When It Feels Like a Migraine — But Isn’t

Occipital neuralgia requires different treatment

woman holding head in pain

If migraine medication isn’t working, your recurring headaches may not be migraines after all. Occipital neuralgia, a nerve-induced headache, can be confused with migraine because the symptoms can be similar:

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  • Aching, burning or throbbing from the base of your head up to your scalp
  • Sharp, shock-like or piercing pain in your upper neck and back of head
  • Pain on one or both sides of your head
  • Pain behind your eyes
  • Tender scalp
  • Pain when moving your neck

But that’s where the similarities end. Occipital neuralgia and migraines require different treatments because their sources of pain are different. Migraines are related to changes in the brain. Occipital neuralgia is due to compressed or irritated nerves that run from the neck, up the back of the head to the scalp.

“Nerves can become entrapped due to muscle spasms or head or neck trauma, such as whiplash,” says Shrif Costandi, MD, a pain management specialist at Cleveland Clinic. “Sometimes we don’t know what causes it.”

The difference between occipital neuralgia and migraine

Pain specialists can identify occipital neuralgia through one or more of these methods:

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  1. Patient history. “If the pain starts in the neck and radiates up the head to the eyebrows, that’s typical occipital neuralgia,” says Dr. Costandi.
  2. Basic exam. Doctors can sometimes reproduce the pain by pressing on occipital nerves at the base of the skull.
  3. Nerve block. “If the pain disappears after we numb the occipital nerve, then we can be confident that occipital neuralgia is causing the headache,” says Dr. Costandi.

Migraines tend to have identifiable triggers, he adds. Plus, they can be accompanied by aura (visual disturbances and other symptoms that precede the headaches). Occipital neuralgia typically has neither of those characteristics.

How to treat occipital neuralgia

Taking oral anti-inflammatories is the first step to treating occipital neuralgia. Using heat or massage to soothe tight neck muscles can help as well. If those treatments don’t provide relief, interventional pain specialists can perform an occipital nerve block. That’s when a local anesthetic and steroid are injected around the irritated nerve.

“Pain relief can last from several weeks to several months, and sometimes the pain doesn’t recur,” says Dr. Costandi.

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If your headaches have persisted for more than three months and have not responded to conventional treatments — including migraine medication — it’s time to see a doctor.

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