Resident Physician UCF GME Pace, Florida, United States
Case Diagnosis: A 45-year-old female with hypertension, diabetes mellitus type II, hyperlipidemia, and morbid obesity was diagnosed with a large right frontoparietal intraparenchymal hemorrhage (6.2 × 3 × 3.5 cm), presenting with left hemiplegia, altered mentation, and persistent headache. She was admitted to inpatient rehabilitation for functional recovery and medical optimization.
Case Description: During rehabilitation, the patient experienced ongoing right-sided occipital headaches with a flat affect and impaired participation in therapies. These symptoms were initially attributed to her ICH. On physical exam, she was tender over the greater occipital nerves bilaterally, more prominent on the right, and this reproduced her headache. Given the characteristic distribution and focal tenderness, occipital neuralgia was clinically diagnosed and confirmed by complete resolution of symptoms following a diagnostic bilateral occipital nerve block with 1.5 mL of 0.5% bupivacaine per side. Gabapentin 300 mg TID was initiated for maintenance therapy. Oxycodone was successfully weaned, and the patient demonstrated improved alertness and participation in therapy, with progressive functional gains in ADLs and mobility.
Discussions: Occipital neuralgia is a relatively rare but important cause of secondary headache, characterized by paroxysmal, stabbing pain in the distribution of the greater or lesser occipital nerves, often with tenderness on palpation. It is more common in middle-aged women and is a clinical diagnosis supported by relief after nerve block. Although post-stroke headaches are common, peripheral pain generators may be overlooked due to diagnostic anchoring. In this case, targeted examination allowed for diagnosis and treatment of occipital neuralgia—uncommonly reported in post-ICH populations. Nerve blocks are a first-line, minimally invasive intervention with short-term efficacy, often followed by pharmacologic agents such as gabapentin for longer-term management.
Conclusions: Clinicians should maintain a broad differential for post-stroke headaches, including peripheral etiologies like occipital neuralgia. Early recognition and targeted nerve block interventions can improve pain, reduce opioid use, and enhance engagement in rehabilitation therapies.
