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Cervicogenic headache, aka occipital neuralgia or C2 neuralgia, is a peripheral nerve irritation resulting in paroxysmal shooting or stabbing pain in the dermatomes of the greater occipital nerve (GON) or lesser occipital nerve (LON).  From its origin in the suboccipital region, the pain spreads throughout the upper neck, back of the head, and behind the eyes. The pain may be accompanied by hypoesthesia or dysesthesia in the affected areas. (1) The most common trigger is irritation or compression of the GON or LON in the suboccipital musculature (2), with the GON more frequently involved (90%) than the LON (10%) (3).

This blog will review a particularly helpful suboccipital nerve floss and provide some new information to help you differentiate suboccipital neuropathy from radiculopathy.

First, let’s check out this earlier video where Dr. Steele discusses the anatomic basis of cerviogenic headache and demonstrates a very useful suboccipital nerve floss to relieve cervicogenic headaches.

However, what if the nerve irritation is not a peripheral neuropathy, but rather a radiculopathy?

A recent article by Ko (2018) in the Asian Journal of Neurosurgery describes a compelling case that may offer additional options for stubborn cases.

“Here, we report a unique case of chronic temporo-occipital headache due to C3 radiculopathy — a 62-year-old male presented with a chronic left-sided temporo-occipital headache with a duration of 4 years. The headache was aching and pressure like in nature. It had a typical radiating pattern on every occasion. It started in the posterior temporal area above the ear. It then extended to retroauricular area, then suboccipital area, and lateral neck. No hypesthesia, allodynia, or limitation in neck motion was noted.

Myelographic CT revealed a left-sided C2/C3 foraminal stenosis. Subsequent foraminotomy and decompression of the left C3 completely alleviated the chronic left-sided temporo-occipital headache. The present case might be a typical example of “headache attributed to upper cervical radiculopathy” (A11.2.4) rather than cervicogenic headache according to the International Classification of Headache Disorders.” (4)

Although chiropractors may prefer to start with a less aggressive means of treatment, this paper by Ko reminds us that suboccipital pain may arise from within the IVF. Cervical spondylosis is a common age-related degenerative change, eventually triggering nerve root irritation and compression, resulting in head, neck, or upper extremity radicular signs and symptoms.  Neck stiffness is a common presenting complaint of cervical spondylosis; along with pain, paresthesia or numbness in the arm (99%), neck (80%), or shoulder & periscapular region (52%) (5). Suboccipital pain is also common, and headaches are present in 10-33% of cases (5,6).

Evidence-based chiropractors must spend the time to accurately identify and correct all of the variables associated with each diagnosis.

In practice, neurogenic symptoms typically arise from multiple sources of irritation or compression, including degeneration, posture, hypertonic muscles, habits, hobbies, and sports.  For example, Carpal Tunnel Syndrome may result from cumulative compression of the median nerve fibers at the intervertebral foramen, scalenes, pronator teres, and carpal tunnel. However, if we ride by on a fast horse and forget about the patient’s posture, job requirements, and sleep positions, we may not be treating all of the pertinent factors.  Lasting resolution of symptoms requires addressing all of the variables responsible for a condition’s etiology. 

A thorough understanding of progressive mechanical dysfunction is the foundation for management and patient education, regardless if you’re treating a neck, lumbar spine, or any other joint. ChiroUp subscribers employ an incredible tool that simplifies learning and patient education, but more importantly, allows like-minded, evidence-based peers to work together to redefine our role in healthcare. If you’re not yet part of this team, click HERE to start today at no cost.


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  1. Il Choi and Sang Ryong Jeon Neuralgias of the Head: Occipital Neuralgia J Korean Med Sci. 2016 Apr; 31(4): 479–488.
  2. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24(Suppl 1):9–160. [PubMed]
  3. Hammond SR, Danta G. Occipital neuralgia. Clin Exp Neurol. 1978;15:258–270.[PubMed]
  4. Ko HC, Son BC. Chronic Unilateral Temporo Occipital Headache Attributed to Unilateral C3 Radiculopathy. Asian J Neurosurg. 2018 Oct-Dec;13(4):1229-1232. doi: 10.4103/ajns.AJNS_197_17.
  5. Henderson CM, Hennessy RG, Shuey HM Jr, Shackelford EG. Posterior-lateral foraminotomy as an exclusive operative technique for cervical radiculopathy: a review of 846 consecutively operated cases. Neurosurgery. 1983;13:504-12.
  6. Heller JG. The syndromes of degenerative cervical disease. Orthop Clin North Am. Jul 1992;23(3):381-94.

About the Author

Dr. Brandon Steele

Dr. Brandon Steele


Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.

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