Dear Patients and Friends:
Happy New Year!
In the New Year, we all are facing a stressful time with new challenges because of the economy. You may sometimes have neck pain, headaches and/or poor sleep, etc. One of the possible causes of the aforementioned list might be occipital neuralgia. Please read the following case discussion; you may have some idea about it.
You are welcome to send the news letter to your friends as long as it is not for commercial use.
Jun Xu, M.D. and Hong Su, C.M.D.
News Letter, Vol. 2 (1), January, 2010, © Copyright
Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.
Rehabilitation Medicine and Acupuncture Center
1171 East Putnam Avenue, Building 1, 2nd Floor
Greenwich, CT 06878
Tel: (203) 637-7720
Case Discussion 13: Occipital Neuralgia
Linda, a 45-year-old female dental assistant, came to me complaining of severe headaches that started at the back of her head and continued down a portion of her neck. The pain also radiated up to her scalp, around her ears and sometimes into the bilateral temporal area. The pain was off-and-on, but occurred every day. The pain ranged from dull to sharp, and was sometimes located directly behind the right eye. As a dental assistant, she constantly turned her head to the right when dealing with patients. This caused the headache to become more severe, and she was frustrated that it interfered with her daily work. She had consulted several doctors about her condition, and had been prescribed Naprosyn, Percocet and Neurotin, but none of them alleviated her condition.
These headaches intensified when Linda was under stress, which was often because of her job: if she had many patients waiting for her and felt under pressure, the headaches worsened.
When I examined Linda, I discovered that when I pressed her scalp at the base of the skull and suboccipital area, the pain radiated to the back, front and side of her head, and also to the right side of the eye. When I pressed hard on the suboccipital area (the base of the skull) the pain was exacerbated and I could feel the bilateral temporal artery palpating.
The patient probably suffers from occipital neuralgia, which is a cycle of pain spasms originating in the suboccipital area, caused by an inflammation of the occipital nerves. The two pairs of occipital nerves (each nerve contains a greater and lesser occipital nerve) originate in the second and third vertebrae of the neck. These nerves supply areas of the skin along the base of the skull and behind the ear, but are not always connected directly with the structures inside the skull. However, they do interconnect with other nerves outside the skull and continue into the neuro-network. Eventually they can affect any given area along the scalp, mainly on the bilateral temporal area behind the ear and sometimes connect to the nerve branch on either side of both eyes.
Occipital neuralgia may occur continuously, often as the result of the nerve impingement, especially from arthritis, muscle spasm, or as the result of a prior injury or surgery. Sometimes these conditions will impinge the occipital nerve root, leading to severe headaches at the back of the head, leading to muscle spasm. Linda exhibits the severe form of occipitical neuralgia, most likely because her profession causes her to tilt her head in the same manner for a good part of her day. This stress causes the occipital nerve to be impinged, sending a constant signal to the nerve network in her scalp, leading to headaches and the pain behind her right eye.
The clinical diagnosis of this condition is based on palpation by the doctor of the bilateral occipital nerve root, which will induce or trigger the headache. Doctors currently use various treatments. One option is to inject 1% lidocaine 5cc into the occipital nerve root, which decreases or relieves the pain, confirming the diagnosis. A second option is to use surgery to cut or burn the nerve with a radial wave probe. A third option is to use a small injection of Botox or a similar medication. Western medicines include anti-inflammatory or narcotics such as Percocet or Darvocet, Naurontin, anti-epilepsy medication, etc. For the majority, these medications do not work well, though occasionally they can reduce the occurrence and frequency of the occipital neuralgia.
Some patients respond to physical therapy and massages to decrease the spasm of the neck muscle, which might temporarily relieve the occipital neuralgia. Though doctors may recommend surgery, many patients resist this type of treatment.
According to Traditional Chinese Medicine, occipital neuralgia belongs in the category of the side headache, i.e. the Shao Yang Gallbladder meridian headache. Gallbladder meridians are distributed around the sides of the head, and excessive heat in the gallbladder can lead to headaches. The gallbladder meridian originates from the outside of the eye, and continues up the temporal nerve area, around the lateral skull area, down the occipital nerve area, down through the trunk and to the outside of the leg. If there is excessive heat along this meridian, there will be an imbalance of yin and yang. For example, if the patient undergoes stress, muscle spasm or arthritis, the nerve and the gallbladder meridian will be impinged. This, in turn, will cause the gallbladder to heat up, leading to excessive heat, an imbalance of yin and yang and a severe headache.
Another meridian identified in occipital neuralgia by Traditional Chinese Medicine is the urinary bladder meridian, which starts from the inside corner of the eye, continues through the middle and the top of the scalp, and follows down the back of the trunk and into the back of the leg. Due to the connection between the gallbladder and urinary bladder meridians, heat in one will cause heat in the other to rise, generating pain around the eye, the temporal area and the scalp, and making the ensuing headache severe and highly unbearable. Therefore, the principal acupuncture treatment is to relieve this excessive heat in the gall bladder and urinary tract.
The main acupuncture points used for treatment are: Du 20 Bai Hui, GB 20 Feng Chi, GB1 Tong Zi Liao, GB 8 Shuai Gu, Extra point Tai Yang, GB 34 Yang Ling Quan, SI 3 Hou Xi, Lu 7 Lie Que, Kid 6 Zhao Hai, Li 3 Tai Chong.
Linda underwent my treatment three times a week for one month, resulting in immediate, short-term relief of her headaches. However, the headaches continued to plague her because of her strenuous work. In addition, her irregular menstrual cycle and hormonal changes led to more severe headaches. Thus, I also treated her for hormonal changes by utilizing a Chinese herb Da Zhi Xiao Yao San. The combination of acupuncture and herbal therapy seemed to be effective and, after about two months of treatment, Linda reported that her headaches occurred only infrequently and were very mild, and that she was satisfied with her treatments.
Usually, acupuncture, with or without the addition of herbal supplements, can alleviate the problems and pain associated with these headaches. However, sometimes it is best to combine acupuncture with a nerve block (utilizing 4cc of 1% lidocaine plus 10 mg Kenalog mixed together) injected into both sides of the occipital nerve origin. One month of this combined treatment should give the patient 95% relief from his/her symptoms.
Tips for acupuncturists:
- You should identify the location of the pain and tenderness, and treat the headache accordingly. For example, the frontal headache belongs to the Yang Ming meridian; the temporal side headache belongs to the Shao Yang meridian; the top scalp headache belongs to the Jue Ying meridian.
- Always use Du 20 Bai Hui for all the different types of headaches. This is based on my personal experience over 20 years of practice.
Tips for patients:
- You should be very specific when describing the tender points on your head because each tender-point location belongs to a different meridian, and treatment varies based on each location.
- Massaging the Tai Yang and UB 20 Feng Chi points for 20 minutes, 2 to 3 times a day, will greatly decrease the headache.