Occipital neuralgia and Suboccipital headache – C2 neuralgia treatments without nerve block or surgery

Ross A. Hauser, MD.

Occipital neuralgia – C2 neuralgia treatments without nerve block or surgery

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 the problem of not getting enough medications. Such is the seemingly hopelessness of their situation.

“My big problem is my MRI, MRA, and CT Scan show nothing. So all I get is pain medications”

A typical patient history will describe that: one day, I had a headache, it never went away. I have had this headache for years. Some days it is bad, other days it is a dull throbbing that I can manage along with ice and NSAIDs. My biggest problem is that when I finally get an MRI, or an MRA, or CT Scan, they show nothing. My doctors are confused, I am confused and I am back on pain medications because there is nothing else that they can do.

Compounding this frustration is the reach for answers these patients are getting from health care providers and specialists who are seemingly guessing at what their problem is. Is it a pinched nerve? Is it muscle inflammation? Is it nerve inflammation? Further, as the headaches increase, other symptoms develop including hearing problems, vision problems, and dizziness.

In their search for answers, few are told that their problems may be related to cervical spine and neck instability. This, despite clear and mounting evidence that cervical spine and neck instability is a primary causative factor in the diagnosis of occipital neuralgia. BUT, without clear evidence on MRI, or MRA, or CT Scan, there can be no diagnosis of Cervical spine problems, neck instability, or Cervical Facet Joint Syndrome if the images offer no appearance of degenerative or traumatic injury to the C1-C2 area.

For some of you, this article may represent the first time you are exploring an in-depth discussion and research that cervical spine and neck instability may be the root of your problem. In many patients we see, a discussion with their health care providers have continued to singularly focus on symptom suppression and dealing with their neuralgia, their nerve pain, as the case of their base of the skull pain and painful range of motion and headache problems.

Occipital release, muscle relaxants, NSAIDs, and massages

For some people, a conservative care regimen of NSAIDs, muscle relaxants and massage will be all they need to get pain relief and a good night’s sleep.  Some patients will report that they initially had great results from a massage of “Occipital release” that helped with their painful muscle spasms. However, these pain relief advances they were getting soon became less effective and they were in fact “back to square one.”

At square one, new treatments were brought in or “upped,” and continued.

The location and relation between the suboccipital muscles to the C1 vertebra - the Atlas, and the C2 vertebra - the Axis and the path of the occipital nerve. Upper cervical spine instability at C1-C2 can cause pressure in the area resulting in the contraction and spasm of the muscle contraction

The location and relation between the suboccipital muscles to the C1 vertebra – the Atlas, and the C2 vertebra – the Axis and the path of the occipital nerve are illustrated. Upper cervical spine instability at C1-C2 can cause pressure on the base of the spine resulting in the contraction and spasm of the suboccipital muscle. This can cause headaches, migraines, and occipital neuralgia.

The path to treatment using regenerative medicine injections and DMX imaging studies 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 evidence that simple dextrose injections can fix a very complicated problem. Below we will also discuss another imaging type, the use of DMX or Digital Motion X-ray that helps uncover “hidden,” cervical spine and neck instability. The difference with DMX images is that it takes a movie of your cervical spine moving through various motions.

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?

In our clinic, we see many patients with a chief complaint of headache. The obvious challenges of these people’s headaches are first, obtaining 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)

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 on headaches, you may have come upon many websites that suggest that:

Your doctor may think you have Occipital neuralgia because your migraine medications are not working

For many patients, it is common to go through a long medical history that is in reality a process of elimination. Often Occipital neuralgia will be diagnosed on a basis of a medication or treatment that is not working.

In The Journal of Head and Face Pain, (3) researchers at the Department of Neurology, the 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 a migraine headache.

The doctors of this study were trying to sort through the confusion. Here is what they said:

Note: We want to point out here that the term “uncommon,” suggests a rarely diagnosed cause.

Symptoms, headache, strange vibration in the upper lip, deep pain at the base of the skull, or severe pain between the eyebrows. Sometimes all of them.

In this video Ross Hauser, MD. discusses C0-C1 instability and the problems it creates on C1 nerve root compression. The highlights and summary transcript are below.

The Occiput bone smashes against the C1 vertebra

At 0:50 video – the patient’s Digital Motion X-Ray demonstrates that their occiput is violently colliding with their C1 vertebra every time they move their head forward and their chin juts out.

IIn this still fame from the video, Dr. Hauser points to the back of the patient's skull, the occiput bone as it smashes into the patient's C1 vertebrae every time they move their head forward and their chin juts out, as in reaching out for something, looking upwards, etc. When this happens the patient's C1 nerve root and vertebral artery are compressed. This compression would lead to headaches, facial pain, and vibrating sensations in the upper lip.

In this still frame from the video, Dr. Hauser points to the back of the patient’s skull, the occiput bone as it smashes into the patient’s C1 vertebrae every time they move their head forward and their chin juts out, as in reaching out for something, looking upwards, etc. When this happens the patient’s C1 nerve root and vertebral artery are compressed. This compression would lead to headaches, facial pain, and vibrating sensations in the upper lip.

“The clinical implications of distinguishing occipital neuralgia and migraine headache and isolated occipital neuralgia include differences in the treatment regimen, avoidance of inappropriate use of medical resources, and differences in long-term outcomes.”

So to answer this challenge, the researchers looked at 35  patients all diagnosed with 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. The main learning point of this research is that patients with migraines should also be screened for symptoms of occipital neuralgia. Why?

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.

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 headaches. 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.


Ross Hauser, MD. Cause of occipital neuralgia and migraines seen on DMX and resolved with Prolotherapy

In this video, Ross Hauser, MD offers a brief introduction to causes and diagnosis of occipital neuralgia and migraines and treated with the aid of DMX (Digital Motion X-Ray and simple dextrose Prolotherapy cervical spine injections.

Summary highlights of the video:


Desperate for answers, doctors start the slow turn away from nerve blocks and towards cervical ligament repair and treating the muscle spasms of the suboccipital region

Treating muscle spasms with manipulation

Another study (December 2017) in the Journal of Manipulative and Physiological Therapeutics (6) brings together observations from previous studies and clinical outcomes to suggest that cervical spinal manipulations that help “unfreeze,” or move the neck about, would help eliminate pressure in the muscles and neck and thereby reduce or alleviate Suboccipital headache.

As we have documented in our research and discussed in our articles on Over Manipulation Syndrome, when the ligaments are exposed to continued stress, they will slowly stretch. Repeated stretching such as from excessive high-velocity manipulations will cause them to elongate and deform. The stretched-out cervical and capsular ligaments of the spine will cause instability of the spine. When this goes on for too long, the ligaments stretch to the point of no return and are unable to hold the vertebrae in place. The vertebrae shift and start to cause pain and other symptoms of spinal instability.

You can see how this could lead to a pattern of even more manipulations because the vertebrae are now shifting more frequently. But manipulations at this point will only make things worse. The attempt at realignment with manipulations will not hold but will stretch the ligaments further, potentiating the symptoms of the over-manipulation syndrome.

This image shows the occipital muscles at the base of the skull. The muscles include the rectus capitis posterior major, rectus capitis posterior minor, the obliquus capitis, inferior and obliquus, and capitis superior

This image shows the occipital muscles at the base of the skull. The muscles include the rectus capitis posterior major, rectus capitis posterior minor, the obliquus capitis, inferior and obliquus, and capitis superior

Suboccipital muscle spasm and the path towards nerve blocks

When a patient comes in with headache and neck pain related to the base of the skull we see on examination the hallmark finding of tenderness in the suboccipital muscles.

The function of the suboccipital muscles is underrated, which is confusing because these four fine-tuning muscles are vital in stabilizing the position of the head by helping provide stability in the upper cervical region.

The four muscles are the:

Two terms to quickly identify before we move on:

Because of its location, the obliquus capitis inferior plays an important role in the static and dynamic stability of the atlantoaxial joint (the joint between the first and second cervical vertebrae C1-C2), especially when there is upper cervical ligament laxity. When cervical neck instability is present the obliquus capitis inferior muscle pulls back the transverse process of the atlas (C0 vertebrae), pulling the atlas back or in extension.

When all four muscles contract on one side, they pull on the neck to that side. When they contract on both sides, they extend the head on the upper cervical spine; this extension is produced at both the atlantooccipital and atlantoaxial joints. The forward head posture position causes the cervical spine to straighten or go into a kyphotic position, which puts more strain on the structures of the upper cervical spine to hold the top two vertebrae, thus the head goes into extension.

Damage of soft tissue and increase of tension in neck limits stationary contraction of deep cervical muscle, posing difficulty in sustaining upright neck posture. With this process, cervical pain and cervicogenic headache occur, and as pain occurs or aggravates from the motion of returning to normal posture.

A brief explanation of cervical ligament injury and headaches

In this video, Ross Hauser, MD, explains the mechanisms of cervical ligament injury and headaches.

Transcript summary:

Suboccipital headache Moving away from nerve blocks and getting results from ligament repair


The desperation of pain relief – patients opt for high dose nerve blocks

Here is a study from the Mayo Clinic that appeared in the August 24th, 2018 edition of The Journal of Head and Face Pain. (7)

When all else fails in helping patients with headaches, doctors turn towards High-Volume Anesthetic Suboccipital Nerve Blocks. Let’s see what happened to the patients.

RESULTS:

The person who had the 30 injections developed avascular necrosis of the hip

The result of this study are clear, for the desperate patient, High-Volume Anesthetic Suboccipital Nerve Blocks can provide pain relief.  In our research, we believe we can show similar results without the threat of bone damage.

The treatment of overstretched cervical neck ligaments as an alternative to High-Volume Anesthetic Suboccipital Nerve Blocks

Back to the Korean study at the top of this article

According to the researchers, this study was conducted to compare and analyze the influence of craniocervical flexion and suboccipital relaxation in cervicogenic headache patients of their cervical muscular fatigue, tone, and headache intensity.

In a discussion of their research, the Korean team cited:

Cervicogenic headache patient with forward neck posture has high muscle tone and fatigue in superficial muscles to keep the unstable head from gravity, which easily induces postural disorder and pain. Consequently, an effort to keep an upright posture is necessary and exercise intervention is most crucial.

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 spasms. This is symptom suppression. It should be noted that botulinum toxin injections (Botox®) 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 (8)

Despite good results with Botox, these researchers wrote of the following concerns: 

A noisy neck is a 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 clinic, 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 heads 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 clinic, we often find people have 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:

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 (9) 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.

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. (10)

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.

Posterior view of upper cervical region

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. (11)

Here are the learning points:

Dry Needling as opposed to acupuncture

A case history was presented in The Journal of the Canadian Chiropractic Association (12) by the Department of Physical Therapy, University of Saint Mary, Kansas. This is the introduction to this case history:

The role of cervical instability in occipital neuralgia. Focus on the cervical neck ligaments

Do weakened ligaments in the neck causes 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 (13) 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.

Treatment: Occipital neuralgia is a whole-body disorder

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 and not a problem exclusive of the cervical neck region.

University researchers in Spain published an interesting study in the Latin American Journal of Nursing (14) 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).

These are 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 suggestion here is to align the posture. In our clinic, 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 that 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.

Summary transcript:

Dr. Hauser: One of the more common conditions we see in the office is occipital neuralgia. Treatment focuses on the greater occipital nerve, the lesser occipital nerve, and, the third occipital nerve which are branches of the C2 nerve root.

We treat the problem of occipital neuralgia with nerve release and Prolotherapy.

Nerve Release and Regeneration Injection Therapy?

Nerve Release and Regeneration Injection Therapy is a nerve hydrodissection technique that can be highly successful in releasing peripheral nerve entrapments. It is a quick, straightforward process, often with instant results (results do vary) for the patient. Solutions are injected around the nerve to nourish the nerve and mechanically release it from the surrounding tissue, fascia, or adjacent structures. Often, cellular solutions, such as stem cell or platelet solutions, are also injected at the nerve to promote nerve healing during the procedure as well.

Dr. Hauser (0:30) of the video. Nerve Release and Regeneration Injection Therapy

I had a patient yesterday who had Nerve Release and Regeneration Injection Therapy and I released the lesser occipital nerve and immediately the patient’s headache went away. (Results vary). However, the most common way I treat occipital neuralgia is with Prolotherapy.

Dr. Hutcheson at (0:53) of the video. Occipital neuralgia adjustments under chiropractic care 

With occipital neuralgia or obstruction or interference in the C2 nerve root, we may be able to get the patient relief with something as simple as one adjustment. The C2 bone could be malpositioned or could be just turned slightly and it could be putting compression on that nerve root, and we can do a small adjustment which we can visualize under our digital motion x-ray or even just watch to see if that correction was made after doing the adjustment may be enough to fix that

If we don’t get results quickly we can find out why on our digital motion X-ray and then develop a plan to correct it with Prolotherapy

Dr. Hauser (1:35) of the video. C1 instability 

C1 Instability and hyperextension

Dr. Hauser explains that he looks for cervical spine instability by how much space (or displacement) there is between the vertebrae. This is typically and especially seen when there is a disruption of the cervical spine lordosis or curve. This instability leads to a narrowing of the space between the vertebrae and nerve compression.

Dr. Hutcheson at (2:05) of the video. C1 Instability and hyperextension

An explanation of the adjustment to C1 is given to help release the nerve.

Dr. Hutcheson at (2:30) of the video. The value of DMX in evaluating a patient’s condition. Compression may only occur in extension. DMX allows doctors to see this.

The great thing about visualizing on the DMX as we can see for example that this patient may only get that bone pinching down a certain position. When their head is in a neutral position there is no compression. We can see this and correct it.

 

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.

Spasm and tension in the cervical muscle fixes

What we see in the medical literature is a clear understanding that these headaches are caused by spasms and tension in the suboccipital muscles and the upper trapezius muscles that extend from mid-back to base of the skull.

This was discussed in a study by Korean medical university doctors. In this research, the doctors found that the tone and stiffness of the suboccipital muscles and upper trapezius were higher in patients with cervicogenic headache than in healthy subjects. Here muscle tone refers to the degree of tension in relaxed skeletal muscle, and the most significant factor affecting the level of tone is muscle contraction (spasm) even in a resting state. (15)

Prolotherapy for Suboccipital headache

In 1993, Caring Medical opened its doors and among our first patients were people who suffered from chronic headaches. Sixteen years later we were able to document our experience in treating patients with headaches:

In 2009 we published research in the journal Practical Pain Management (16) that showed weak or loose neck ligaments and/or tendons may act as headache triggers in some people.

Our findings strongly suggest that Prolotherapy injections can play a role in decreasing intensity level, frequency, duration, number of associated symptoms, and light sensitivity in patients with headache and migraine pain.

It should be pointed out we did not report any cases of avascular necrosis of the hip from the treatments.

Prolotherapy heals the way the body heals

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.

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your neck pain. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

References

1 National Institute of Neurological Disorders and Stroke at the National Institutes of Health [NIH page]
2 Hauser RA, McCullough H. Dextrose Prolotherapy for recurring headache and migraine pain. Practical Pain Management. 2009:58-65. [Google Scholar]
3 Sahai‐Srivastava S, Zheng L. Occipital neuralgia with and without migraine: difference in pain characteristics and risk factors. Headache: The Journal of Head and Face Pain. 2011 Jan;51(1):124-8. [Google Scholar]
4 Williams KA, Lawson RM, Perurena OH, Coppin JD. Management of Chronic Migraine and Occipital Neuralgia in Post 9/11 Combat Veterans. Military Medicine. 2019 Jan 23. [Google Scholar]
5 Yang DJ, Kang DH. Comparison of muscular fatigue and tone of neck according to craniocervical flexion exercise and suboccipital relaxation in cervicogenic headache patients. Journal of physical therapy science. 2017;29(5):869-73. [Google Scholar]
6 Malo-Urriés M, Tricás-Moreno JM, Estébanez-de-Miguel E, Hidalgo-García C, Carrasco-Uribarren A, Cabanillas-Barea S. Immediate Effects of Upper Cervical Translatoric Mobilization on Cervical Mobility and Pressure Pain Threshold in Patients With Cervicogenic Headache: A Randomized Controlled Trial. Journal of Manipulative & Physiological Therapeutics. 2017 Nov 1;40(9):649-58. [Google Scholar]
7 Rozen TD. High‐Volume Anesthetic Suboccipital Nerve Blocks for Treatment Refractory Chronic Cluster Headache With Long‐Term Efficacy Data: An Observational Case Series Study. Headache: The Journal of Head and Face Pain. 2018 Aug 24. [Google Scholar]
8 Castelão M, Marques RE, Duarte GS, Rodrigues FB, Ferreira J, Sampaio C, Moore AP, Costa J. Botulinum toxin type A therapy for cervical dystonia. The Cochrane Library. 2017. [Google Scholar]
9 Jose A, Nagori SA, Chattopadhyay PK, Roychoudhury A. Greater Occipital Nerve Decompression for Occipital Neuralgia. Journal of Craniofacial Surgery. 2018 Jul 1;29(5):e518-21. [Google Scholar]
10 Choi I, Jeon SR. Neuralgias of the head: Occipital neuralgia. Journal of Korean medical science. 2016 Apr 1;31(4):479-88. [Google Scholar]
11 Kastler A, Attyé A, Maindet C, Nicot B, Gay E, Kastler B, Krainik A. Greater occipital nerve cryoneurolysis in the management of intractable occipital neuralgia. Journal of Neuroradiology. 2018 Oct 1;45(6):386-90. [Google Scholar]
12 Bond BM, Kinslow C. Improvement in clinical outcomes after dry needling in a patient with occipital neuralgia. The Journal of the Canadian Chiropractic Association. 2015 Jun;59(2):101. [Google Scholar]
13 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326.  [Google Scholar]
14 López-Soto PJ, Bretones-García JM, Arroyo-García V, García-Ruiz M, Sánchez-Ossorio E, Rodríguez-Borrego MA. Occipital Neuralgia: a noninvasive therapeutic approach. Revista latino-americana de enfermagem. 2018;26. [Google Scholar]
15. Park SK, Yang DJ, Kim JH, Heo JW, Uhm YH, Yoon JH. Analysis of mechanical properties of cervical muscles in patients with cervicogenic headache. Journal of physical therapy science. 2017;29(2):332-5. [Google Scholar]
16. Hauser RA, McCullough H. Dextrose Prolotherapy for recurring headache and migraine pain. Practical Pain Management. 2009:58-65. [Google Scholar]

 

 

 

 

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