How to diagnose Occipital Neuralgia

How to diagnose Occipital Neuralgia

Occipital Neuralgia is considered a headache characterized by paroxysmal shooting or stabbing pain over the posterior scalp, in the distribution of the occipital nerve. The distribution of pain could be in the greater or lesser occipital nerve, or both. See picture of the occipital nerve(s) below.

Greater occipital nerve on right side is shaded purple.

Lesser occipital nerve on right side is shaded yellow.

Picture courtesy of Complete Anatomy Application.

This brief article will provide 3 approaches to ruling-in occipital neuralgia.

  1. ICHD-3 criteria

  2. STAB mnemonic

  3. Pillow sign

The gold standard for diagnosing occipital neuralgia is by the guidelines presented in the International Classification of Headache Disorders.

The International Classification of Headache Disorders, 3rd Edition (ICHD–3) provides the following diagnostic criteria for Occipital Neuralgia:

A. Unilateral or bilateral pain in the distribution(s) of the greater, lesser

and/or third occipital nerves and fulfilling criteria B-D

B. Pain has at least two of the following three characteristics:

  1. recurring in paroxysmal attacks lasting from a few seconds to minutes

  2. severe in intensity

  3. shooting, stabbing, or sharp in quality

C. Pain is associated with both of the following:

  1. dysesthesia and/or allodynia apparent during innocuous stimulation of the scalp and/or hair

  2. either or both of the following:

• (a) tenderness over the affected nerve branches

• (b) trigger points at the emergence of the greater occipital nerve or in the distribution of C2

D. Pain is eased temporarily by local anesthetic block of the affected nerve(s)

E. Not better accounted for by another ICHD-3 diagnosis

Occipital Neuralgia must be differentiated from other headache disorders, including cervicogenic headache, tension-type headache and migraine. As described in the guidelines above, the characteristics of the headache, physical examination and detailed history will help determine if your headache is occipital neuralgia.

The mnemonic, “STAB”, has even been coined to help make the diagnosis of occipital neuralgia.


Trigger point (C2), positive Tinel’s sign
Attacks (paroxysmal)
Base of skull/nerve Block

“Pillow Sign”

Occipital neuralgia is typically “side-locked”, meaning, the pain is on one side (posterior to anterior distribution) of the neck. Therefore, neck rotation or direct pressure over the nerve trunk as shown in the picture above, can be painful. This may occur when sleeping on a pillow, and considered the “pillow sign”.

We always recommend consulting a physician for an evaluation for any headache condition. Your physician may even order imaging, such as Computed tomography (CT) or Magnetic resonance imaging (MRI) to rule out other conditions.

Physical therapy and preventive medication with antiepileptics and tricyclic antidepressants are often effective treatments for occipital neuralgia. Refractory cases may require intervention with pulsed radiofrequency or occipital nerve stimulation (Doughtery 2014).

As physical therapists, I hope we can be of help to manage your occipital neuralgia. We provide several non-pharmacologic management strategies that can be used alone or in conjunction with your medical care to help you with your pain. Contact us to learn more how we can help you.

Call us: 919-728-0335