Them Bones: Harnessing your headache: The nerve of it all


Tom Neviaser

How on earth can an orthopedist treat headaches, you may ask?

If you suffer from headaches at the back of your head or at the top of your neck, the diagnosis may be as occipital neuritis.

Doctors refer to a particular nerve depending on what part of the body it serves. In this case, the affected nerve serves the lower back of the head, the occiput (OX-si-put), hence the diagnosis of occipital headaches.

These headaches occur when the greater occipital nerve is irritated as it emerges from the base of the skull on the right or left. This nerve runs toward the base of your skull, then quickly turns 90 degrees upward through small muscles to become subcutaneous,“under the skin,” giving sensation to the skin in this area.

What can be done to relieve these headaches? Various treatments are available: medications, heat, physical therapy,acupuncture, holistic therapy, and chiropractic manipulation, with varying degrees of success.

Your doctor will probably prescribe some or all of these same treatments.

Because patients with occipital headaches or doctors who see these people believe they’re dealing with actual “aches” inside the head or skull, the true diagnosis may not be made. Some physicians do not believe in this specific diagnosis. I’m not certain why. The doctor may try a “shotgun” approach in the hope that one of these treatments will take care of the problem.

If the doctor performs a thorough history and carries out a careful physical examination, he can generally pinpoint the painful area. A single instruction, “Point to the area of your pain with one finger,” may be all that’s needed. When the patient points to the anatomical location of the greater occipital nerve, it may well be the source of the pain.

In my practice, when a person complained of this off-center headache and pointed to this area, I often found a pinpoint tenderness there. Other types of headaches—migraines, for example—will not exhibit pinpoint tenderness. Injecting this “trigger point”—an area of greatest tenderness—with a short-acting local anesthetic such as Lidocaine may cause the pain to vanish for a short period of time, thereby proving that this specific area is the cause of the symptoms. Adding a refined steroid to this injection may reduce the inflammation or irritation of the nerve even longer.

Injecting this trigger point on the first visit can eliminate the need for other treatments, saving time and money and bringing immediate relief rather than allowing the pain to continue while other treatments are scheduled, waited for, and undergone without success, only to have the patient come back weeks or months later with the same symptoms. Long-term treatment may necessitate occasional injections followed by physical therapy; however, the injection usually did the trick in my hands most of the time.

The treatment goal of a doctor should be to make the earliest possible diagnosis, followed by the most advantageous and effective treatment. Sending the patient off for six weeks of therapy without a true diagnosis never made much sense to me. Eliminating the pain on the first office also gives the patient great relief and the doctor a feeling of accomplishment, and a mutually beneficial doctor-patient relationship quickly is established, even though the symptoms may return later.

Posterior Auricular Neuritis

This is another neuritis similar to the occipital neuritis, Auricular (aw-RICK-cue-lar) refers to the ear and posterior means “behind”; therefore, the affectation is an inflammation of the posterior auricular nerve which is located behind the ear at the base of the skull. I know this entity exists because I have had it and despite anti-inflammatory medications including oral cortisone, my pain, severe at times, was not relieved until the trigger point of tenderness was injected with a refined steroid and local anesthetic. The local anesthetic permits the physician injecting the area a quick feedback as to whether he was in the correct area. As for me, I could tell my physician that he had hit it directly because the majority of my pain was relieved within 30 to 45 seconds. Over the next few days, the pain dissipated and disappeared totally.

Although these neuritis problems are not seen routinely, they can be diagnosed and often successfully treated.