The Anatomy of the Occipital Nerves and Their Function

The back of your head gets its feeling from a small group of nerves that rise out of the top of the neck, not from the nerves that serve the face. They pass through layers of neck muscle on their way up, and those crossing points are where many cases of back-of-the-head pain are thought to start.1PubMed Central. Emerging evidence of occipital nerve compression in unremitting head and neck pain Their signals also end up in the same part of the brainstem as the face’s pain nerve, which is why trouble in the neck can be felt as a headache behind the eye or across the forehead.2PubMed Central. Understanding Cervicogenic Headache

The Four Occipital Nerves at a Glance

Three of these nerves carry touch and pain from the skin. The suboccipital nerve works muscles rather than reporting feeling. So numbness or pain on the scalp usually points to the greater, lesser or third nerve, while trouble with the suboccipital nerve tends to show up as stiffness or weakness in the small movements that steady the head. Each side of the head has its own set.

All of them branch from the spinal nerves of the top three neck vertebrae, C1 to C3.7PubMed Central. Neural tension patterns during cervical spine rotation: diagnostic implications from a cadaveric study The greater occipital nerve comes mainly from the second neck nerve, C2, and carries both feeling and some muscle fibers.8Kenhub. Occipital nerves

The main landmark doctors use to find these nerves is the bony bump you can feel at the center of the back of your skull. Another is the bone you can feel just behind your earlobe. The greater nerve rises between these two points, nearer the center, and tenderness in that spot is often what a doctor checks first.

The Path of the Greater Occipital Nerve

The nerve begins deep, wrapping around the lower edge of a small muscle that turns the head.9PubMed Central. The Intramuscular Course of the Greater Occipital Nerve: Novel Findings with Potential Implications for Operative Interventions and Occipital Neuralgia From there it climbs underneath the thick semispinalis muscle, one of the long muscles beside the spine, before pushing through it.10PubMed Central. The Intramuscular Course of the Greater Occipital Nerve: Novel Findings with Potential Implications for Operative Interventions and Occipital Neuralgia It typically pierces that muscle about 1.3 cm out from the center line and about 2.8 cm below the skull bump.11PubMed Central. Stereotactic topography of the greater and third occipital nerves and its clinical implication Next it passes through the trapezius, the large muscle at the top of the shoulders and neck, mostly through its flat tough tendon sheet.12PubMed Central. The Intramuscular Course of the Greater Occipital Nerve: Novel Findings with Potential Implications for Operative Interventions and Occipital Neuralgia In one larger survey, about 3 in 4 sides followed this most common pattern.13PubMed Central. Morphological features of the greater occipital nerve and its possible importance for interventional procedures

The route is not identical in everyone. It varies from person to person and even from side to side, and some nerves pass through muscle where others go through tendon sheet. That variation is normal and not a disease.

Each place the nerve goes through muscle is a tight spot. A nerve has a tiny blood supply, and steady pressure from tense or injured muscle can limit it. A nerve under pressure can fire signals it should not, which is why people describe burning, shooting or electric sensations felt in the scalp the nerve supplies.

Once under the skin, the nerve travels next to the occipital artery, which supplies blood to the back of the scalp.14Kenhub. Occipital nerves Its branches spread out like a fan, with most of them going upward and outward toward the top and side of the head.15PubMed Central. Anatomical analysis of the distribution patterns of occipital cutaneous nerves and the clinical implications for pain management

The Lesser and Third Occipital Nerves

The third occipital nerve sits about 3 mm out from the center line, below the bump at the back of the skull.16PubMed. Anatomical study of the third occipital nerve and its potential role in occipital headache/neck pain following midline dissections of the craniocervical junction It reaches the skin about 5 cm below that bump, close to the strong ligament at the back of the neck.17PubMed. Anatomical study of the third occipital nerve and its potential role in occipital headache/neck pain following midline dissections of the craniocervical junction In about two-thirds of people, it also sends branches to a small joint in the upper neck spine.18PubMed. Anatomical study of the third occipital nerve and its potential role in occipital headache/neck pain following midline dissections of the craniocervical junction That joint can become painful from arthritis or injury, and because it shares this nerve with the central scalp, joint pain can be felt as a headache at the back of the head.

In about two-thirds of people, small branches also cross the center line to link up with the other side’s nerve.19PubMed. Anatomical study of the third occipital nerve and its potential role in occipital headache/neck pain following midline dissections of the craniocervical junction The nerves on the two sides are therefore partly connected, and the boundary between left and right feeling is not a sharp line.

The lesser occipital nerve is far thinner than the greater nerve but can still be seen on ultrasound.20PubMed. The lesser occipital nerve visualized by high-resolution sonography–normal and initial suspect findings Its location in the neck makes it vulnerable to being squeezed or stretched, which is linked to head and face pain.21Clinical Anatomy. Anatomy of the lesser occipital nerve in relation to cervicogenic headache

Location gives hints about which nerve is involved. Pain near the center of the upper neck points to the third nerve, pain behind and above the ear points to the lesser nerve, and pain over the back and top of the head points to the greater nerve. The areas overlap, so a doctor examines rather than guessing from the location alone.

Where the Nerves Get Pinched

Six possible pressure points have been mapped along the greater occipital nerve.22PubMed Central. Morphological features of the greater occipital nerve and its possible importance for interventional procedures The first three are where it rounds the deep head-turning muscle, pierces the semispinalis, and goes through the trapezius.23PubMed Central. Morphological features of the greater occipital nerve and its possible importance for interventional procedures The other three are where it crosses the occipital artery, which in some people happens up to three times.24PubMed Central. Morphological features of the greater occipital nerve and its possible importance for interventional procedures

One theory holds that pressure on the nerve slowly inflames it.25PubMed Central. Emerging evidence of occipital nerve compression in unremitting head and neck pain A blow to the back of the head or a stretch injury can make this worse.26PubMed Central. Emerging evidence of occipital nerve compression in unremitting head and neck pain Swelling and muscle spasm may then press on it further, keeping the pain going.27PubMed Central. Emerging evidence of occipital nerve compression in unremitting head and neck pain A short squeeze usually passes when the pressure is released, but a nerve that stays under pressure can become more sensitive. Once sensitized, it can react to touches that are normally painless, which is why light contact with the scalp may hurt.

This pain is called occipital neuralgia: burning or aching attacks along these nerves, first described in 1821.28PubMed. Occipital neuralgia: anatomic considerations It often starts as shooting, burning or aching pain at the base of the skull, usually on one side, sometimes spreading toward the top of the head. The scalp may feel tender to light touch, like brushing hair, and pressing over the nerve may bring the pain on.

Turning the head increases tension on the upper neck nerves on the side you turn toward.29PubMed Central. Neural tension patterns during cervical spine rotation: diagnostic implications from a cadaveric study Everyday habits can add strain: long periods of looking down tighten the back neck muscles, sleeping with the neck twisted may stretch these nerves, and pressure on the back of the head, such as a hard headrest, may provoke pain. These are patterns worth mentioning to your doctor.

Why Neck Nerves Can Cause Pain Behind the Eye

Signals from the greater occipital nerve and from the trigeminal nerve, which carries pain from the face and the brain’s coverings, arrive at the same nerve cells at the top of the spinal cord.30Headache Currents. Anatomy and Physiology of Pain Referral Patterns in Primary and Cervicogenic Headache Disorders The brain can’t always tell which source the pain is coming from,31PubMed Central. Understanding Cervicogenic Headache so pain starting in the neck can spread to the eye, forehead and temples.32PubMed Central. Understanding Cervicogenic Headache Painfully stimulating the greater occipital nerve in people produced pain felt in the face’s territory.33PubMed. Referred pain after painful stimulation of the greater occipital nerve in humans: evidence of convergence of cervical afferences on trigeminal nuclei This referred pain is a normal feature of how the nervous system is wired, not something imagined.

When a headache comes from the neck in this way, doctors call it a cervicogenic headache, and bad posture or pressure on the neck can set it off repeatedly.34PubMed Central. Understanding Cervicogenic Headache Many people assume a forehead headache must be sinus-related, but referred pain from the neck can feel identical. Pain that changes with neck position is one clue pointing to the neck, though not proof on its own. Pain felt in the eye may not come from the eye, so a doctor may press on the back of the head to see if it reproduces the frontal pain.

How Nerve Blocks Use This Anatomy

An occipital nerve block is an injection of numbing medicine, often with a steroid, around one of these nerves.35PubMed Central. Effectiveness of treatment of occipital neuralgia using the nerve block technique: a prospective analysis of 44 patients For the common version, the needle goes in about 1.5 to 3 cm out from the center and 1 to 2 cm below the skull bump.36PubMed Central. Nerve blocks for occipital headaches: A systematic review and meta-analysis The nerve lies just inside the occipital artery, which the doctor can feel as a pulse about 2 cm from the center.37PubMed Central. Occipital nerve block for headaches: a narrative review Ultrasound lets the doctor see the nerve, which is about 4 mm wide and under 1 to 2 cm of tissue.38PubMed. Sonographic visualization and ultrasound-guided blockade of the greater occipital nerve: a comparison of two selective techniques confirmed by anatomical dissection

In a typical appointment you sit or lie face-down with your head bent slightly forward. The skin is cleaned and a thin needle is used. The doctor pulls back on the syringe before injecting to make sure the needle isn’t in the artery.39PubMed Central. Occipital nerve block for headaches: a narrative review You may feel brief pressure and then numbness over the scalp, and most people go home the same day.

Pain often eases 20 to 30 minutes after the injection,40PubMed Central. Occipital nerve block for headaches: a narrative review and relief can last from several weeks to several months.41PubMed Central. Occipital nerve block for headaches: a narrative review A deeper injection near the second neck vertebra, done with ultrasound, gives longer relief at 1 to 2 months than the scalp-level version.42PubMed Central. Occipital nerve block for headaches: a narrative review Ultrasound guidance reduces side effects and raises the chance the block works.43PubMed Central. Occipital nerve block for headaches: a narrative review

If numbing the nerve quickly reduces the pain, that suggests the nerve is part of the pain pathway. If there is little or no relief, the pain may come from another source, though a block can also miss the nerve, so the doctor weighs this with other findings. A nerve block is therefore sometimes used as a test as well as a treatment.

When Blocks Aren’t Enough

Release surgery frees the nerve where it passes through the semispinalis, trapezius and deep head-turning muscle.44PubMed Central. Peripheral Occipital Nerve Decompression Surgery in Migraine Headache Surgeons often remove small pieces of muscle, tie off nearby arteries and pad the nerve with tissue.45PubMed Central. Peripheral Occipital Nerve Decompression Surgery in Migraine Headache The padding is meant to cushion the nerve so it is not squeezed again. In a small number of reported cases, all three sensory nerves were released through a single vertical cut at the back of the neck.46PubMed Central. Single midline incision approach for decompression of greater, lesser and third occipital nerves in migraine surgery

Good but short relief from a nerve block suggests the nerve is the pain source, and that result is often used before considering surgery. These are options for long-lasting pain, not a first step. Midline neck surgery can stretch the third occipital nerve, and numbness of the scalp can follow nerve work. It is reasonable to ask the surgeon how many such operations they perform.

Occipital nerve stimulation uses a small implanted device to send gentle electrical pulses to these nerves. How it works is unclear, though it may slowly rebalance the brain’s pain system.47PubMed Central. Occipital nerve stimulation in primary headache syndromes It involves thin wires placed near the nerve under the skin and a small battery pack, and it needs to be tested before being left in place. Because it is a device, it can be switched off or adjusted, and it is generally considered after less invasive options.