39 y/o M no significant past medical history presents with severe right sided occipital headache since this morning. The pain comes and goes, lasting a few minutes each time. He has had these headaches before, and feels that this episode is consistent with his previous ones. He denies fevers or chills, neck stiffness, numbness, tingling or weakness, vision or hearing changes, or other focal neurologic symptoms.
His neuro exam is normal except for tenderness and slightly diminished sensation over the affected area and the rest of his exam is non-focal, although he looks uncomfortable.
What is his likely diagnosis and what treatment can be given?
Occipital neuralgia. You can try an occipital nerve block to treat his pain.
Occipital neuralgia presents similarly to the patient above, with seconds to minutes of pain; tenderness and decreased sensation. It may be provoked by any sort of touch to the area. A detailed history and neuro exam should be done to rule out other dangerous causes of headache and neck pain.
An occipital nerve block is both diagnostic and theraputic. Lidocane and bupivicane, often mixed with steroids, are used for injection. To perform this procedure, palpate the occipital prominence and go 2-3 cm lateral toward the side of the pain, or just medial to the occipital artery (which should be palpable). The area should be prepped with alcohol, and injected with a small gauge needle (25 or smaller) at 90 degrees, taking care to aspirate first to avoid intravascular injection. A diagram is shown below.
The patient should feel better immediately and despite the relatively short duration of action of these medications, relief can last months.
Epic also now allows you to document these procedures under a new nerve block template. Check it out.