Occipital neuralgia is headache from the occipital nerves at the base of the skull. It is often one-sided, and neck movement sets it off. Post-concussive headache is more often diffuse (spread across the head) or frontal. It tracks with mental and visual load. An occipital nerve block separates them. If numbing the nerve stops the headache, the nerve was the source.
A patient who still gets headaches four months after a rear-end collision usually hears the same thing. This is post-concussion syndrome, give it time. Sometimes that is right. Sometimes the headache is not coming from the brain at all. It is coming from the upper neck, and it is treatable this month rather than eventually.
Can one crash injure both the head and the neck?
The mechanism that concusses a brain is the same mechanism that strains the upper cervical spine (the top of the neck) and the nerves running through it. Whiplash and concussion are not two explanations to choose between. They commonly happen together in the same event. So the question is rarely which one. It is usually how much of this headache is which.
How long does a headache last after a concussion?
Most post-traumatic headaches fade over days to a few weeks, along with the rest of the concussion. The international headache classification calls a headache post-traumatic when it starts within seven days of the injury, and persistent once it passes three months. Crossing that line is the signal to stop waiting and find the source.
A headache still going at three months is often no longer the brain injury itself. It may be the upper neck, as this page explains; an eye-movement deficit that turns every screen into a trigger; sleep that never recovered; or rebound from the painkillers taken daily to get through work. Each has its own fix, set out in how we treat concussion headache. A headache that is getting steadily worse rather than slowly better is an emergency department visit the same day.
What do occipital neuralgia and cervicogenic headache feel like?
Both are secondary headache disorders. The pain starts in the occiput, at the base of the skull, and radiates forward toward the vertex (the top of the head). Occipital neuralgia involves the greater or lesser occipital nerves. Cervicogenic headache arises from the cervical facet joints (the small joints at the back of the neck) and related structures. Their presentations overlap substantially with each other. Both can be mistaken for migraine, tension-type headache, or post-traumatic headache.
- Pain starting at the base of the skull and traveling up and forward, often one-sided
- Tenderness over the occipital nerve where it crosses the skull base. Pressing there (palpation) often brings on the patient’s own headache.
- Sharp, shooting or electric pain, sometimes with a sensitive scalp, on top of a duller background ache
- Headache provoked by neck position or movement, and limited neck range of motion
Post-concussive headache, by contrast, is more often diffuse or frontal. It tracks with thinking and visual load. It travels with the rest of the post-concussive picture: light sensitivity, fogginess, disrupted sleep. In practice, patients often have both. That is exactly why examination beats assumption.
Barmherzig R, Kingston W. Occipital Neuralgia and Cervicogenic Headache: Diagnosis and Management. Curr Neurol Neurosci Rep. 2019;19(5):20. doi:10.1007/s11910-019-0937-8
How does an occipital nerve block show where the headache comes from?
This is where the difference stops being academic. An anesthetic occipital nerve block (numbing medicine placed at the nerve) has a dual role. It is both a treatment and a diagnostic test. If numbing that nerve wipes out the headache, the headache was substantially coming from that nerve. If the headache is unchanged, it was not, and attention returns to the post-concussive picture.
Few tests in this field give an answer that clean. That is one reason a concussion practice run by an interventional pain physician is equipped differently from one that is not. The diagnostic block is a procedure we perform, not a referral we make.
How is each type of headache treated?
Once the source is found, the published treatment paths split sharply:
- Occipital neuralgia: conservative care comes first. That means education, self-management, physical therapy, pain relief and TENS. Anesthetic blocks give relief and help diagnosis. Pulsed radiofrequency of the occipital nerves is used where longer control is needed. Occipital nerve stimulation is saved for refractory cases (ones that have not responded to other care).
- Cervicogenic headache: the same conservative base. But radiofrequency treatment of the cervical facet joints is the indicated interventional step. Reported improvement lasts over a year.
- Post-concussive headache — none of the above. It is managed as part of concussion care: vestibular and oculomotor rehabilitation, sleep, graded return to load. See treatment.
Injections at various sites can relieve pain for a short period. A deep cervical plexus block may help for under six months. Those are useful facts. They are also a reminder that a single injection is a diagnostic step and a bridge, not a cure.
Lefel N, van Suijlekom H, Cohen SPC, Kallewaard JW, Van Zundert J. 11. Cervicogenic headache and occipital neuralgia. Pain Pract. 2024;25(1):e13405. doi:10.1111/papr.13405
What happens if the headache is misdiagnosed?
A treatable neck-origin headache can get misfiled as post-concussion syndrome. Then it gets rest and patience. It does not get the procedure that would have resolved it, sometimes for years. The opposite mistake happens too. Everything gets treated as a neck problem, while an unaddressed vestibular or oculomotor injury keeps causing symptoms. That produces a patient who gets partial relief and no explanation.
If a claim is attached, the distinction matters again. Listed as a general complaint, “headache” is easy to discount. A named diagnosis confirmed by a diagnostic block is a documented finding. See building the record.
Common questions
Can I have occipital neuralgia and a concussion at the same time?
Yes, and it is common. The forces that concuss a brain also strain the upper cervical spine. The clinical task is not choosing one. It is working out how much of the headache belongs to each, because they are treated differently.
How do you tell them apart?
History and examination come first. Where does the pain start? What sets it off? Does pressing over the occipital nerve bring on the patient’s own headache? How does the neck move? Where it is still unclear, an anesthetic occipital nerve block is both diagnostic and therapeutic. If numbing the nerve wipes out the headache, that nerve was the source.
Is a nerve block a permanent fix?
Usually not on its own. Anesthetic blocks relieve pain for a limited period. Early on, their larger value is answering the diagnostic question. Where longer control is needed, pulsed radiofrequency of the occipital nerves is the described next step for occipital neuralgia. For cervicogenic headache, it is radiofrequency of the cervical facet joints.
My MRI was normal, so is my headache in my head?
Neither occipital neuralgia nor cervicogenic headache shows up on brain imaging. They are diagnosed clinically and confirmed by response to a block. A normal MRI is expected in both. It is not evidence against either. See diagnosis and testing.
What gets mistaken for occipital neuralgia?
Its presentation overlaps with cervicogenic headache, which comes from the cervical facet joints. Both are often mistaken for migraine, tension-type headache or post-traumatic headache. After a crash, the usual mix-up is filing a neck-origin headache as post-concussion syndrome. An anesthetic occipital nerve block settles it. If numbing the nerve stops the headache, the nerve was the source.
How does a post-concussion headache feel different from occipital neuralgia?
Occipital neuralgia starts at the base of the skull and is often one-sided. It can feel sharp, shooting or electric, and it flares with neck movement. Pressing over the nerve often brings it on. Post-concussive headache is more often diffuse or frontal. It gets worse with thinking and screen work. It comes with light sensitivity, fogginess and poor sleep. Many patients have both.
Can a car accident cause occipital neuralgia?
Yes. The same force that concusses the brain strains the upper cervical spine and the occipital nerves running through it. So whiplash and concussion commonly happen in the same crash. A headache that is still there months after a rear-end collision is not always post-concussion syndrome. Sometimes it comes from the upper neck, and it is treatable this month rather than eventually.