Electrical Dry Needling and Upper Cervical Mobilization for Occipital Neuralgia: a Case Report

Occipital neuralgia (ON), also known as Arnold’s neuralgia,1 was first described in 1821 as a debilitating condition affecting the occipital nerve that results in recurrent pain extending from the back of the neck to the forehead.2 While the prevalence of ON is not well established,3 3.2 in every 100,000 people in the Netherlands suffer from the condition.4 Moreover 5% of soldiers evacuated from combat operation in Iraq present with ON.5

The International Headache Society defines ON as a headache syndrome that consists of “unilateral or bilateral paroxysmal, shooting or stabbing pain in the posterior part of the scalp, in the distribution of the greater, lesser, and/or third occipital nerves, sometimes accompanied by diminished sensation or dysesthesia in the affected area and commonly associated with tenderness over the involved nerve(s).”6

Nerve irritation may be due to vascular, osteogenic, neurogenic and/or muscular etiology that is often the result of degeneration,7 trauma8 or surgery.9 ON is also associated with dysesthesia and/or allodynia on the scalp and/or hair and tenderness over the affected nerve branch.10 Trigger points often develop consistent with the C2 nerve distribution, particularly at the emergence of the greater occipital nerve (GON).11 Patients typically describe short bursts of severe sharp, shooting, or stabbing pain that can be temporarily eased with an anesthetic block of the affected nerve(s).6

Although variations exist, the GON plays a major role in Occipital Neuralgia in approximately 90% of cases.12 The GON runs transversely over the obliquus capitis inferior muscle, courses under the splenius capitis and cervicis, longissimus capitis, and semispinalis capitis before passing through the trapezius and sternocleidomastoid muscles at the superior nuchal line and terminating in various branches across the occiput.12

In 10% of patients with ON, the lesser occipital nerve (LON) may also be involved.13 While the GON and LON come from the dorsal and ventral rami of C2, respectively, the third occipital nerve (TON) is created from the dorsal rami of C3.14 The TON is thought to be rarely involved in patients with ON.12 However, it does provide afferents to the GON and LON and has been shown to generate pain in 27% of patients with whiplash and 53% of patients with primary headaches.15

Local anesthetic nerve blocks are commonly used to confirm occipital nerve involvement and rule out alternative pain generators in the cervical spine.7 While Botulinum toxin (Botox), lidocaine, bupivacaine, fentanyl, and/or steroids are commonly used to treat ON, some patients require occipital neurectomy, GON neurolysis, C2 ganglionectomy, C2 ganglion decompression, rhizotomy, and occipital nerve stimulation.16, 17 Integrated conservative measures include various oral medications, acupuncture, chiropractic, and physical therapy.7 However, there is a paucity of evidence on the effectiveness of physical therapy interventions for ON.18, 19

A number of studies suggest acupuncture may be effective for ON.20 In a recent case series, 56 patients with ON were successfully treated with acupuncture.21 While 31 patients reported complete recovery, 24 patients noted significant improvement of ON symptoms.22 In addition, a 2009 randomized controlled trial reported significantly better short-term and long-term outcomes following perineural needling compared to traditional acupuncture in patients with ON.23 Notably, the perineural treatment was 93.5% and 64.1% effective at short-term and long-term follow-up, respectively, while the control group was only 69.4% effective at short-term and 43.3% at long-term.24

While acupuncture and dry needling differ in their philosophy, terminology, and theoretical construct, both procedures use monofilament needles to treat neuromusculoskeletal conditions.25, 26 Although dry needling has gained popularity among Western-based healthcare practitioners in recent years,27 only a single case study has suggested that dry needling may be useful for patients with ON.28 While the patient reported an improvement on both the Neck Disability Index (NDI) and Headache Disability Index (HDI) scores following treatment, the dry needling was confined to trigger points in muscle associated with the neck, shoulder, and scapula.28


A 61-year-old female with a 6-month history of insidious headaches and neck pain was referred to physical therapy by her neurologist with a diagnosis of left-sided occipital neuralgia, which was verified by a local anesthetic diagnostic nerve block. The neurologist attempted four separate nerve blocks, but they only provided limited and temporary relief for less than 48-72 hours. MRI and radiographic imaging were also unremarkable. The patient reported left-sided posterior head and neck pain with cervical rotation, side bending, and flexion. The patient also reported being confined to her bed and recliner due to her condition, and she minimized the movement of her head to avoid pain.

The posterior cervical musculature was tender to palpation, and manual pressure to the left posterior upper cervical muscles consistently reproduced the patient’s symptoms. She rated her best and worst pain as 6/10 and 9/10 on the NPRS, respectively. Notably, the patient demonstrated 10 degrees of active left rotation, 20 degrees of active right rotation, 10 degrees of active right/left side bending, 25 degrees of active flexion, and 12 degrees of active extension. Passive range of motion was limited to active ranges secondary to guarding and pain response to light touch. Cranial nerves were intact and upper quarter/lower quarter myotomes, dermatomes, and reflexes were unremarkable. Vitals were within normal ranges.

On the day of evaluation, the patient scored an 82 on the HDI and a 42 on the NDI. A 29 point29 and 5.5 point30 improvement on the HDI and NDI, respectively, is considered a clinically meaningful change for patients that suffer from headaches.


Initial treatment included pain neuroscience education, gentle sub-occipital myofascial release, and instructions on repeated rotation and upper cervical chin nods in a pain-free range. The treating therapist also educated the patient on the use and possible benefits of dry needling for ON, and she consented to try the treatment during the next visit.

During the second treatment, the patient only received dry needling with both manual and electrical stimulation. Needles were inserted into the left upper cervical paraspinal muscles from C1-C3 at a depth of approximately 25 mm. Additionally, periosteal pecking was performed on the back of the occiput where teno-osseous insertions matched with the patient’s symptoms. In addition, needles were obliquely inserted into the occipitalis muscle to approximate perineural stimulation of the GON—i.e. BL9 and GB19 if using TCM acupoint nomenclature. All needles were manipulated bi-directionally to patient tolerance so as to elicit a sensation of aching, tingling, deep pressure, heaviness, or warmth.11, 12The needles were left in situ for 15-20 minutes with electrical stimulation (ES-160 electro stimulator ITO co.) using a continuous biphasic waveform set to a frequency of 2 Hz and pulse duration of 250 microseconds. The intensity of the electric stimulation was slowly increased until the patient described a stimulation that was “strong but not intolerable.” The patient was then sent home with an updated home program, which included pain-free, active cervical range of motion in all planes and light self-massage.

During the third treatment session, the patient again received electrical dry needling to the left upper cervical and posterior occiput region. In addition, general cervical distraction (10 repetitions held for 20 seconds) along with Maitland-style grade III PA and left unilateral PA mobilizations at C2 (3 sets for 30-second durations) were administered.


Immediately following the electrical dry needling during the second treatment session, the patient reported a 50% improvement in her upper neck and head pain symptoms and demonstrated a significant increase in range of motion. However, following the third treatment session, which consisted of electrical dry needling and upper cervical mobilization, the patient noted some post-treatment soreness. Nevertheless, the patient reported a full resolution of all symptoms two days later. Moreover, at the 1-month follow-up, the patient continued to report 0/10 neck and head pain on the NPRS and no functional limitation per the HDI and NDI.


This case report suggests that electrical dry needling and upper cervical mobilization may be a useful treatment strategy in patients with occipital neuralgia.  However, no cause and effect relationship can be established from a single case study. Well-designed randomized controlled trials are required to fully determine the additive potential of joint mobilization and electrical dry needling for this patient population.


Joshua Jones, DPT, OCS, Dip. Osteopractic
Clinical Coordinator, Harris Sports Medicine and Physical Therapy, Cullowhee, NC
Fellow-in-Training, AAMT Fellowship in Orthopaedic Manual Physical Therapy

Raymond Butts, PhD, DPT, MSc (NeuroSci), Dip. Osteopractic
Senior Faculty, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Louisville, KY

James Dunning, PhD, DPT, MSc (Manip Ther), FAAOMPT, Dip. Osteopractic
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Montgomery, AL


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