Chronic Craniofacial Pain from Entrapment of the Greater Occipital Nerve Misdiagnosed as Chronic Migraine, Idiopathic Odontalgia, and Atypical Facial Pain

Abstract

Although the cause of occipital neuralgia is mostly unknown, entrapment of the greater occipital nerve (GON) at its piercing point of the tendinous aponeurotic attachment of the trapezius at the superior nuchal line has been reported to be the most common cause. We report an occurrence of unilateral facial pain associated with continuous aching and stabbing headache in the frontotemporal and occipital regions in a patient whose occipital neuralgia has lasted for years. These symptoms were completely different from those of typical occipital neuralgia, making diagnosis very difficult. A 52-year-old male patient with a 6-year history of intermittent stabbing pain in his right suboccipital area presented with an unremitting continuous pain in his right frontotemporal and malar areas that lasted 5 months. The aching and stabling pain in his frontotemporal and malar areas developed suddenly 5 months prior to presentation. Although he was treated after visiting neurology, dentistry, opthalmology, ENT, and pain clinic, the pain was not controlled. It spread to right periorbital and right occipital areas. At 3 months following decompression of the right GON, he reported no more pain and was able to stop the medication. Until 12 months after the operation, his craniofacial pain did not recur.

Referred Trigeminal Facial Pain from Occipital Neuralgia Occurring Much Earlier than Occipital Neuralgia

“…Although it has been suggested that the pain of occipital neuralgia can reach the frontoorbital (V1) area through trigeminocervical interneuronal connections in the trigeminal spinal nucleus [1], reports of referred trigeminal pain from occipital neuralgia are rare [2]. However, recently, pain referred to the facial trigeminal nerve distribution by occipital neuralgia due to GON entrapment has been reported [2][3][4][5]. Referral to the facial trigeminal distribution occurred not only in the V1 region but also in the V2 and V3 regions and even caused hemifacial sensory changes [2][3][4][5].…”

“…ese aspects made the diagnosis very difficult. e natural course of untreated occipital neuralgia due to chronic entrapment of the GON remains unknown [5].…”

“…However, recently, pain referred to the facial trigeminal nerve distribution by occipital neuralgia due to GON entrapment has been reported [ 2 – 5 ]. Referral to the facial trigeminal distribution occurred not only in the V1 region but also in the V2 and V3 regions and even caused hemifacial sensory changes [ 2 – 5 ]. The referred trigeminal facial pain was immediately improved by decompression of the GON.…”

“…The referred trigeminal facial pain was immediately improved by decompression of the GON. In the previous reports, the nature of the referred facial trigeminal pain caused by GON entrapment showed continuous aching pain and occurred months after the symptoms of occipital neuralgia [ 2 – 5 ]. However, the authors experienced a very rare case where referred facial trigeminal pain appeared in the form of severe paroxysmal stabbing pain in the preauricular temporal area rather than aching pain.…”

“…The natural course of untreated occipital neuralgia due to chronic entrapment of the GON remains unknown [ 5 ]. The GON originates from the medial branch of the dorsal rami of the second cervical nerve root [ 6 – 9 ].…”