Occipital neuralgia

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Anyone have experience treating this? I've seen it a couple times but I'm unaware of any practice guidelines or evidence based procedures for PT and I've looked. I gave the patient a resource to bring to f/u appt with PA who referred her. On subsequent visit, pt returns and noted that the PA didn't agree with me and did lidocaine injections into the skin. Symptoms improved thus far with PT rx, but pain increased to 12/10 same day of injections. Her main complaint is HA's with pain behind the eye, upper neck pain on L side.

This pt has L sided referral into C2 distribution and behind eye, there is provocation with upper cervical L lateral flexion, symptoms aggravated with distraction (gentle manual and mechanical at 15# force at 15 degree incline.

Recommendations?

I would like to refer to a PM&R or other pain specialist. Looks like radiofrequency ablation is an effective procedure.

Originally Posted by Fiveoboy11

Anyone have experience treating this? I've seen it a couple times but I'm unaware of any practice guidelines or evidence based procedures for PT and I've looked. I gave the patient a resource to bring to f/u appt with PA who referred her. On subsequent visit, pt returns and noted that the PA didn't agree with me and did lidocaine injections into the skin. Symptoms improved thus far with PT rx, but pain increased to 12/10 same day of injections. Her main complaint is HA's with pain behind the eye, upper neck pain on L side.

This pt has L sided referral into C2 distribution and behind eye, there is provocation with upper cervical L lateral flexion, symptoms aggravated with distraction (gentle manual and mechanical at 15# force at 15 degree incline.

Recommendations?

I would like to refer to a PM&R or other pain specialist. Looks like radiofrequency ablation is an effective procedure.

First of all, I would say that anyone who rates pain 12/10 might just be a symptom magnifier. Not to say that he/she is not experiencing severe pain, but there is no 12 out of 10.

I have had success with gentle pressure on the suboccipital triangle muscles/nerves. Patient lies supine with your palm up fingertips just inferior to his/her skull. let the weight of his/her head do the work, just keep your fingers straight. Some gentle mobilization of C1 is also sometimes helpful. assess posture, if they wear bifocals, recommend "computer glasses" that are just full sized reading glasses. Also, sometimes a simple ice pack in the same place for 15 minutes will break some nasty cycles.

Rationale: they have hyper responsive protective reflexes in their suboccipital triangle muscles and the sustained contraction/spasm is causing localized ischemia in the neural tissue. Working on posture can reduce the loads that trigger the protective responses/fatigue/spasm, and the manual stuff can reduce that which is already there.

If it is what I am saying it is, they should experience noticeable relief within minutes (not complete relief but meaningful reduction in pain right away). If they don't, then a referral is very reasonable.

Originally Posted by truthseeker

First of all, I would say that anyone who rates pain 12/10 might just be a symptom magnifier. Not to say that he/she is not experiencing severe pain, but there is no 12 out of 10.

I have had success with gentle pressure on the suboccipital triangle muscles/nerves. Patient lies supine with your palm up fingertips just inferior to his/her skull. let the weight of his/her head do the work, just keep your fingers straight. Some gentle mobilization of C1 is also sometimes helpful. assess posture, if they wear bifocals, recommend "computer glasses" that are just full sized reading glasses. Also, sometimes a simple ice pack in the same place for 15 minutes will break some nasty cycles.

Rationale: they have hyper responsive protective reflexes in their suboccipital triangle muscles and the sustained contraction/spasm is causing localized ischemia in the neural tissue. Working on posture can reduce the loads that trigger the protective responses/fatigue/spasm, and the manual stuff can reduce that which is already there.

If it is what I am saying it is, they should experience noticeable relief within minutes (not complete relief but meaningful reduction in pain right away). If they don't, then a referral is very reasonable.

This approach seems very reasonable and is how I usually approach a patient like this. From the OP's description, it may not be true occipital neuralgia, so RF ablation seems a bit aggressive at this point. Get that upper cervical area moving as best you can and release those suboccipitals as mentioned above. If that fails, I'd refer to pain mgmt for consideration of upper cervical joint injections.

Originally Posted by facetguy

This approach seems very reasonable and is how I usually approach a patient like this. From the OP's description, it may not be true occipital neuralgia, so RF ablation seems a bit aggressive at this point. Get that upper cervical area moving as best you can and release those suboccipitals as mentioned above. If that fails, I'd refer to pain mgmt for consideration of upper cervical joint injections.

Thanks for the responses. I have been doing things as above mentioned by truthseeker as well as upper thoracic biased mobility exercises and thorax expansion, shoulder horiz abd mobility exercises, chin tucks.

I don't know what else it could be besides occipital neuralgia? I know it is relatively rare but it is paresthesia/radicular symptoms into one hemisphere of the scalp as well as around the eye/behind the eye. No loss of vision, no stroke S/S. She definitely has tenderness L occiput and suboccipitals and provocation with compression of that side.

She is a magnifying type of patient but her symptoms definitely appear legitimate. She is cooperative and pleasant but in obvious pain vs negative and catastrophizing.

Originally Posted by Fiveoboy11

Thanks for the responses. I have been doing things as above mentioned by truthseeker as well as upper thoracic biased mobility exercises and thorax expansion, shoulder horiz abd mobility exercises, chin tucks.

I don't know what else it could be besides occipital neuralgia? I know it is relatively rare but it is paresthesia/radicular symptoms into one hemisphere of the scalp as well as around the eye/behind the eye. No loss of vision, no stroke S/S. She definitely has tenderness L occiput and suboccipitals and provocation with compression of that side.

She is a magnifying type of patient but her symptoms definitely appear legitimate. She is cooperative and pleasant but in obvious pain vs negative and catastrophizing.

Could be facet mediated. The periorbital symptoms can arise via the trigeminocervical nucleus projecting into the V1 of the trigeminal nerve. It could be more of a cervicogenic headache than occipital neuralgia. Not saying the dx is wrong but trying to think of other factors to address. Sounds like you're doing all the right things.

Originally Posted by facetguy

Could be facet mediated. The periorbital symptoms can arise via the trigeminocervical nucleus projecting into the V1 of the trigeminal nerve. It could be more of a cervicogenic headache than occipital neuralgia. Not saying the dx is wrong but trying to think of other factors to address. Sounds like you're doing all the right things.

ty for the pointers

How old is she, by the way?

Fiveoboy11,

Interesting. Have you tried using manual techniques to C2/3 area, as in mobilization or manipulation? Based on her pain levels, perhaps you've avoided that treatment? I don't think it would be too much to try to get at the upper cervical and C2/3 area and see what happens, though her high level of pain is a bit of precaution to me, i.e, fear-avoidance and if she's even a good candidate for those treatment techniques.

Also, check out some of the readings on "trigeminal facilitation" and "facilitated segments." I don't have the time this AM to pull some of them up, but will later and/or you can do a lit search on it. Interesting reads as well.

It does seem like a cervicogenic HA to me. Cheers!

Any consideration for thrust?

Does she have any contraindications for thrust?

It's rarely what I consider first off, but might be worth a shot here.

How's this patient doing?

I referred her to a PM&R doc, she wasn't getting significant enough or quick enough symptom relief...

Originally Posted by Fiveoboy11

I referred her to a PM&R doc, she wasn't getting significant enough or quick enough symptom relief...

If you hear anything by way of follow-up, let us know.