Anyone that likes to watch professional football on TV has probably read at least one news story about concussions and the subsequent traumatic brain injury that can occur after prolonged and repeated blows to the head and neck. Sadly, this phenomenon is not limited to football and can be seen in any number of sports from volleyball and soccer, to equestrian and car racing. Moreover, the pathology from such injuries is not limited to the brain. It has now been noted in a few papers in the published literature that occipital neuralgia can occur following sports-related injury. The etiology, at least in my mind, is most likely a traction (i.e. stretch) injury to the occipital nerves. What exactly happens as a result of this type of injury remains unclear, but there are several possibilities.
Studies of concussion patients using advanced imaging techniques that are not yet widely available have shown that there can be disruption of the myelin sheath of neurons in the brain. This sheath represents an important component of nerve support and insulation that allows physiologic conduction of nerve impulses. A similar event could happen as a result of trauma to a peripheral nerve and represents one possible cause for neuralgia. Another possibility is post-injury scarring reducing the space through which these nerves have to glide and thereby causing compression. Third, the scarring may be intra-neural (i.e. within the nerve) thus, in effect making the nerve stiffer and unable to glide smoothly with certain movements. These latter two possibilities may help explain why people who develop ON following sports-related concussions often report increasing pain or triggering of their pain with certain movements such as head rotation. Finally, if left untreated, prolonged compression has itself been shown to cause thinning or elimination of the myelin sheath and eventually neuronal cell death.
Remarkably, there are over five million Americans living with the sequelae of concussions. Even more frightening is that post-traumatic headache has been estimated to occur in almost 90% of such patients and is one of the more long-lasting symptoms, causing significant disability. Certainly, conservative measures are the first line of treatment and include modalities such as pharmacologic agents, massage, and physiotherapy. However, as with migraines, these modalities are not always successful. Happily, surgical decompression has also been shown to be effective in such patients with positive results reported in up to 88% of those treated. In addition, I personally believe that if occipital nerve compression is suspected, the sooner it is addressed, the quicker nerve function will be restored and the greater the ultimate degree of recovery will be since the amount of neuronal cell death can be limited. This latter postulate has not yet been studied, but certainly makes sense given what we know about chronic compression of peripheral nerves in the upper extremities. Therefore, anyone with such symptoms should look into the possibility of occipital nerve injury and have a frank discussion with their treating clinician regarding a timeline within which to evaluate the current treatment plan and what to do if there are no results within a certain period of time. Always trying to leave on a positive note, the take home message is that there may be a lifeline if chronic post-concussive headaches appear to be refractory to more conventional methods.
For more information on how nerve surgery can help with chronic migraines or the aftermath of concussions, visit www.peledmigrainesurgery.com or call 415-751-0583 to schedule a consultation with Dr. Peled.