Abstract
I am very grateful to Dr Evans for his interest in this case report. I do not think it is possible to make a diagnosis of occipital neuralgia in this case, however. The International Classification of Headache Disorders describes occipital neuralgia as a ‘paroxysmal jabbing pain in the distribution of the greater or lesser occipital nerves or of the third occipital nerve’, a symptom that was never experienced by this patient. Absence of decreased facial sensation does not exclude trigeminal neuropathy as a diagnosis, and although occipital and neck discomfort in association with occipital nerve tenderness are indeed consistent with greater occipital neuralgia, they are also commonly found in patients with migraine, cluster headache and other primary headache disorders manifesting primarily in the distribution of the trigeminal nerve. It is not inconceivable, therefore, that they might also be found in patients with trigeminal neuropathy, if looked for. We will, I am sure, both agree that this case provides further evidence for the physiological reality of the concept of the trigeminocervical complex, and should act as a spur to further research into the physiological effects of greater occipital nerve injection on central pain processing systems.