Expert opinion: greater occipital nerve and other anesthetic injections for primary headache disorders.

In his 1948 headache book, Harold Wolff described 3 types of occipital neuralgia.“The first and most common is characterized by a long-lasting (day, weeks, or months), more or less sustained aching of low or moderate intensity. It is commonly bilateral but may be unilateral. It is associated with stiffness of the muscles of the neck, tender points, often with muscle nodules, and with head tilting. . . . and results from the sustained contraction of skeletal muscle. It may be reduced in intensity or eliminated by procaine injection into the tender regions.” “A second type of occipital headache is characterized by recurrent attacks of high intensity pain with complete freedom from pain between attacks. The headache is of 2 to 36 hours’ duration, is usually unilateral in onset, but may spread to the opposite side. It is throbbing. . . . The headache is commonly associated with anorexia, nausea, and vomiting, and is occasionally preceded by visual scotomas and paresthesias of the extremities. It is promptly and dramatically modified by ergotamine tartrate. . . . Procaine injection into the region of the occipital artery may eliminate the headache. The interval between attacks and the intensity of attacks is modified by adjustments of life situations and changes in attitude.” “A third type of occipital headache is due to inflammation, injury, or pressure on the occipital nerves, upper cervical spinal roots or dorsal horn or root ganglions. . . .” Sixty years later, Wolff’s descriptions are still insightful. He even reported a novel treatment, occipital nerve block, for acute migraine (although misdiagnosed as occipital neuralgia).