J Neurol Surg A Cent Eur Neurosurg 2021; 82(05): 494-499
DOI: 10.1055/s-0040-1719109
Case Report

Entrapment of the Greater Occipital Nerve with Chronic Migraine and Severe Facial Pain: A Case Report

Byung-chul Son
1   Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seocho-gu, Seoul, the Republic of Korea
› Author Affiliations


Migraine is thought to be a primary neurovascular headache due to brain dysfunction and is known to involve peripheral and central sensitization. A female patient with chronic migraine symptoms for 30 years reported severe pain in the deep ear and face. This headache always showed the same pattern and temporal progression. The sudden onset of ache and throbbing pain in the right temporo-occipital area extended to the left temporo-occipital areas. She felt sick as if the head would burst, and nausea and vomiting occurred. During the last 3 years, the patient endured sharp pain in bilateral deep ears and severe pain in the face as if all the facial bones were broken, and tears flowed. Chronic disabling headache and facial pain improved with the decompression of the greater occipital nerve. This case suggests that peripheral sensitization may be related to the pathophysiology of migraine, especially in the migraine without aura.

Publication History

Received: 02 May 2020

Accepted: 08 June 2020

Article published online:
01 January 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

  • References

  • 1 Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders. 3rd edition. Cephalalgia 2018; 38 (01) 1-211
  • 2 GBD 2016 Headache Collaborators. Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 2018; 17 (11) 954-976
  • 3 Noseda R, Burstein R. Migraine pathophysiology: anatomy of the trigeminovascular pathway and associated neurological symptoms, cortical spreading depression, sensitization, and modulation of pain. Pain 2013; 154 (Suppl. 01) S44-S53
  • 4 Vanelderen P, Lataster A, Levy R, Mekhail N, van Kleef M, Van Zundert J. 8. Occipital neuralgia. Pain Pract 2010; 10 (02) 137-144
  • 5 Natsis K, Baraliakos X, Appell HJ, Tsikaras P, Gigis I, Koebke J. The course of the greater occipital nerve in the suboccipital region: a proposal for setting landmarks for local anesthesia in patients with occipital neuralgia. Clin Anat 2006; 19: 332-336
  • 6 Ducic I, Moriarty M, Al-Attar A. Anatomical variations of the occipital nerves: implications for the treatment of chronic headaches. Plast Reconstr Surg 2009; 123 (03) 859-863 , discussion 864
  • 7 Mosser SW, Guyuron B, Janis JE, Rohrich RJ. The anatomy of the greater occipital nerve: implications for the etiology of migraine headaches. Plast Reconstr Surg 2004; 113 (02) 693-697 , discussion 698–700
  • 8 Cesmebasi A, Muhleman MAP, Hulsberg P. et al. Occipital neuralgia: anatomic considerations. Clin Anat 2015; 28 (01) 101-108
  • 9 Lee CI, Son BC. Chronic craniofacial pain from entrapment of the greater occipital nerve misdiagnosed as chronic migraine, idiopathic odontalgia, and atypical facial pain. Nerve 2019; 5 (02) 78-82
  • 10 Son BC, Choi JG. Hemifacial pain and hemisensory disturbance referred from occipital neuralgia caused by pathological vascular contact of the greater occipital nerve. Case Rep Neurol Med 2017; 2017: 3827369
  • 11 Ko HC, Choi JG, Son BC. Hemifacial trigeminal pain referred from occipital neuralgia due to compression of the greater occipital nerve by the occipital artery. J Neurol Surg A Cent Eur Neurosurg 2018; 79 (05) 442-446
  • 12 Lee CI, Son BC. V2 trigeminal referred pain from chronic occipital neuralgia caused by entrapment of the greater occipital nerve. Indian J Neurosurg 2019; 8 (01) 76-80
  • 13 Tubbs RS, Salter EG, Wellons III JC, Blount JP, Oakes WJ. Landmarks for the identification of the cutaneous nerves of the occiput and nuchal regions. Clin Anat 2007; 20 (03) 235-238
  • 14 Baron EM. Spinal cord and spinal nerves: gross anatomy. In: Standring S. ed. Gray's Anatomy: The Anatomical Basis of Clinical Practice. 41st ed. London: Elsevier; 2016: 762-773
  • 15 Piovesan EJ, Kowacs PA, Tatsui CE, Lange MC, Ribas LC, Werneck LC. Referred pain after painful stimulation of the greater occipital nerve in humans: evidence of convergence of cervical afferences on trigeminal nuclei. Cephalalgia 2001; 21 (02) 107-109
  • 16 Bartsch T, Goadsby PJ. Stimulation of the greater occipital nerve induces increased central excitability of dural afferent input. Brain 2002; 125 (Pt 7): 1496-1509
  • 17 Bartsch T, Goadsby PJ. The trigeminocervical complex and migraine: current concepts and synthesis. Curr Pain Headache Rep 2003; 7 (05) 371-376
  • 18 Jakubowski M, McAllister PJ, Bajwa ZH, Ward TN, Smith P, Burstein R. Exploding vs. imploding headache in migraine prophylaxis with botulinum toxin A. Pain 2006; 125 (03) 286-295
  • 19 Olesen J, Burstein R, Ashina M, Tfelt-Hansen P. Origin of pain in migraine: evidence for peripheral sensitisation. Lancet Neurol 2009; 8 (07) 679-690
  • 20 Kosaras B, Jakubowski M, Kainz V, Burstein R. Sensory innervation of the calvarial bones of the mouse. J Comp Neurol 2009; 515 (03) 331-348
  • 21 Files JA, Schwedt TJ, Mayer AP. et al. Imploding and exploding migraine headaches: comparison of methods to diagnose pain directionality. Headache 2014; 54 (06) 1010-1018
  • 22 Perry CJ, Blake P, Buettner C. et al. Upregulation of inflammatory gene transcripts in periosteum of chronic migraineurs: implications for extracranial origin of headache. Ann Neurol 2016; 79 (06) 1000-1013
  • 23 Burstein R, Blake P, Schain A, Perry C. Extracranial origin of headache. Curr Opin Neurol 2017; 30 (03) 263-271
  • 24 Blake P, Nir RR, Perry CJ, Burstein R. Tracking patients with chronic occipital headache after occipital nerve decompression surgery: a case series. Cephalalgia 2019; 39 (04) 556-563
  • 25 England JD. Entrapment neuropathies. Curr Opin Neurol 1999; 12 (05) 597-602
  • 26 Kuhn WF, Kuhn SC, Gilberstadt H. Occipital neuralgias: clinical recognition of a complicated headache. A case series and literature review. J Orofac Pain 1997; 11 (02) 158-165
  • 27 Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988; 8 (07, Suppl 7): 1-96
  • 28 Headache Classification Committee of the International Headache Society. The classification of headache, 3rd edition (beta version). Cephalalgia 2013; 33 (09) 629-808