Paroxysmal pain may occur in the distribution of the greater or lesser occipital nerves (suboccipital, occipital, and posterior parietal areas). While tenderness may be localized to the region where these nerves cross the superior nuchal line, there is only questionable evidence of an occipital nerve lesion at this site. The finding of hypesthesia in the distribution of the occipital nerves makes the possibility of an entrapment neuropathy more convincing. Carbamazepine or gabapentin may provide some relief. Blocking the nerves with lidocaine may abolish the pain and encourage attempts to section one or more occipital nerves or the second or third cervical dorsal root, but the results of the sectioning procedure have had variable success, and several such patients who had these procedures were later referred to us with disabling anesthesia dolorosa. Experts advise repeated injections of local anesthetic agents and the use of steroids, botulinum toxin, and analgesic and anti-inflammatory drugs. The pain at times may be difficult to distinguish from that arising in the upper three cervical facet joints, one type of which is discussed below. The approach of treating migraine by injection of the occipital nerves, mentioned earlier, is controversial.
This condition, a unilateral occipital and suboccipital ache, may be a prominent symptom in patients with neck pain, particularly after neck injuries (a prevalence of 27 percent, according to Lord et al). Bogduk and Marsland attribute it to a degenerative or traumatic arthropathy involving the C2 and C3 facet joints with impingement on the “third occipital nerve” (a branch of the C3 dorsal ramus that crosses the dorsolateral aspect of the facet joint. Elimination of the neck pain and headache by percutaneous blocking of the third occipital nerve near the facet joint under fluoroscopic control is diagnostic and temporarily therapeutic. More sustained relief (weeks to months) has been obtained by radiofrequency coagulation of the nerve or steroid injections in and around the joint. NSAIDs also may provide some relief.
Carotidynia was coined by Temple Fay in 1927 to designate a special type of cervicofacial pain that could be elicited by pressure on the common carotid arteries of patients with atypical facial neuralgia. Compression of the artery in the neck in these patients, or mild electrical stimulation at or near the bifurcation, produced a dull ache that was referred to the ipsilateral face, ear, jaws, and teeth or down the neck. This type of carotid sensitivity occurs as part of cranial (giant cell) arteritis and of the rare condition known as Takayasu arteritis (Chap. 33), and during attacks of migraine or cluster headache. It has also been described with displacement of the carotid artery by tumor and dissecting aneurysm of its wall; among these causes, the last is of greatest concern. The idiopathic variety of carotidynia may have to do with a swelling or inflammation of the tissue surrounding the carotid bifurcation, a change that has been demonstrated on MRI by Burton and colleagues, but the problem has been seen most frequently in migraineurs.
Roseman has described a variant of carotidynia that has a predilection for young adults. This syndrome takes the form of recurrent, self-limited attacks of pain and tenderness at the carotid bifurcation lasting a week or two. Dissection of the carotid artery, as discussed below, is always a concern. During the attack, aggravation of the pain by head movement, chewing, and swallowing is characteristic. This condition is treated with simple analgesics. Yet another possible variety of carotidynia appears at any stage of adult life and recurs in attacks lasting minutes to hours in association with throbbing headaches indistinguishable from common migraine (Raskin and Prusiner). This form responds favorably to the administration of ergotamine and other drugs that are effective in the treatment of migraine.