Head and neck pain
Occipital Neuralgia and Cervicogenic Headache
Stabbing pain at the back of the head, or headaches starting in the neck? Gulf Coast Pain & Spine in Houston treats occipital neuralgia with nerve blocks.
Occipital neuralgia is sharp, shooting or electric pain at the back of the head along the greater or lesser occipital nerves. Cervicogenic headache is head pain that is generated by structures in the upper neck, usually the joints or nerves at C2 and C3. Both are treatable with image-guided nerve blocks and, when a block confirms the source, radiofrequency ablation or nerve stimulation. Gulf Coast Pain & Spine does not manage primary headache disorders such as migraine, which are co-managed with neurology; it does offer occipital nerve blocks and, on neurology referral, sphenopalatine ganglion blocks for cluster and other neurology-diagnosed headaches.
Key facts
| What it is | Occipital neuralgia: irritation of the occipital nerves as they pass through the muscles at the base of the skull. Cervicogenic headache: pain referred to the head from the upper cervical joints, discs or nerves |
|---|---|
| Most common causes | Neck muscle tension and posture, whiplash or neck injury, upper cervical facet arthritis, nerve entrapment in the neck muscles; rarely tumors or vascular problems |
| Typical course | Fluctuates with neck strain; responds well to blocks in most patients; recurrence is common and repeat blocks or ablation give longer control |
| See a specialist when | Headache is one-sided, starts at the neck or skull base, is triggered by neck movement or pressure, and has not responded to primary care treatment |
| Treatments we offer | Greater and lesser occipital nerve blocks, third occipital nerve and C2-3 medial branch blocks with radiofrequency ablation, occipital peripheral nerve stimulation, sphenopalatine ganglion block on neurology referral |
When to get emergency care
Go to an emergency room or call 911 if you have:
- A headache that reaches maximum intensity within a minute ("thunderclap") or the worst headache of your life
- Headache with fever and a stiff neck, confusion, drowsiness or seizure
- Headache with new weakness, numbness, slurred speech, double vision, drooping face or trouble walking
- A new or different headache after a head injury or fall, especially if you take blood thinners or are over 65
- New headache after age 50 with scalp tenderness, jaw pain when chewing or vision changes (possible giant cell arteritis, which can cause blindness)
- Headache that is steadily worsening over days to weeks, wakes you from sleep, or is worse lying down, coughing or straining
- Headache during pregnancy or shortly after delivery with high blood pressure, swelling or vision changes
Occipital neuralgia and cervicogenic headache are diagnoses made only after these dangerous causes have been considered. A new headache pattern should be evaluated by your primary care physician or neurologist before it is treated as a neck problem.
What these headaches are, and what we do and do not treat
Headache is one of the most common symptoms in medicine, and most headaches are primary headache disorders: migraine, tension-type headache and cluster headache, where the headache itself is the disease and the brain's pain networks are the source. These are diagnosed and managed by primary care and neurology, with preventive and acute medications, and Gulf Coast Pain & Spine does not serve as the treating clinic for them.
A smaller group of headaches are secondary to a structure in the neck or a specific nerve, and those are what a pain clinic treats well:
- Occipital neuralgia: pain along the greater occipital nerve (which runs from C2 up over the back of the skull toward the top of the head) or the lesser occipital nerve (behind the ear). The nerve is irritated where it passes through tight neck muscles or by upper cervical arthritis or injury.
- Cervicogenic headache: pain referred to the head from the upper neck, most often the C2-3 facet joint (served by the third occipital nerve), the C1-2 joint, or the C2-3 disc. The joint hurts, and the brain feels it in the head because the upper cervical nerves and the trigeminal nerve share a relay center in the brainstem.
What we offer: occipital nerve blocks, diagnostic third occipital nerve and C2-3 medial branch blocks followed by radiofrequency ablation when the block confirms the source, and occipital peripheral nerve stimulation for refractory cases. On referral from a neurologist, we also perform sphenopalatine ganglion blocks for cluster headache and other neurology-diagnosed headaches, with the neurologist remaining the managing physician. Gulf Coast Pain & Spine offers these procedures in Houston, Webster and Pearland (opening November 2026).
What causes them
Occipital neuralgia is most often caused by compression or irritation of the nerve where it pierces the semispinalis and trapezius muscles at the base of the skull. Contributing factors include chronic neck muscle tension and forward-head posture, whiplash or a direct blow to the back of the head, upper cervical facet arthritis or C2 nerve root irritation, and, rarely, a vascular loop, tumor or infection, which is why imaging is sometimes ordered. Diabetes and other neuropathies can make the nerve more vulnerable.
Cervicogenic headache follows the same sources as neck pain: facet joint arthritis at C2-3 and C3-4, whiplash (the C2-3 joint is the most commonly injured level in whiplash headache), disc degeneration, and postural strain. It is more common in people who work with the neck bent or rotated, and after neck injury.
Symptoms, and how they differ from migraine
Occipital neuralgia (per the International Classification of Headache Disorders, ICHD-3):
- Paroxysmal stabbing, shooting or electric pain at the back of the head, lasting seconds to minutes, often with a dull ache between attacks
- One-sided more often than both sides
- Tenderness over the nerve where it exits at the base of the skull; pressing there reproduces the pain
- Sometimes tingling or pain behind the eye on the same side, and scalp sensitivity so that brushing hair or lying on a pillow hurts
- Temporary relief from a local anesthetic block of the nerve is part of the definition
Cervicogenic headache (ICHD-3):
- One-sided head pain that starts in the neck or back of the head and spreads forward to the temple, forehead or eye, without switching sides
- Provoked or worsened by neck movement, sustained awkward posture, or pressure on the upper neck
- Reduced neck range of motion and neck pain or stiffness
- Evidence of a neck source, such as pain relief after a diagnostic block of the joint or nerve
How they differ from migraine. Migraine typically throbs, lasts 4 to 72 hours, comes with nausea, light and sound sensitivity, is worsened by routine activity, and may switch sides between attacks; it is not reliably reproduced by pressing on the neck. Cervicogenic headache is steady rather than throbbing, stays on one side, and is triggered by neck movement. The two coexist often, and many patients with migraine also have neck pain, which is why a neurologist's diagnosis matters before a neck procedure is planned. Tension-type headache is usually both-sided, band-like and mild to moderate.
How we diagnose it
The exam looks for tenderness over the greater and lesser occipital nerves (a positive Tinel sign, where tapping reproduces the shooting pain), reduced upper cervical range of motion, pain on pressing over the C2-3 facet joint, and the flexion-rotation test (limited rotation with the neck flexed points to C1-2). A neurologic exam checks that there are no signs pointing to the brain.
Imaging is not required for typical occipital neuralgia. Cervical spine X-rays or MRI are ordered when there is a history of injury, arthritis symptoms, nerve root signs, or when ablation is being planned. Brain imaging is ordered if any red flag or atypical feature is present, usually through your PCP or neurologist.
Diagnostic blocks confirm the source. A greater occipital nerve block with local anesthetic that removes the pain, even briefly, confirms occipital neuralgia; this block is both a test and a treatment. For cervicogenic headache, a third occipital nerve block or C2-3 medial branch block under X-ray guidance is a test: if the headache disappears for the duration of the anesthetic on two occasions, radiofrequency ablation of that nerve is likely to give months of relief. We use a pain diary for the hours after each block to score the response.
Treatment options, in order
Conservative care and procedures run together. Because most of these headaches have a neck component, physical therapy is part of nearly every plan, and blocks are timed to allow it.
- Physical therapy and posture
Upper cervical mobilization, deep neck flexor strengthening, and workstation changes reduce cervicogenic headache frequency in trials. Heat, gentle stretching of the suboccipital muscles and a supportive pillow help occipital neuralgia. Learn more →
- Medication
NSAIDs or acetaminophen for flares; for nerve pain, gabapentin, pregabalin, or a low-dose tricyclic at night; muscle relaxants short-term. Frequent use of pain relievers (more than 10 to 15 days a month) can itself cause medication-overuse headache, so we limit them. Opioids are not used for headache. Learn more →
- Occipital nerve block
Local anesthetic with or without a small dose of steroid injected around the greater and, if needed, lesser occipital nerve at the base of the skull, guided by landmarks or ultrasound. Takes about 5 to 10 minutes in the office; relief typically begins within 15 minutes and lasts from weeks to a few months. Repeated up to every 2 to 3 months. This is both a test and a treatment. Learn more →
- Third occipital nerve / C2-3 medial branch block, then radiofrequency ablation
For cervicogenic headache confirmed by two positive diagnostic blocks, radiofrequency ablation of the third occipital nerve or C2-3 medial branches produces a heat lesion that typically gives 6 to 12 months of relief; nerves regrow and the procedure can be repeated. Learn more →
- Occipital peripheral nerve stimulation
For occipital neuralgia that responds to blocks but keeps returning, a thin lead placed under the skin along the occipital nerve delivers mild stimulation. A trial period comes first. Evidence is from smaller studies; coverage is reviewed by the insurer individually. Learn more →
- Sphenopalatine ganglion block (on neurology referral)
A transnasal application of local anesthetic to the sphenopalatine ganglion, used for cluster headache and other neurology-diagnosed headaches when the neurologist requests it. The neurologist remains the managing physician for the headache disorder. Learn more →
What you can do now
- Keep a headache diary for four weeks: time of onset, side, where it started, what triggered it, what you took. It separates neck headaches from migraine faster than any test.
- Fix the screen. Monitor at eye level, phone raised rather than head bent; take a 30-second neck break every 30 minutes.
- Heat on the neck for 15 minutes and gentle chin tucks and upper-neck stretches, twice daily.
- Change the pillow if you wake with the headache; it should keep the neck level with the spine, not propped up.
- Limit pain relievers to fewer than 10 days a month to avoid rebound headache.
- See a neurologist first if your headaches throb, come with nausea or light sensitivity, or you have never had a headache diagnosis. We work alongside them.
New patients can start at new patient information; physicians can use the referral page.
Frequently asked questions
Do you treat migraines?
No. Migraine and other primary headache disorders are managed by primary care and neurology, and we do not act as the treating clinic for them. We treat headaches that come from the neck or the occipital nerves, and on a neurologist's referral we perform sphenopalatine ganglion blocks for cluster headache and other neurology-diagnosed headaches while the neurologist manages the condition.
How do I know if my headache comes from my neck?
Cervicogenic headache is one-sided and stays on that side, starts at the back of the head or upper neck and spreads forward, is triggered by neck movement or pressure on the upper neck, and comes with reduced neck motion. A diagnostic nerve block that stops the headache confirms it.
What does an occipital nerve block feel like, and how long does relief last?
A brief sting at the base of the skull, then numbness of the scalp on that side for a few hours. Relief of the neuralgia typically starts within minutes and lasts weeks to a few months; many patients have a series of two or three blocks. Risks are minor: soreness, a small bruise, temporary dizziness, and, if steroid is used, a small patch of hair thinning or skin lightening at the site.
Is radiofrequency ablation for cervicogenic headache safe?
Yes, with X-ray guidance and after two confirming diagnostic blocks. The specific side effects at the third occipital nerve are temporary numbness of a patch of scalp, brief dizziness or unsteadiness for a few days, and, uncommonly, a temporary flare of burning pain (neuritis) that settles within weeks. Relief typically lasts 6 to 12 months.
Can whiplash cause headaches years later?
Yes. Injury to the C2-3 facet joint is the most common source of chronic headache after whiplash, and it can persist long after the neck pain has become tolerable. It is diagnosed with a third occipital nerve block and treated with radiofrequency ablation.
Will my insurance cover these procedures?
Occipital nerve blocks, diagnostic medial branch blocks and radiofrequency ablation are covered by Medicare and most commercial plans when the diagnosis is documented. Occipital nerve stimulation is reviewed case by case. Sphenopalatine ganglion block coverage varies by plan. The practice does not accept Medicaid.
Do I need a neurologist's referral?
Not for occipital neuralgia or cervicogenic headache; a primary care referral or a self-referral is fine, though a prior headache evaluation is helpful. For sphenopalatine ganglion blocks, yes: we perform them on a neurologist's request for a neurology-diagnosed headache disorder.
Sources
- The International Classification of Headache Disorders, 3rd edition (ICHD-3): Occipital neuralgia (13.4) and Cervicogenic headache (11.2.1) (opens in new tab) — International Headache Society
- Occipital Neuralgia (opens in new tab) — National Institute of Neurological Disorders and Stroke
- Cervicogenic Headache (opens in new tab) — American Migraine Foundation
- Headache: Hope Through Research (opens in new tab) — National Institute of Neurological Disorders and Stroke
Request an appointment
Call (832) 916-2075 or request an appointment online. New patients are welcome; the team confirms insurance and referral requirements before scheduling.