Kinds of headache we see
A headache that keeps coming back usually falls into one of a few groups, and the history and exam are what separate them.
- Tension headache. A dull, pressing, band-like ache on both sides of the head, often worse late in the day and tied to neck and shoulder tightness, stress or poor sleep. When it happens more than 15 days a month it is chronic tension headache.
- Migraine. Throbbing pain, usually one-sided, lasting hours to days, with nausea, sensitivity to light and sound, and sometimes visual aura. Chronic migraine means 15 or more headache days a month.
- Occipital neuralgia. Pain that starts at the base of the skull and shoots up over the back of the head, sometimes to behind the eye. It is sharp, stabbing or electric rather than throbbing, and the scalp can be tender to touch. Pressing on the occipital notch, where the nerve leaves the skull, reproduces the pain.
- Medication overuse headache. Daily or near-daily headache in someone taking pain relievers most days. Common, and frustrating, because the treatment is often to take less.
Pain at the back of the head can be occipital neuralgia, a neck problem referring pain upward (cervicogenic headache), or migraine felt there. Each is treated differently.
Occipital neuralgia or migraine? Why the difference matters
The two are confused often, and some patients have both. The neurologist looks at the character of the pain (stabbing and brief versus throbbing and prolonged), where it starts, whether there is nausea or light sensitivity, and whether pressing on the occipital nerve at the base of the skull sets it off. A diagnostic occipital nerve block settles it in many cases: if numbing the nerve stops the pain, the nerve is the source.
Getting this right changes the plan. Occipital neuralgia responds to nerve blocks and treatment of the neck muscles that irritate the nerve, and migraine preventives do little for it. Chronic migraine, on the other hand, may qualify for Botox, which is not a treatment for occipital neuralgia on its own.
How our neurologists treat it
- Occipital nerve blocks: a small injection of local anesthetic, usually with a steroid, around the greater and lesser occipital nerves. Relief can last weeks to months, and the block is both a test and a treatment.
- Medication management: choosing the right preventive and rescue medication, and tapering pain relievers when overuse is part of the problem.
- Trigger point injections for the tight bands in the neck and upper shoulder muscles that feed tension headache and irritate the occipital nerves.
- Botox for chronic migraine when the diagnosis is chronic migraine and preventive medications have not worked. We handle the prior authorization.
Does insurance cover it? Neurology consultations, follow-up visits, occipital nerve blocks and trigger point injections are covered by Medicare, Aetna, Blue Cross Blue Shield and Cigna when medically necessary. Some Medicare Advantage and HMO plans need a referral from your primary doctor before the first visit and prior authorization for injections, and our front desk handles both. Botox always requires prior authorization. Read more about insurance and self-pay.
What to expect
- Before you come in, count your headache days over the last month and bring any imaging and your medication list.
- At the consultation, the neurologist takes your history, examines you, including the neck and the occipital nerves, and tells you which type of headache you have and why.
- The plan may start with a nerve block or trigger point injection at that visit, a medication change, or imaging if the exam raises any concern.
- Follow-up is usually within four to eight weeks to measure the response and adjust.
Headaches that need urgent care
Go to the emergency room or call 911 rather than waiting for a clinic appointment if you have:
- A sudden, severe headache that peaks within a minute, the worst headache of your life.
- Headache with fever and a stiff neck.
- Headache after a fall or a blow to the head, especially if you take blood thinners.
- Headache with weakness or numbness on one side, trouble speaking, confusion or loss of vision.
How do I know if my headache is occipital neuralgia?
Pain starting at the base of the skull and shooting up the back of the head, sharp or electric rather than throbbing, with tenderness when you press just below the skull. Only an examination can confirm it, and a diagnostic nerve block is often the deciding test.
Can I have a nerve block at the first visit?
Often, yes. If the examination points clearly to occipital neuralgia and your plan does not require prior authorization for the procedure, the neurologist can do the block at the consultation. Otherwise it is scheduled once authorization comes through.
Can headaches come from my neck?
Yes. Arthritis, disc problems and muscle tightness in the upper neck commonly refer pain to the back of the head (cervicogenic headache). It is treated by addressing the neck, often with trigger point injections or nerve blocks. See our neck pain page.
Which clinic treats headaches?
Both. Neurology consultations, occipital nerve blocks, trigger point injections and Botox for migraine are offered at Davie for Broward County and at Boynton Beach for Palm Beach County.
Is an occipital nerve block covered by insurance?
Yes, when medically necessary. Medicare, Aetna, Blue Cross Blue Shield and Cigna cover it as an in-office procedure. Some Medicare Advantage and HMO plans require prior authorization, which the front desk submits for you before the appointment.