A consecutive series of 100 patients was studied to determine the prevalence of third occipital nerve headache in patients with chronic neck pain (> three months in duration) after whiplash. Seventy one patients complained of headache associated with their neck pain. Headache was the dominant complaint of 40 patients, but was only a secondary problem for the other 31. Each patient with headache underwent double blind, controlled diagnostic blocks of the third occipital nerve. On two separate occasions the nerve was blocked with either lignocaine or bupivacaine, in random order. The diagnosis of third occipital nerve headache was made only if both blocks completely relieved the patient's upper neck pain and headache and the relief lasted longer with bupivacaine. The prevalence of third occipital nerve headache among all 100 whiplash patients was 27% (95% confidence interval (95% CI) 18-36%) and among those with dominant headache the prevalence was as high as 53% (95% CI 37-68%). There were no distinguishing features on history or examination that enabled a definitive diagnosis to be made before the nerve blocks. Those patients with a positive diagnosis, however, were significantly more likely to be tender over the C2-3 zygapophysial joint (p = 0.01). Third occipital nerve headache is a common condition in patients with chronic neck pain and headache after whiplash. Third occipital nerve blocks are essential to make this diagnosis.
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"The third occipital nerve (TON), found over the C2/C3 joint, innervates a small patch of skin in the suboccipital area and is the only medial branch with a reliable cutaneous distribution. Its clinical importance lies in the mediation of cervicogenic headaches, a common and disabling condition . While CMBBs are often used to identify patients for thermo-radiofrequency procedures, they also possess an intrinsic therapeutic effect, providing pain relief for several weeks or months . "
"However, there were felt to be no clinical features by which pain from the TON can be diagnosed. The combination of an occipital headache and tenderness over the C2-C3 facet has an 85 % sensitivity, but collectively those clinical features have a positive likelihood ratio of only 2:1 when confirmed by diagnostic injections . "
[Show abstract][Hide abstract]ABSTRACT: The third occipital nerve (TON) is an under-recognized cause of occipital headaches and can sometimes cause headaches with similar characteristics to migraine headaches. Diagnosis is made by fluoroscopic injections of local anesthetic. Treatment for TON includes medications, nerve injections, cryoneuroablation, radiofrequency lesioning, neuromodulation, and surgical decompression.
"Lord et al. (1994) stated that the prevalence of TON headache among patients in whom headache is the predominant complaint after whiplash was as high as 53%. This suggests that third occipital neuralgia is the most common cause of headache in patients who experienced whiplash (Lord et al., 1994). Various therapies for the treatment of third occipital neuralgia exist giving clinicians a variety of nonsurgical options to treat their patients (Ashkenazi and Levin, 2004; Tobin and Flitman, 2009). "