Approaches to Occipital Neuralgia Treatment: A Systematic Review and Case Examples

Background: Occipital neuralgia (ON) is a debilitating craniofacial pain disorder characterized by paroxysmal pain in the distribution of the greater, lesser, or third occipital nerves. Despite a growing array of interventions, clinical decision-making remains highly variable, with no standardized algorithm to guide diagnostic evaluation, procedural selection, or treatment escalation. Our objective was to synthesize the existing literature on ON management. Methods: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines and registered with PROSPERO (International Prospective Register of Systematic Reviews). PubMed, Embase, and Scopus were searched from 2000 to 2025. Studies were assessed using AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews), SANRA (Scale for the Assessment of Narrative Review Articles), and AGREE II (Appraisal of Guidelines for Research and Evaluation) tools. A narrative synthesis was performed, and studies with decision frameworks were compared against our clinical approach. Results: Fourteen studies met the inclusion criteria, including 7 systematic reviews and 7 narrative reviews or guidelines. Most included diagnostic nerve blocks, decompression, neurectomy, and peripheral nerve stimulation; however, only a minority proposed structured algorithms. Our proposed framework integrates botulinum toxin stratification, nerve block response, imaging, and intraoperative findings to guide decompression versus neurectomy. A secondary escalation pathway addresses early versus late surgical failure and neuromodulation treatments. Conclusions: This review highlighted the need for unified, evidence-informed decision-making in ON. Our clinical approach offered a structured, patient-specific framework to guide diagnosis, treatment, and escalation, addressing key gaps in current practice.