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Occipital neuralgia?

  • 1.  Occipital neuralgia?

    Posted 06-23-2025 16:12

    I saw a particularly vexing patient today because of light sensitivity that seems disproportionate to the history and physical findings.  Athletic in appearance and previously active in soccer and golf.

     

    He now wears category 4, wraparound sunglasses pretty much all the time that he would not remove in my pretty dim exam room.  He could read 20/20 OD through them but needed to switch to his category 3 lenses to read 20/20 OS.  Part of my concluding remarks from the first visit 2 years ago:

     

                    "... structurally healthy eyes... generally healthy young man who has experienced intermittent head and eye pains that have been attributed to occipital neuralgia.  The onset of this condition is mysterious.  He has not sustained neck or head trauma and is not felt to have a generalized inflammatory condition.  His vision is excellent and his eyes are structurally healthy.  The uncorrected acuities are good with evidence of binocularity.  Spectacles are not needed."

     

     

    He would not remove his lenses for examination today.  So we talked for a while.

     

    He had disappeared into the world of neuro-optometry and vision therapy after our one and only meeting 2 years ago.  The ensuing optometry treatments that include various colored lenses and convergence exercises did not lessen his light sensitivity.  5 MRI studies to date all report normal head and neck structures.  The last study found some herniated discs in the thoracic region that he attributes to playing golf.  Mild neck flexion to read books seems to make his light sensitivity worse.  Reading from screens is too unbearable.  He anticipates, probably correctly, that reading from screens will be unavoidable at college.  His grades have always been great in high school and he is interested in language arts as a major in college, a curious interest for someone who says he does not like to read.  I don't think any consideration was ever given to a reading-based learning disorder.  Beyond recommending some dynamic plain films to study the cervical spine in various positions, I'm stumped.  A functional component remains a consideration.

     

    Any suggestions how to help me to help this young man would be appreciated.

     

    Cheers,

    Steven Kane



  • 2.  RE: Occipital neuralgia?

    Posted 06-23-2025 16:27
    I would test him for Bartonella using immunoblot, not standard testing which is far inferior. Igenex makes an excellent kit to do immunoblot testing.
    +=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=
    Scott Forman, MD
    Senior Fellow North American Neuro-ophthalmology Society

    Adult and Pediatric Neuro-ophthalmology
    Comprehensive Ophthalmology
    Functional Medicine













  • 3.  RE: Occipital neuralgia?

    Posted 06-23-2025 17:12

    Sounds like he needs systematic desensitization to light adaptation and migraine evaluation.

    Best,
    Drew





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  • 4.  RE: Occipital neuralgia?

    Posted 06-23-2025 17:25
    Aloha !

    Was a Shirmer test performed?

    Lee Klombers, MD
    Neuro-Oph, Adult Strab, Peds Ophth
    Retired






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  • 5.  RE: Occipital neuralgia?

    Posted 06-23-2025 18:37
    All,
    I have a patient with exactly the same symptoms- incapacitating “white noise” to vision, except this patient is NLP in one eye from endophthalmitis in remote past and HM other eye from glaucoma.
    She is begging to be “back to Glaucoma darkness “
    We have done anti seizure meds and now will try Botox.
    She had + enolase and was treated with steroids and plex but got only momentary relief, if any.
    What is light desensitization therapy?
    Thank you for any thoughts from your experience.

    Martha Schatz
    Sent from my iPhone


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  • 6.  RE: Occipital neuralgia?

    Posted 06-23-2025 18:53
    Corneal sensitivity?

    Russ Edwards




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  • 7.  RE: Occipital neuralgia?

    Posted 06-23-2025 21:57
    I believe her corneal sensitivity is normal, but I will check.

    Sent from my iPhone



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  • 8.  RE: Occipital neuralgia?

    Posted 06-23-2025 23:24

    Corneal neuralgia? We had a nice talk about this at the NANOS meeting.






  • 9.  RE: Occipital neuralgia?

    Posted 06-24-2025 16:17

    It is puzzling that neck flexion would elicit corneal neuralgia and that it would be present in a patient without any corneal history-young, healthy corneal appearance by SL bio-microscopy...no dry eye, no Lasix, etc. 

    Pam Chavis


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  • 10.  RE: Occipital neuralgia?

    Posted 06-24-2025 20:13

    High cervical pathology (C1/2) has been reported in association with pain, either in the medial angle of the eye or the tip of the tongue.

     

    I believe Jim Lance first noted this but have no reference. I have observed it before.

     

    It is presumed related to the descending loff of the trigeminal into the upper spinal canal.

     

    No certainty but have observed the phenomenon.

     

    Regards

     

    Owen

     

    Prof Owen B White MD PhD FNANOS FRACP

    Dept of Neurosciences

    Central Clinical School

    Monash University

    Melbourne, VIC, 3004

    Tel: +61 3 9576 0022

    Fax: +61 3 9576 0019

    Mob: +61 418 822 996

    Email: owen.white@monash.edu

    Orcid ID: 0000-0002-2836-7344




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  • 11.  RE: Occipital neuralgia?

    Posted 06-24-2025 20:29
    Is this pain light sensitivity? If the trigeminal pathway is involved why would the corneal surface be normal?
    Pam

    Sent from my iPhone


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  • 12.  RE: Occipital neuralgia?

    Posted 06-24-2025 21:35

    I agree that confocal microscopy can be done to examine neurites in detail. However, the exacerbation with neck movement may also be an important clue. Certainly in older age groups, where cervical pathology is very common, I see this phenomenon from time to time. I assume it is in part referred pain, since the cranio-cervical lies more or less in a straight line behind the orbits. But the upper cervical structures also feed into the spinal trigeminal nucleus. In addition, there are fascial sleeves that connect the cervical musculature with the meninges. In the thalamus, input from intrinsically photosensitive retinal ganglion cells converges directly onto neurons that receive input from the spinal trigeminal nucleus. Thus occipital irritation should be considered in a photo-oculodynia syndrome, and occipital nerve blocks are an important therapeutic and diagnostic tool for patients with otherwise unexplained eye or periorbital pain. I also have conversations with patients about the importance of posture.

     

     

    Bart K. Chwalisz, M.D.

    Neuro-ophthalmology, Headache Unit, and Skull Base Disorders Clinic. Division of  Neuroimmunology, Massachusetts General Hospital/Harvard Medical School

    https://www.massgeneral.org/neurology/treatments-and-services/inflammatory-neuroophthalmology-and-skull-base-disorders-clinic

    Neuro-ophthalmology, Massachusetts Eye & Ear Infirmary/Harvard Medical School

    Neurology, Martha's Vineyard Hospital

     

     

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  • 13.  RE: Occipital neuralgia?

    Posted 06-25-2025 12:39
    Hi

    The best next step might be a Neuropysch exam to understand the patient’s goals and motivations and help him.

    He has had 2 years of near-optometry, 5 MRIs (all normal and without cervical pathology); he has done well evidently in school despite non -painful light sensitivity and a normal eye/cornea exam. The non painful light sensitivity is triggered by neck flexion despite the neck's otherwise normalcy on multiple exams.

    Good luck,

    Pam.


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  • 14.  RE: Occipital neuralgia?

    Posted 06-25-2025 13:00
    Have the Senior neuroophthalmologists like Dr Gordon Plant ,Dr Neil Miller moved to the new NANOSNET platform ? Miss their input on the cases ever since we have shifted to the new NANOSNET .
    I wonder if it can be facilitated any way.

    Dr Shikha Bassi
    Sankara Nethralaya 
    Chennai
    India



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  • 15.  RE: Occipital neuralgia?

    Posted 06-23-2025 23:52
    He may be able to use an E-ink monitor, as opposed to the typical computer monitor 






  • 16.  RE: Occipital neuralgia?

    Posted 06-24-2025 13:11

    Thanks for these suggestions that seem to center on the corneas, not where my attention was directed in this 17 years old with beautifully lustrous corneal surfaces last time I was able to see them, and adaptive strategies.  He doesn't have pain, discomfort, or other symptoms of ocular surface disease beyond photophobia.  His neurologist does not feel his symptoms are due to migraine.  I'm skeptical of that idea, too.  I'll invite this young man back for some corneal testing and add the Bartonella test with Immunoblot through Igenex.  I take it, Scott, that you have had a patient with a similar story who responded to treatment for Bartonella?  The E-link monitor sounds like a good option - thanks, Floyd, I did not know that such monitors exist - that, if accepted, could give him a sense of relief as he prepares for college in the fall.  I like the idea of psychological evaluation for desensitization therapy.  That idea, if accepted, might also be a good way to introduce another potentially relevant contribution into his health care, particularly if I end up with nothing else concrete.  Steven Kane


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  • 17.  RE: Occipital neuralgia?

    Posted 06-24-2025 14:55

    He may need confocal microscopy to see the aberrant corneal nerves. Deb




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  • 18.  RE: Occipital neuralgia?

    Posted 06-24-2025 15:21
    Yes I have had such a patient
    S Forman



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  • 19.  RE: Occipital neuralgia?

    Posted 06-24-2025 18:56
    This are hard to obtain, as not readily available. Also apparently, not always so easy to interpret, as bends in the nerves can be misinterpreted as pathology. 





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  • 20.  RE: Occipital neuralgia?

    Posted 06-24-2025 20:13
    Is there tenderness along the occipital nerves? You might even consider occipital nerve lidocaine injection as a therapeutic trial. I've seen significant improvement in pain from occipital neuralgia within minutes after injection.

    Russ Edwards




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