13.4 Occipital neuralgia

Identification: 38-year-old female patient with cervical and occipital pain for 5 months.

History of Present Illness:
Characteristics of Pain:
Location:
- Unilateral (right) in the occipital region
- Radiation to ipsilateral parietal and orbit

Type:
- Paroxysms of "stabbing" or "electric shock" (seconds to minutes)
- Intensity 8-9/10 (VAS)
- Frequency: 10-30 episodes/day

Triggers:
- Pressure on the emergence point of the greater occipital nerve (2cm below the inion)
- Cervical movements (especially rotation)
- Hair tied up or wearing a tight hat

Associated Symptoms:
- Scalp hypersensitivity (allodynia)
- Mild nausea during intense attacks (no vomiting)

Relevant History:
- Cervical trauma in a car accident 6 months ago (whiplash)
- No history of migraine or primary headache

Physical/Neurological Examination:
Cervical Palpation:
- Pain reproduced with pressure on the greater occipital nerve (positive Tinel's sign)
- Spasm of the ipsilateral semispinalis capitis muscle

Sensory Examination:
- Hypoesthesia in "shotgun" distribution in the occipital territory
- Hyperpathia when brushing hair

General Examination:
- Reduced cervical range of motion (right rotation 60%)
- No motor deficits or abnormal reflexes

Complementary Exams:
Cervical MRI:
- Compression of the greater occipital nerve by hypertrophy of the semispinalis muscle
- No significant disc protrusions

Dynamic Ultrasound:
- Reduction of perineural space during contralateral rotation

Diagnostic Block:
- Infiltration with local anesthetic (lidocaine 2% + triamcinolone) → complete relief for 48h