A patient who is still getting headaches four months after a rear-end collision is usually told 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.
The same crash injures both the head and the neck
The mechanism that concusses a brain is the same mechanism that strains the upper cervical spine and the nerves running through it. Whiplash and concussion are not alternative explanations to choose between — they commonly happen together in the same event. So the question is rarely which one, and usually how much of this headache is which.
What occipital neuralgia and cervicogenic headache look like
Both are secondary headache disorders — the pain originates in the occiput, at the base of the skull, and radiates forward toward the vertex. Occipital neuralgia involves the greater or lesser occipital nerves; cervicogenic headache arises from the cervical facet joints and related structures. Their presentations overlap substantially with each other, and both can be mistaken for migraine, tension-type headache, or post-traumatic headache.
- Pain starting at the base of the skull and travelling up and forward, often one-sided
- Tenderness over the occipital nerve where it crosses the skull base — often reproducing the patient’s own headache on palpation
- Sharp, shooting or electric quality, sometimes with scalp sensitivity, layered over a duller background ache
- Headache provoked by neck position or movement, and restricted cervical range of motion
Post-concussive headache, by contrast, is more often diffuse or frontal, tracks with cognitive and visual load, and travels with the rest of the post-concussive picture — light sensitivity, fogginess, disrupted sleep. In practice patients frequently have both, which 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
The diagnostic block: a test that answers the question
This is where the distinction stops being academic. An anaesthetic occipital nerve block has a dual role — it is both a treatment and a diagnostic test. If numbing that nerve abolishes 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. It is one of the reasons a concussion practice run by an interventional pain physician is differently equipped from one that is not: the diagnostic block is a procedure we perform, not a referral we make.
What follows from the answer
The published treatment pathways diverge sharply once the source is identified:
- Occipital neuralgia — conservative care first (education, self-management, physical therapy, analgesia, TENS); anaesthetic blocks for relief and diagnosis; pulsed radiofrequency of the occipital nerves where longer control is needed; occipital nerve stimulation reserved for refractory cases.
- Cervicogenic headache — the same conservative foundation, but radiofrequency treatment of the cervical facet joints is the indicated interventional step, with reported improvement lasting 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, and a deep cervical plexus block may help for under six months — useful facts, and 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
Why getting this wrong is costly
A treatable neck-origin headache misfiled as post-concussion syndrome gets rest and patience instead of the procedure that would have resolved it — sometimes for years. In the opposite direction, treating everything as a neck problem while an unaddressed vestibular or oculomotor injury keeps generating symptoms produces a patient who gets partial relief and no explanation.
If a claim is attached, the distinction matters again: “headache” as an undifferentiated complaint is easy to discount, while 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 but working out how much of the headache belongs to each, because they are treated differently.
How do you tell them apart?
History and examination first — where the pain starts, what provokes it, whether pressing over the occipital nerve reproduces the patient’s own headache, and how the neck moves. Where it remains unclear, an anaesthetic occipital nerve block is both diagnostic and therapeutic: if numbing the nerve abolishes the headache, that nerve was the source.
Is a nerve block a permanent fix?
Usually not on its own. Anaesthetic blocks relieve pain for a limited period; their larger value early on is answering the diagnostic question. Where longer control is needed, pulsed radiofrequency of the occipital nerves is the described next step for occipital neuralgia, and radiofrequency of the cervical facet joints for cervicogenic headache.
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, and is not evidence against either. See diagnosis and testing.