In their search for answers, few talk about their problems being one of cervical neck instability, this despite clear and mounting evidence that cervical neck instability is a main causative factor in the diagnosis of occipital neuralgia.
Yet for some of you, this article may represent the first time you are learning that cervical neck instability may be the root of your problem. In many patients we see, a discussion with their health care providers continue to singularly focused on their neuralgia, their nerve pain. For many people, we will stress here, it is not the neuralgia that needs to be treated as primary, it is cervical neck instability that is their problem and that is what we will focus on in this article.
The path to treatment using regenerative medicine injections to restore cervical neck stability
We are very hopeful that this article will be a journey of understanding for you. What we hope to present is good evidence that the challenges of occipital neuralgia can be overcome, not with sedation in the form of stronger pain medications, or the constant treatment of symptoms with short-term treatments that may or may not work or may make the situation worse. We are going to present the evidence that simple dextrose injections can fix a very complicated problem.
When is it a headache and when is it Occipital neuralgia?
In our clinics we see many patients with a chief complaint of headache. The obvious challenges of these people’s headaches are first, getting them pain relief and secondly, finding the source of what is causing them their headaches and stop future occurrences.
But when is it a headache and when is it Occipital neuralgia?
This may be a confusing question for some. Isn’t Occipital neuralgia a headache?
This is the description provided by The National Institute of Neurological Disorders and Stroke (1)
- “Occipital neuralgia is a distinct type of headache characterized by piercing, throbbing, or electric-shock-like chronic pain in the upper neck, back of the head, and behind the ears, usually on one side of the head. Typically, the pain of occipital neuralgia begins in the neck and then spreads upwards. . . . In many cases, however, no cause (for Occipital neuralgia) can be found. A positive response (relief from pain) after an anesthetic nerve block will confirm the diagnosis.”
This definition may confirm your worst fears, nothing can be done for you other than nerve blocks and increasingly heavier doses of medication.
Occipital neuralgia and migraines are different problems and while similar in symptoms are vastly different in treatment needs. Or are they?
In your research of your headaches, you may have come upon many websites that suggest that:
- Occipital neuralgia is a “headache” pain.
- Occipital neuralgia is not a “headache” pain but a nerve related pain.
- Occipital neuralgia and migraine headaches share the same symptoms.
- Occipital neuralgia and migraines require different treatments as one is a nerve pain and one is “chemical” related imbalanced caused by many problems. .
- As we documented in our research that appeared in the journal Practical Pain Management (2) These include numerous risk factors, often labeled “triggers,” may result in a migraine-eliciting environment. These include skipped meals, sleep deprivation, hormonal changes, alcohol consumption and acute stress, among others. Individuals may also report pain sensations in areas innervated by the trigeminal system—notably nasal and neck regions, which can then lead to misdiagnosis of sinus or tension headache.
Your doctor may think you have Occipital neuralgia because your migraine medications are not working
In the journal Headache, (3) researchers at the Department of Neurology, University of Southern California, Keck School of Medicine, conducted a study to identify differences in patient symptoms with a diagnosed isolated occipital neuralgia and patients with occipital neuralgia who also had migraine headache.
The doctors of this study were trying to sort though confusion. Here is what they said:
- “Occipital neuralgia is an uncommon cause of headaches. Very little is known about the pain characteristics and associated features of patients with occipital neuralgia and migraine headache and whether these pain characteristics differ from those of patients with isolated occipital neuralgia.”
So to answer this challenge, the researchers looked at 35 patients all diagnosed with occipital neuralgia
- Twenty patients had occipital neuralgia and migraine headache and 15 had isolated occipital neuralgia.
- Patients with occipital neuralgia and migraine headache had significantly more complaints of pain traveling to the scalp and presence of scalp tenderness and tingling compared with patients with isolated occipital neuralgia.
- 25% patients in the occipital neuralgia and migraine headache group described the pain as “dull” whereas none of the isolated occipital neuralgia group reported this characteristic.
- There was higher use of chiropractors and massage therapy in patients from occipital neuralgia and migraine headache group than from isolated occipital neuralgia.
The findings of this study were offered to help doctors identify differences in pain characteristics for patients with occipital neuralgia and migraine headache and those for patients with isolated occipital neuralgia. A main learning point of this research is that patients with migraine should also be screened for symptoms of occipital neuralgia. Why?
- “The clinical implications of distinguishing occipital neuralgia and migraine headache and isolated occipital neuralgia include differences in treatment regimen, avoidance of inappropriate use of medical resources, and differences in long-term outcomes.”
What we see here is that migraine and occipital neuralgia are difficult to understand and that makes it difficult to get at the root of their cause and apply appropriate treatments.
Treating migraine and occipital neuralgia together?
A study in the January 23, 2019 edition of Military Medicine, (4) sought to fix the problem of misdiagnosis or inappropriate treatment by treating both occipital neuralgia and migraine together.
In this study, doctors working with post 9/11 combat veterans addressed the problems of chronic migraine in veterans with a history of traumatic brain injury. To help these veterans, the doctors tried to offer the “best,” migraine treatment and the “best” occipital neuralgia treatments together.
The doctors documented studies that have shown that medications such as oral topiramate or intramuscular injections of onabotulinum toxin A (Botox) and occipital blocks to be helpful in treating occipital neuralgia and provided short-term relief of chronic migraine. This study wanted to see what happened when both treatments were employed in a more aggressive treatment campaign.
The veterans in this study reported that the month before treatments they suffered a headache on average for 24 days of that month. Following 6 months of combined nerve block / botox treatment the patients reported an average of about 13 days a month where they suffered from headache. The researchers and doctors while noting this was good success, still acknowledged that the results only reflected one month post treatment, longer term studies were needed.
Comment: What did the doctors find here? Botox reduced muscle spasms by acting as a muscle relaxant. In our treatments we have found dextrose injections can reduce muscle spasms by strengthening the cervical neck ligaments, thereby reducing the need for the muscle to spasm in the first place. We will show that dextrose injections can be long-lasting as well.
Botox injections are not disease altering – they do not fix what is causing the muscle spasms – cervical instability
It is clear that the main attribute of Botox injections is the reduction of pain through the management of painful muscle spasm. This is symptom suppression. It should be noted that Botox injections are not disease altering, meaning they do not fix what is causing the muscle spasms.
In December 2017, researchers in Portugal published in The Cochrane database of systematic reviews (5)
Despite good results with Botox, these researchers wrote of the following concerns:
- There are no data from randomized control trials evaluating the effectiveness and safety of repeated botulinum toxin type A injection cycles.
- There is no evidence from randomized control trials to allow us to draw definitive conclusions on the optimal treatment intervals and doses, usefulness of guidance techniques for injection, the impact on quality of life, or the duration of treatment effect.
A noisy neck is the clue to cervical neck instability being the underlying cause of Occipital neuralgia and headaches
When we listen to patients diagnosed with occipital neuralgia and migraine headache, who come to their first visit in our clinics, we are listening not only to what they are saying, but we are listening to their neck. Their necks are often the loudest “talker” in the room. When these people gently turn their head to the side, you can easily hear the chronic popping, cracking and grinding sounds coming from the neck. If your neck were part of a machine, the repair person would listen and likely say, “it sounds like something is loose.” In our clinics we often find people have a something loose in their neck, and that something is cervical neck ligaments.
If headaches are the main symptom you are suffering from, please see our companion articles:
- Cervicogenic headaches – Migraines, tension headaches and cervical neck instability
- Suboccipital headache – Moving away from nerve blocks and getting results from ligament repair and treatment of muscle spasms
- Numerous studies have also documented Atlantoaxial instability the abnormal, excessive movement of the joint between the atlas (C1) and axis (C2) as the cause of a myriad of neck and head pain problems including headache and occipital neuralgia.
A discussion of surgery and other treatments
People with occipital neuralgia are offered a vast array of treatments, some of which we have already discussed. In this section we will begin our discussions of the surgical options.
Rewards and risk of surgery – “Clinicians should bear in mind the risk that destructive procedures carry, which include the possibility of the development of painful neuroma or causalgia (severe burning pain), conditions that may be even harder to control than the original complaint.”
In July 2018 The Journal of craniofacial surgery (6) doctors tested the effectiveness of greater occipital nerve decompression, the freeing up of the nerve from surrounding soft tissue or bone which may compress or squeeze the nerve and cause pain.
- Eleven patients of medical refractory (difficult to treat) occipital neuralgia were enrolled in the study.
- All of them underwent surgical decompression of greater occipital nerve at the level of semispinalis capitis and trapezial tunnel. (Behind the ear in the C3-C4 region).
- Three patients reported complete elimination of pain after surgery while 6 patients reported significant relief of their symptoms.
- Two patients failed to notice any significant improvement.
- Surgical decompression of greater occipital nerve is a simple and viable treatment modality for the management of occipital neuralgia.
Like most surgical procedures, some will benefit greatly, some will benefit to more or lessening degrees, some will not benefit at all.
A combined study from the Departments of Neurological Surgery at the University of Hallym and the University of Ulsan College of Medicine in South Korea, published these observations on the surgical management of occipital neuralgia in the Journal of Korean medical science.(7)
Surgical treatment of occipital neuralgia can be considered when a patient does not respond adequately to medical therapies, such as repeated injections, or minimally invasive procedures, such as PRF treatment.
- Neurolysis (destruction or burning) of the occipital nerve (with or without sectioning of the inferior oblique muscle), C2 gangliotomy or ganglionectomy (the removal of the nerve bundles), C2 to C3 rhizotomy (destroying the nerve roots at the spinal cord), C2 to C3 root decompression (removing materials that may be pressing on the nerve root at C2-C3), and neurectomy (surgical removal of nerve) were historically introduced for medically refractory patients However, the results were variable.
- There have been a few positive reports on peripheral nerve stimulation surgery (the permanent placement of electrodes, a less invasive surgery, of the greater occipital nerve or lesser occipital nerve.
- Of these approaches, both occipital neurolysis and occipital nerve stimulation (ONS) have been used commonly in the clinical field, recently. In selective cases, these methods have shown good outcomes
- HOWEVER Clinicians should bear in mind the risk that destructive (nerve burning and surgery) procedures carry, which include the possibility of the development of painful neuroma or causalgia (severe burning pain), conditions that may be even harder to control than the original complaint.
Other treatment options: Is freezing the nerve better than burning the nerve?
A French research team examined the feasibility of cryoneurolysis (freezing) of the greater occipital nerve in the management of occipital neuralgia. They published their finding in the Journal of neuroradiology. (8)
Here are the learning points:
- Six patients suffering from unilateral refractory (one side non-responsive to treatment) greater occipital neuralgia and underwent 7 cryoneurolysis treatments.
- Technical feasibility (you can perform procedure without great risk) was 100% as cryoneurolysis could be performed in all 7 cases with accurate sensitive nerve stimulation prior to freezing cycle.
- One patient benefited from a second session after failure of the first session. More than 50% pain reduction was achieved at day 7 in all cases, and 5 of 6 cases at one and three months follow-up.
- Initial results are promising as 5/7 cases benefited from a 3-month pain alleviation period.
Dry Needling as opposed to acupuncture
A case history was presented in the The Journal of the Canadian Chiropractic Association (9) by the Department of Physical Therapy, University of Saint Mary, Kansas. This is the introduction to this case history:
- This case report is to outline the diagnosis, intervention and clinical outcome of a patient presenting with occipital neuralgia. Upon initial presentation, the patient described a four-year history of stabbing neck pain and headaches.
- The patient underwent a total of four dry needling sessions over a two-week duration. During each of the treatment sessions, needles were inserted into the trapezii and suboccipital muscles.
- Post-intervention, the patient reported meaningful improvement in her neck pain and headaches.
- The researchers noted: “To the best of our knowledge, this is the first case report describing Dry Needling to successfully improve clinical outcomes in a patient diagnosed with occipital neuralgia.”
The role of cervical instability in occipital neuralgia. Focus on the cervical neck ligaments
Do weakened ligaments in the neck cause an unnatural head posture which can cause occipital neuralgia? Can strengthening these neck ligaments resolve the problem of occipital neuralgia by resolving the problem of cervical instability?
In our decades of practice, we rarely find a problem of the cervical spine to be isolated. The problem of occipital neuralgia is not different. The problems of occipital neuralgia revolve around compression to the occipital nerve and how to resolve that problem. In many patients we see, weakened cervical ligaments, the structures that hold the vertebrae in proper alignment, have become weakened through wear and tear or traumatic injury.
In our 2014 research lead by Danielle R. Steilen-Matias, MMS, PA-C and published in The Open Orthopaedics Journal (10) our research team was able to demonstrate that when the neck ligaments are injured, they become elongated and loose, which causes excessive movement of the cervical vertebrae. In the upper cervical spine (C0-C2), this can cause a number of other symptoms including, but not limited to, nerve irritation, vertebrobasilar insufficiency with associated vertigo and dizziness, tinnitus, facial pain, arm pain, and migraine headaches.
Dextrose Prolotherapy treatment
Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments. In most cases it is the injection of the simple sugar dextrose.
Prolotherapy heals the way the body heals
- Prolotherapy solutions are injected into your painful areas to repair damaged tissue.
- The injections create a localized inflammation triggering the immune system to create the building blocks of ligaments, tendons, cartilage, and bone.
An introduction to the treatment is best observed in the video below. A patient with cervical neck instability is treated with Prolotherapy using a Digital Motion X-ray machine.
Occipital neuralgia is the end product of instability – researchers say the instability can start in your feet
In our many years of practice we have always found that chronic, degenerative problems are not problems that sit in isolation of themselves. In other words the problem of occipital neuralgia may not be limited to the area at the base of the skull. It could be a problem of posture as well.
University researchers in Spain published an interesting study in the Latin American Journal of Nursing (11) that helps illustrate this point. The medical team embarked on a four year study of occipital neuralgia patients where the treatment program consisted of postural modification using personalized plantar orthoses (shoe inserts) and osteopathy (massage and manipulation).
This is the results they found:
“The application of customized orthoses, and in some cases osteopathy, substantially improves the postural alignment (acromion-clavicular (shoulder), trochanter (hip) and external malleolus (ankle) and as a consequence, the symptomatology of occipital neuralgia. It is possible to conclude that after the noninvasive intervention, the level of neuropathic pain decreased significantly. . . Clinicians should consider that invasive (including chiropractic) and/or surgical techniques may trigger less controllable clinical conditions than the underlying entity.”
The suggest here is to align the posture. In our clinics we align the posture and keep it aligned through the use of dextrose Prolotherapy injections and sometimes Caring Cervical Realignment Therapy (CCRT). To fix the problems related to the cervical spine, you need to restore the natural curvature of the neck. This is part of our Caring Cervical Realignment Therapy (CCRT) developed by Ross Hauser, M.D. This program was the evolutionary product of decades of treating patients with neck disorders, including cervical instability and degenerative disc disease, to provide long-term solutions to cervical neck instability related symptoms. CCRT combines individualized protocols to objectively document spinal instability, strengthen weakened ligament tissue that connects vertebrae, and re-establish normal biomechanics and encourage the restoration of lordosis.
The challenges of occipital neuralgia are many. Fixing cervical neck instability is not something can be treated simply or easily, it takes a comprehensive non-surgical program to get the patient’s instability stabilized and the symptoms abated. We believe that if you have been going from clinician to clinician, practitioner to practitioner, doctor to doctor, there is a good likelihood that you have problems of cervical neck instability coming from weakness and damage to the cervical ligaments.
If this article has helped you understand the problems of Occipital neuralgia and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists
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