The lesser occipital nerve (LON) originates from the ventral ramus of C2 and loops inferiorly to the spinal accessory nerve. It ascends along the posterior border of the sternocleidomastoid muscle, piercing the deep cervical fascia. The nerve then passes across the posterior edge of the sternocleidomastoid insertion and enters the supercial fascia of the scalp. It divides into three branches: the auricular, mastoid, and occipital branches [7, 8].

curves around the dorsolateral surfaces of C2 and C3, travelling along the semispi­nalis capitis muscle. It then turns dorsally at the C2 spinous process, piercing the semispinalis capitis, splenius capitis, and trapezius muscles. After exiting these muscles, the TON innervates a small cutaneous area just below the nuchal line. Additionally, the TON sends branches to the greater occipital nerve (GON) and lesser occipital nerve (LON) [7, 8].

Both structural and non-structural causes can lead to ON.Still, almost always it results from the compression or irritation of one of the nerves at one of several ana­tomic points, the great occipital nerve (GON) being responsible for the great major­ity of the cases. Anatomical variations, such as the course of the greater occipital nerve through the obliquus inferior capitis muscle, may lead to nerve compression. Other causes of compression of the occipital nerves include hypertrophic ligaments, brosis, and bone spurs [9].

Familial cases of ON are extremely rare but have been reported, with an autoso­mal dominant or X-linked inheritance pattern. These cases often involve neuralgia of multiple cranial nerves, suggesting potential peripheral sensory anastomoses or central convergence of afferent pathways [15, 16].

A 65-year-old female with a medical history of well-controlled arterial hyperten­sion and hypothyroidism presented to the headache clinic with complaints of severe, acute, stabbing pain in the right occipital region. The pain, which started approxi­mately 10months ago, initially occurred four times a week. However, over the last ve months, the frequency of the episodes increased to daily occurrences, often with multiple attacks per day, occasionally extending into the nighttime. The patient denied any positional inuence on the pain and reported no associated symptoms, though tenderness over the affected region was present most of the time. The patient had been treated with a combination of non-steroidal anti-inammatory drugs (NSAIDs), venlafaxine, pregabalin, and carbamazepine, but none provided signi­cant relief. Occipital nerve blocks with lidocaine offered temporary pain relief.

The diagnosis of occipital neuralgia (ON) is primarily clinical, based on the pres­ence of intermittent, typically unilateral, painful episodes of stabs in the occipital region. However, bilateral involvement can occur in some cases. The individual pain episodes can last seconds to minutes, and physical examination often reveals tender­ness over the affected occipital nerves [10, 17].

1. Recurring in paroxysmal attacks lasting from a few seconds to minutes

2. Severe in intensity

Inammation of the cervical spinal cord may present as occipital neuralgia, espe­cially when there are lesions at high levels of the cervical spine, such as C2, but is often associated with additional neurological decits, such as sensory or motor changes, that are not typical of ON [5, 21].

A thorough differential diagnosis is essential and can be supported by anesthetic occipital nerve blocks, which help conrm occipital neuralgia (ON) if pain relief is achieved [2, 22]. In addition, there are less common symptoms of ON that may be present and can be useful in distinguishing this condition from others:

Although pain is the predominant symptom, some patients may experience spasms in the cervical muscles, which can contribute to pain and stiffness in the region.

Acupuncture has been assessed in systematic reviews and meta-analyses, dem­onstrating signicantly higher efcacy compared to drug treatment alone. It is asso­ciated with a notable reduction in pain on the visual analogue scale and fewer adverse events [26].

Botulinum toxin A injection has emerged as a treatment with a relatively lower side effect prole compared to many other approaches. Recent trials have shown that it can result in a 50% or greater improvement in symptoms [10, 28].

In very refractory cases, surgical procedures such as occipital nerve decompression or neurectomy may be considered, but there are associated risks [11, 33, 34].

Occipital neuralgia is an uncommon but signicant cause of intense, paroxysmal, sharp headaches that typically last from seconds to minutes. These headaches are localized in the areas innervated by the greater occipital nerve (GON), lesser occipi­tal nerve (LON), or third occipital nerve (TON). The primary etiologies include anatomical, traumatic, iatrogenic, and vascular causes. Diagnosis is based on a thor­ough patient history, clinical examination, and a positive response to an anesthetic block of the occipital nerves. Other conditions may mimic occipital neuralgia and can also respond to nerve blocks, so these must be ruled out through careful clinical assessment and, if necessary, imaging studies. Conservative treatments, such as pharmacological therapy combined with physical therapy, are often effective. Minimally invasive interventions, such as occipital nerve blocks, can be both diag­nostic and therapeutic. In cases that are refractory to these treatments, additional options like radio frequency (RF) ablation or neuromodulation may be required for long-term relief. Surgical decompression, neurotomy, and neurolysis are considered last-resort options for particularly challenging cases.