Article Review: The Anatomy of the Greater Occipital Nerve: Part II. Compression Point Topography

A special thank you to Dr. Glen Harris for sending me this article:

Advances in the understanding of migraine trigger points have pointed to entrapment of peripheral nerves in the head and neck as a causation of

The Greater Occipital Nerve

this debilitating condition.  Injection of the greater occipital nerve (GON), for example, with local anesthetic and corticosteroids has been widely used in clinical practice for many years, yet there is no clear understanding of its mechanisms of action.  In a study by Afridi et al (2005) published in the journal ‘Pain,’ twenty-six of fifty-seven injections onto this nerve in 54 migraineurs yielded a complete or partial response that lasted for a median of 30 days.  They also noted that tenderness over the GON was strongly predictive of outcome, although local anesthesia after the injection was not.  They suggested that the mechanism of action may well be through changes in brain nociceptive pathways.

The greater occipital nerve is the medial branch of the dorsal primary ramus of the C2 spinal nerve. This nerve arises from between the first and second vertebrae, along with the lesser occipital nerve. It ascends after emerging from the subocciptal triangle obliquely between the obliquus capitis inferior and semispinalis capitis muscles, which it often pierces along with the trapezius muscle, close to its occipital attachments. It then passes through the trapezius muscle in the areas just inferior to the superior nuchal line, and ascends to innervate the skin along the posterior part of the scalp to the vertex. It innervates the scalp at the top of the head, over the ear and over the parotid glands.

In this cadaveric dissection article by Janis et al., published in the journal Plastic and Reconstructive Surgery (Advance Online Article), they discuss the possible compression points (or frictional irritation points as I prefer to call them) along the GON as it travels superiorly to the posterior scalp.  These areas, 6 in total, include:

Point 1 – The deepest (most proximal) point was between semispinalis and obliquus capitis inferior, near the spinous process

Point 2 – The second point was at its’ entrance into semispinalis.

Point 3 – The previously-described “intermediate” point was at the nerve’s exit from semispinalis.

Point 4 – A fourth point was located at the entrance of the nerve into the trapezius muscle.

Point 5 – The fifth point of compression is where the nerve exits the trapezius fascia insertion into the nuchal line.

Point 6 – The occipital artery often crosses the nerve and this frequently occurs in this distal region of the trapezius fascia, which is the final point

From a manual therapy perspective, these represent areas of focus for our soft tissue interventions, and/or acupuncture treatments.  Fascial release of the frictional irritation in these areas can be expected to also offer a less invasive relief of pain symptoms for these patients.

You may also want to review my blog post regarding the Corrugator Supercilli muscle and its resection/treatment for migraine suffers.  This is also a structure of interest for manual therapists treating headaches.

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