symptom.
In general, the pain in occipital neuralgia can be described as continuous or intermittent, severe, sharp, burning or stabbing pain, and usually is localized to a particular nerve distribution. In many cases, these spiking, sharp, and painful attacks are triggered by apparently insignificant stimulation( such as a simple touch, a whiff of air, cold or hot temperatures) to the affected area or even by subtle neck or head motion. Some patients may describe specific trigger zones at which stimulation immediately triggers a painful attack – such as rubbing an area of the neck. In most cases, there is no observed neurological damage. Occasionally, patients with occipital neuralgia may show signs of allodynia, which is pain due to a stimulus that does not normally provoke pain( pressure from clothing or a gentle massage); or of dysesthesia, which is an unpleasant, abnormal sense of touch.
TYPES OF TREATMENT
Patients with acute occipital neuralgia may benefit from local application of heat or cold. A short course of muscle relaxants and nonsteroidal anti-inflammatory medications( NSAIDs) may be of great value. Ultimately, an occipital nerve block, administered by a physician, may be helpful for both diagnostic and therapeutic efforts. In some cases in which the patient is experiencing frequent, severe lancinating, painful spasms – which may be quite disabling – this interventional approach should not be reserved as a last treatment option. Occipital nerve block procedure may be very effective and safe and could be easily and safely performed by a trained physician in a non-hospital setting. This procedure may provide prompt and lasting( for several weeks or even months) pain relief or in some cases even abort the disorder completely.
Unfortunately, occipital nerve block frequently provides only temporary pain relief, indicating the need for longterm treatment modalities.
Before initiation of long-term therapy, the health care provider must first assess the patient’ s behavioral inactivity patterns, emotional background, cognitive factors, sleep pattern, compliance, and existing conditions. Evaluation of these factors should help tailor potential therapy for the individual patient.
Overall, one of the most successful and effective medications in patients with occipital neuralgia is carbamazepine( Tegretol ®). Treatment usually starts at a dose of 100 mg per day which may be increased by 100 mg increments every 2 to 3 days, to a maximum of 1200 mg. per day, as tolerated. Sedation and dizziness are the most common side effects. Because one of the rare side effects is aplastic anemia, the patient will need frequent monitoring of the carbamazepine serum levels as well as other routine blood tests( complete blood count and comprehensive metabolic panel).
If initial therapy with carbamazepine did not produce significant pain relief, other treatment options should be considered. For example, patients with a history of depression and insomnia may benefit from the use of tricyclic antidepressants, such as amitriptyline or nortriptyline. Patients with a history of depression who do not report a significant sleep disturbance but do experience difficulty staying active during the day, may benefit from another tricyclic antidepressant – protriptyline – which typically does not produce sedation.
Patients with coexisting fibromyalgia or diabetes may also benefit from tricyclic antidepressant use. Alternatively, these patients may be considered for treatment with certain membrane stabilizers such as gabapentin and pregabalin. Patients with coexisting migraine may benefit from topiramate and valproic acid
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