Last updated: 2026-10-29
The Role of Injections and Manual Therapy in Treating Occipital Neuralgia
When you've been diagnosed with occipital neuralgia and are weighing injections against manual therapy, the two treatments have clearly distinct roles. Ultrasound-guided occipital nerve block injections are given around the greater occipital nerve to calm the pain signals the nerve sends, while manual therapy addresses muscle tension and restricted movement around the upper cervical spine and the jaw joint (temporomandibular joint) by hand.
We often see office workers in their 40s who stare at a monitor all day come in with a shooting, electric-shock-like pain on one side of the back of the head, hear the diagnosis of occipital neuralgia, and ask whether they should get injections or manual therapy.
Cervicogenic headache and occipital neuralgia are both related to upper cervical spine structures, so the location and pattern of pain running from the back of the head into the neck overlap between the two conditions.(Lefel Nicole et al., 2024) An injection placed around the nerve lowers the signaling of the overexcited nerve, reducing pain in the short term. Manual therapy, in turn, releases the accompanying tension in the neck muscles and the restricted movement of the joints by hand.(PMID 38958920) In treating occipital neuralgia, we perform ultrasound-guided occipital nerve block injections and manual therapy for the upper cervical spine and jaw joint together, tailored to each patient's condition.
Inserting the Needle While Viewing Nerve Location on Ultrasound
Ultrasound shows nerves, blood vessels, and muscles directly without using radiation, which is why it is used for nerve blocks in the head and neck region.(Li Jinlei et al., 2021) During the procedure, the clinician first locates the greater occipital nerve and the blood vessels and muscle layers running alongside it on the ultrasound image, then injects the target point around the nerve while directly watching the position of the needle tip.
In a randomized clinical trial of 32 patients with occipital neuralgia and cervicogenic headache, the group that received an ultrasound-guided block at the level of the second cervical vertebra (C2) showed a 2.5-point reduction in pain score 4 weeks after the procedure, and no serious adverse effects were reported in this trial.(Kissoon Narayan R et al., 2022) Right after the block injection, the scalp at the back of the head—the area supplied by the greater occipital nerve—may feel temporarily numb or dull, a response that indicates the injection properly reached the area around the targeted nerve.(Blumenfeld Andrew et al., 2013)
If the electric, shooting pain decreases after the injection, this response serves as supporting evidence that the occipital nerve is actually involved in the back-of-head pain the patient is currently experiencing.(Lefel Nicole et al., 2024) To keep the procedure safe, before the injection the clinician checks whether the patient is taking antiplatelet or anticoagulant medication, whether the patient is pregnant, any history of drug allergies, any past fainting during injection procedures, and any history of skull surgery.(Blumenfeld Andrew et al., 2013)
If the Back of the Neck Stays Stiff Even After the Pain Subsides
The greater occipital nerve branches mainly from the second cervical (C2) nerve, passes between the deep muscles at the back of the neck, and runs up to the scalp.(Li Jinlei et al., 2021) The muscles around the upper cervical spine support the weight of the head and take part in rotation and flexion movements; when these muscles are tight, they also place a burden on the nerve that runs between them. Jaw joint movement and the activity of the chewing muscles are also anatomically and functionally connected to the activity of the neck muscles. So a habit of keeping the head bent forward for long periods, or unconsciously clenching the jaw, keeps the muscles at the back of the neck and around the jaw in continuous tension.
If the back of the neck remains stiff, or a catching sensation when turning the head remains, even after an injection has calmed the sharp, shooting pain, the tension and alignment of the surrounding structures need to be examined as well. We take X-rays of the jaw joint and cervical spine to check the alignment of the bones, and a neurologist evaluates the alignment of the jaw joint and upper cervical spine (C1, C2) before performing correction. Alongside this, TMJ cranial nerve manual therapy releases the excessive tension in the muscles around the jaw.
In a clinical trial of 200 patients with cervicogenic headache, improvements in headache frequency and intensity in the group that received manual correction were maintained through the 12-month follow-up.(Jull Gwendolen et al., 2002)
When Doing Both Together, Which Comes First?
Conservative management of occipital neuralgia addresses both immediate pain relief and the secondary muscle tension and postural problems that come with it.(Lefel Nicole et al., 2024) The decision to start with injection therapy or manual therapy depends on how often and how intensely the patient feels the sharp pain, and how much the neck can currently move.
When even a light touch sends a sharp jolt through the back of the head, making it hard to turn the neck, or when the pain is severe enough to wake the patient at night, an ultrasound-guided occipital nerve block comes first to calm the pain. Severe pain causes the muscles to contract defensively, which greatly limits how far the neck can move during manual therapy. Once the sharp pain eases after the injection, we re-examine the remaining restriction in neck movement and muscle tension to determine the specific scope of manual therapy.
On the other hand, if the electric-shock-like sharp sensation appears only intermittently and the main complaint is a persistent heaviness and stiffness in the back of the neck or pulling pain when turning the head, manual therapy addressing the accompanying muscle tension and restricted movement is considered first.(PMID 38958920) When both treatments are combined, the interval between the injection and manual therapy is decided individually, based on changes in scalp sensation after the procedure, the condition of the injection site, and how much neck movement the patient can tolerate.
How Many Times Can Nerve Blocks Be Given?
Block injections given around the occipital nerve improve symptoms, but the pain relief is usually temporary, so when the pain returns over time, a repeat injection may be considered.(Choi Il et al., 2016) There is no fixed interval or number of repeat injections; the decision depends on the patient's specific indications and on how long pain relief lasted after the previous injection.(Blumenfeld Andrew et al., 2013)
If the pain subsides after an injection but the same area keeps developing a shooting or tingling sensation, it's important to check whether the surrounding cause irritating the nerve is still present. In that case, we re-examine the tension in the posterior neck muscles, reassess the alignment of the upper cervical spine and the temporomandibular joint, and adjust the balance between correction and relaxation treatment accordingly.
On the other hand, even when the pain is in the back of the head, if it starts suddenly and severely, as though struck by a hammer or bursting, or comes together with limb paralysis, fever, altered consciousness, or slurred speech, this points away from a peripheral nerve problem and requires ruling out central nervous system conditions such as cerebrovascular disease or infection. In that case, emergency evaluation should be sought without delay.
References
- Lefel Nicole, van Suijlekom Hans, Cohen Steven P C (2024). 11. Cervicogenic headache and occipital neuralgia.. Pain Pract. PMID: 39219023
- Deuel D, Sandgren A, Nelson EO (2024). Conservative Management of Occipital Neuralgia Supported by Physical Therapy: A Review of Available Research and Mechanistic Rationale to Guide Treatment.. Curr Pain Headache Rep. PMID: 38958920
- Li Jinlei, Szabova Alexandra (2021). Ultrasound-Guided Nerve Blocks in the Head and Neck for Chronic Pain Management: The Anatomy, Sonoanatomy, and Procedure.. Pain Physician. PMID: 34793642
- Kissoon Narayan R, O'Brien Timothy G, Bendel Markus A (2022). Comparative Effectiveness of Landmark-guided Greater Occipital Nerve (GON) Block at the Superior Nuchal Line Versus Ultrasound-guided GON Block at the Level of C2: A Randomized Clinical Trial (RCT).. Clin J Pain. PMID: 35132029
- Blumenfeld Andrew, Ashkenazi Avi, Napchan Uri (2013). Expert consensus recommendations for the performance of peripheral nerve blocks for headaches--a narrative review.. Headache. PMID: 23406160
- Jull Gwendolen, Trott Patricia, Potter Helen (2002). A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache.. Spine (Phila Pa 1976). PMID: 12221344
- Choi Il, Jeon Sang Ryong (2016). Neuralgias of the Head: Occipital Neuralgia.. J Korean Med Sci. PMID: 27051229
Frequently Asked Questions
Q. What should you watch out for when your scalp feels numb after an occipital nerve block?
Right after the injection, while the area still feels numb, avoid rubbing it hard or applying a hot compress. Watch to see whether the sensation returns, and if the numbness lasts longer than the expected time you were told, or spreads to a wider area, have the injection site and the sensory change examined.
Q. Can you receive an occipital nerve block injection and manual therapy on the same day?
Whether to combine both on the same day depends on how the pain changes after the injection, the neck's range of motion, and whether discomfort such as dizziness is present. At THE WELLS Jamsil, we check the patient's condition after the injection before deciding whether to proceed with manual therapy and at what intensity, and if any discomfort is present, we confirm recovery first.
Q. Do you evaluate the jaw joint and upper cervical spine even without jaw pain?
Even without jaw pain, we include the jaw joint and upper cervical spine in the evaluation if there is a habit of clenching the teeth, discomfort when opening the mouth, or limited neck movement. THE WELLS Jamsil asks about these symptoms and habits, examines the jaw and neck, and then determines which areas need further testing and treatment.
Q. What if the pain comes back after an injection? When should I schedule a follow-up visit?
If the pain wakes you up at night or starts interfering with work or neck movement, move up your scheduled follow-up and get examined sooner rather than waiting. Before that visit, keep a record of how long the pain had been reduced, the date it started again, and its location and intensity — this information helps determine the treatment plan going forward.