Clinical synthesis based on the ICHD-3 criteria (13.4), the Melchior 2025 epidemiological meta-analysis, the Deuel 2024 review of conservative management and the most recent systematic reviews and meta-analyses (Oliveira 2024, Demont 2023, Núñez-Cabaleiro 2022, Nguyen 2025).

Greater occipital neuralgia, historically known as “Arnold's neuralgia” in tribute to the German physician Friedrich Arnold (1803-1890), is a secondary headache coded in the third edition of the International Classification of Headache Disorders (ICHD-3) under number 13.4: occipital neuralgia.¹ Its precise recognition is essential because it determines the therapeutic approach: as a focal neuropathic condition, it does not fall within the usual strategies for migraine or tension-type headache. 🎯

How is this condition defined, who does it affect and what are the risk factors?

The ICHD-3 defines occipital neuralgia as unilateral or bilateral paroxysmal pain in the territory of the greater occipital nerve (GON), lesser occipital nerve (LON) or third occipital nerve (TON), associated with dysaesthesia and/or allodynia, with tenderness on palpation of the nerve involved, and relieved by a local anaesthetic block.¹ The pain is typically described as an electric shock, as a stabbing pain or as a burning sensation, which can last from a few seconds to a few minutes per attack, often followed by a residual dull ache.²

🎯 Consolidated epidemiology 2025. The systematic meta-analysis by Melchior et al. (Cephalalgia 2025, 15 pooled studies, n=579 patients) is now the most robust epidemiological reference.² It reports:

• 73 % women among diagnosed patients (homogeneous proportion across studies);
• Mean age 56 years (median 53 years), with a peak incidence in the fifth to sixth decades;
• Presentation unilateral in 81% of cases;
• Character lancinating or stabbing in 59%, severe in 54%;
• Considerable heterogeneity of incidence estimates from one study to another, underlining the need for standardised diagnostic criteria.

The historically cited incidence estimate (3.2/100,000 person-years) comes from the Dutch cohort of Koopman et al. (Pain 2009), covering 360,000 people followed for facial pain in primary care.³ This estimate is still cited in the literature, but must be interpreted with caution: it includes cases diagnosed clinically without systematic confirmation by anaesthetic block.

🧠 Aetiologies: one nerve, multiple causes. The condition results from focal irritation, compression or demyelination of the nerve along its course. The causes fall into two broad categories.

• Mechanical / compressive : compression by the semispinalis capitis muscle or the trapezius at their point of aponeurotic perforation (Janis 2010, reference anatomical study of compression points, PRS Part II)⁴; osteoarthritis of the C1-C2 or C2-C3 facet joints.
• Traumatic : whiplash, direct craniocervical trauma, repeated microtrauma (occupational posture, history of posterior cervical surgery).
• Vascular : loop of the occipital artery in contact with the GON, aneurysms, malformations (see case PMC5346380, Son 2017)⁵; C2 cavernoma (PMC5898127).⁶
• Tumoral : schwannoma of the GON or of the C2 root (Krishnan 2015, PMID 26752925)⁷; metastasis to the occipital condyle (Arivazhagan 2023, PMC9985513).⁸
• Inflammatory / infectious : occipital herpes zoster with post-herpetic neuralgia; inflammatory arthritis of the upper cervical joints.
• Malformation-related : associated Chiari I malformation (PMC5788399).⁹

Primary (idiopathic) form : retained after a secondary cause has been excluded clinically and, where appropriate, by imaging. It accounts for a significant proportion of cases in first-contact practice.

What happens in the body, and how does Arnold's neuralgia naturally evolve?

🧠 Neuropathic pathophysiology. The greater occipital nerve, a dorsal branch of the C2 spinal nerve, runs upward through muscular layers (obliquus capitis inferior, semispinalis capitis) before becoming superficial by perforating the trapezius aponeurosis approximately 2-3 cm lateral and inferior to the external occipital protuberance (a key anatomical point of the clinical examination).⁴ Cesmebasi 2015 (Clin Anat) points out the multiple potential sites of mechanical conflict: muscular passage, aponeurotic point, vascular contact with the occipital artery.¹¹

Chronic irritation of the nerve leads to focal demyelination, to peripheral sensitisation (lowering of the nociceptor activation threshold) and, beyond that, to central sensitisation. Treede et al. (Neurology 2008) set out the operational definition of neuropathic pain with a possible/probable/definite grading, updated by Finnerup et al. (Pain 2016).¹²,¹³ This central sensitisation, mediated by the hyperexcitability of the neurons of the trigeminocervical complex, explains:

• scalp allodynia (pain triggered by a normally non-painful stimulus: brushing the hair, contact with the pillow);
• The radiation to the frontal, orbital and even maxillary regions, via trigeminocervical convergence, perfectly described by Bogduk & Govind (Lancet Neurology 2009) in their review of cervicogenic headache.¹⁴

🔄 Natural history. Arnold's neuralgia is typically a chronic recurrent condition alternating paroxysmal pain attacks with periods of relative remission. The Melchior 2025 meta-analysis underlines the lack of sufficient longitudinal data to characterise the natural history precisely, which is a gap in the literature to flag to patients.²

Factors likely to worsen the course include:

• Persistence of mechanical factors (posture, occupational movements);
• An unidentified secondary cause (progressive structural compression);
• Neuropathic or inflammatory comorbidities;
• Psychosocial factors (kinesiophobia, catastrophising, sleep disorders), major modulators of the chronification of pain (Suzuki 2022 on central sensitisation in migraine, applicable by analogy).¹⁵

Diagnosis rests on the rigorous application of the ICHD-3 13.4 criteria, supplemented by a standardised physical examination and, ideally, confirmed by an anaesthetic block of the nerve concerned.¹ Imaging is not systematic but becomes essential as soon as a red flag is present or the response to well-conducted treatment is insufficient.²

Which questions should you ask to understand the patient and their history?

The structured history explores six key dimensions:

• ⚡ Pain quality : paroxysmal character (“stabbing”, “electric shock”, “burning”), brief attacks lasting a few seconds to a few minutes, sometimes in bursts. According to Melchior 2025, the lancinating character is reported by 59% of patients.³
• Topography : pain starting in the suboccipital region and radiating towards the vertex, sometimes towards the forehead, the orbit or the auricular region (trigeminocervical convergence). Unilateral in 81% of cases.³
• Triggers : neck movements (rotation, extension), pressure on the occiput (chair back, pillow), direct palpation of the course of the nerve, hair brushing (allodynia).
• Associated symptoms : dysaesthesia (abnormal sensations: tingling, burning) and allodynia of the scalp are almost pathognomonic. Possible mild visual discomfort (photophobia) but without the nausea typical of migraine.
• Relevant history : whiplash, posterior cervical surgery, head trauma, recent shingles in the territory, history of cancer, recent vaccination (cases in patients vaccinated against COVID-19 reported, but the evidence is weak).⁴
• Yellow flags and contextual factors : kinesiophobia, catastrophising (Pain Catastrophizing Scale), sleep disturbance, level of occupational activity, workstation ergonomics.

Which clinical tests should you perform, and which other conditions need to be ruled out?

Standardised physical examination

• Posture : look for a forward head posture and for straightening / upper cervical kyphosis.
• Cervical mobility : active and passive ranges of motion, in particular C1-C2 rotation (flexion-rotation test: a reference in cervicogenic headache, Hall 2010; not specific to ON).
• Key diagnostic palpation : firm and sustained pressure at the emergence point of the GON, approximately 2-3 cm lateral and inferior to the external occipital protuberance, at the level of the aponeurotic perforation of the trapezius.⁵ Reproduction of the typical pain is the most telling clinical element.
• Tinel's sign : gentle percussion along the course of the nerve, triggering a sensation of electric shock radiating towards the vertex.
• Allodynia test : light stroking of the scalp in the occipital territory, to be compared with the contralateral side.
• Neurological assessment : sensation, motor function, reflexes; any abnormality must prompt a reconsideration of the diagnosis and referral for imaging.

The anaesthetic block of the greater occipital nerve: the diagnostic gold standard

According to the ICHD-3, criterion C for the neuralgias (including 13.4) requires that the pain be temporarily relieved by an anaesthetic block of the nerve involved.¹ In practice, the procedure consists of injecting a local anaesthetic (lidocaine 1-2%, sometimes combined with a corticosteroid) at the emergence point of the nerve. The block can be performed using anatomical landmarks or guided by ultrasound, a technique increasingly used to improve accuracy and safety (Gürsoy & Tuna 2024, comparative RCT).⁶

The GON block also has a therapeutic value that is documented: Shauly 2019 (SR/MA, PMID 31568309)⁷ showed its efficacy in migraine headaches associated with occipital tenderness, and Cohen 2015 (double-blind randomised trial, PMID 26447705, 81 patients with occipital neuralgia or migraine with occipital nerve tenderness) reports a greater reduction in occipital pain at 6 weeks with pulsed radiofrequency than with anaesthetic and corticosteroid (−2.74 versus −1.38), an advantage still present at 6 months, without comparable improvement in the other outcomes.⁸

⚠️ Limitations of the block : a positive relief may result from the spread of the anaesthetic to neighbouring pain-generating structures (C2-C3 facet joints, suboccipital muscles), creating false positives. Standardisation of the injected volume, the puncture site and the duration of post-block evaluation remains imperfect, a limitation acknowledged in the literature.⁹

Differential diagnosis

Should patients with Arnold's neuralgia be classified, and for what benefit?

Yes, the distinction between primary (idiopathic) and secondary determines the therapeutic approach:

• Primary form : management focused on pain control, cervical rehabilitation (physiotherapy, exercises) and, depending on progress, blocks or pulsed radiofrequency.
• Secondary form : treatment of the underlying cause in parallel (muscular decompression, tumour removal, treatment of shingles, treatment of facet joint osteoarthritis…). Imaging is essential.

A complementary topographical classification (GON, LON, TON, third occipital nerve) guides the anatomical targeting of blocks and, where applicable, of surgery. The literature remains poor in validated classifications specific to ON, unlike the DC/TMD in temporomandibular disorders: this is a gap that the next decade will have to fill.²,³

Criticisms and controversies regarding the diagnosis

🧐 Several major limitations still weigh on the diagnosis of Arnold's neuralgia in routine practice:

1. Variability of clinical presentations and overlap with cervicogenic headache and migraine: the Melchior 2025 meta-analysis highlights the heterogeneity of the cohorts included, some of which do not strictly follow the ICHD-3.²,³
2. False positives of the anaesthetic block through spread to neighbouring pain-generating structures (see Bogduk 2009).⁹,¹⁰
3. Absence of a non-invasive clinical test with high sensitivity and specificity; palpation remains subjective.
4. Frequent confusion with cervicogenic headache in the French-language literature: variable terminology, therapeutic consequences not always relevant.¹⁰

The treatment strategy recommended by recent references, notably the Deuel 2024 review (Curr Pain Headache Rep)¹, the Oliveira 2024 (Can J Pain)² systematic review and the Nguyen 2025 (J Craniofac Surg)³ meta-analysis, rests on a stepped, multimodal approach. The general rule is to start with the least invasive options, reserving interventional techniques for well-selected refractory cases. 🪜

Where do you start? What is the recommended hierarchy of interventions?

The classic hierarchy comprises four levels:

Level 1: Conservative. The Deuel 2024 review (PMID 38958920) is the first modern synthesis devoted to conservative management of occipital neuralgia supported by physical therapy and explicitly recommends physiotherapy as the first line, combined with therapeutic patient education.¹ The mechanistic rationale is threefold: myofascial decompression of the points of conflict, cervical motor control to reduce stress on the nerve, and central desensitisation through supervised exercise.

Level 2: GON block. The combined lidocaine + corticosteroid block provides relief lasting from a few weeks to several months (Shauly 2019, Cohen 2015).⁴,⁵ It can be repeated, particularly to initiate or potentiate the rehabilitation programme.

Level 3: Pulsed radiofrequency (PRF). The Oliveira 2024 systematic review (Canadian Journal of Pain, 22 publications including 2 randomised trials, 608 patients, without meta-analysis) reports relief lasting 6 to 10 months in occipital neuralgia (3 to 6 months in chronic migraine), and rates the quality of the evidence as low.² Cohen 2015 (double-blind randomised trial, 81 patients) found a greater reduction in occipital pain with PRF than with anaesthetic and corticosteroid at 6 weeks, an advantage still present at 6 months.⁵

Level 4: Surgical interventions. Occipital nerve stimulation (ONS) and surgical decompression of the GON are reserved for failures of the previous steps. The Congress of Neurological Surgeons guideline, updated in 2023, maintains that ONS may be offered in refractory occipital neuralgia, on class III evidence;¹⁷ a subsequent open-label randomised trial (StimO, 2026) points in the same direction at 6 months.¹⁸ The Nguyen 2025 meta-analysis (J Craniofac Surg) synthesises the nerve decompression data, suggesting favourable response rates but with variable quality of evidence and limited follow-up.³

What is the place of exercise, and is there a superior approach?

Exercise is central to management, but the literature specific to Arnold's neuralgia remains limited. The recommendations rely largely on extrapolation from data on cervicogenic headache, a neighbouring condition sharing upper cervical mechanisms. 💪

🎯 Reference cervical programme. The most recent synthesis (Martins et al., Ann Phys Rehabil Med 2026, 29 trials, co-authored by Lafrance and Demont) rates the effect of manual therapy against sham at 0-2 weeks as low certainty, with no effect at 12 months;¹⁶ Demont 2023 had already found this absence of effect at 12 months, with moderate certainty.⁶ Against usual care, exercise alone could reduce headache at 12 months (low certainty), and the combination of manual therapy plus exercise remains of uncertain effect.¹⁶ The pivotal Jull 2002 trial (Spine, PMID 12221344, n=200) showed that a programme of specific exercises (deep flexor training using the craniocervical flexion test, CCFT; Jull 2008 PMID 18804003) and cervical manipulation significantly reduced the frequency and intensity of headaches at 12 months.⁷,⁸

• Deep neck flexor training (longus colli, longus capitis): progressive CCFT protocol up to 10 seconds × 10 repetitions at 26-30 mmHg on biofeedback.⁸
• Cervical extensor endurance : isometric and endurance exercises.
• Scapular stabilisation : strengthening of the middle/lower trapezius, rhomboids, serratus anterior.
• Stretching / mobility : upper trapezius, levator scapulae, scalenes, suboccipitals.
• Global motor control : postural integration, awareness of forward head posture.

Manual therapies, technologies: how effective are they really?

Before any upper cervical technique (mobilisation, traction, manipulation, including exercise), the IFOMPT cervical framework (JOSPT 2023) calls for explicit vascular reasoning: history of cardiovascular risk factors and of whether the headache or neck pain is recent or unusual, blood pressure, cranial nerve examination and neurological examination when the history suggests it, then informed consent; pre-manipulative positional tests are no longer recommended there. This framework, distinct from the spinal red flags framework (Finucane 2020), is a position statement based on evidence and expert consensus.¹⁹ It documents the decision without guaranteeing it: the only accuracy measurement available, the Go4Safe study, concerns the earlier version of the framework, which showed a sensitivity of 0.50 and a specificity of 0.63, and the accuracy of the 2023 framework has not been evaluated; a negative screen therefore does not rule out vascular risk, and monitoring of symptoms remains appropriate during and after the session.²⁰

👐 Manual therapies. The Núñez-Cabaleiro 2022 meta-analysis (Headache, PMID 35294051), which focuses on manual therapy in cervicogenic headache, concludes that there is short-term effectiveness on pain and function;⁹ the 2026 synthesis rates its certainty as low.¹⁶ The techniques evaluated include C0-C2 joint mobilisations, manipulations of the cervicothoracic junction, SNAGs and treatment of the suboccipital soft tissues. The Xu & Ling 2025 network meta-analysis (Front Neurol) finds SNAGs superior to other mobilisations in direct comparison and ranks manipulation first in the network, stressing the role of the clinician's expertise: no single technique stands out.¹⁰

💡 Adjunct technologies. For Arnold's neuralgia specifically:

• TENS, ultrasound, low-level laser : indirect evidence, weak to moderate, usable as symptomatic adjuncts.
• Pulsed radiofrequency (PRF) : medical intervention (not physiotherapy), low-quality evidence (Oliveira 2024).²
• Botulinum toxin : the 2025 update (Toxicon) rates the efficacy in occipital neuralgia as “indeterminate” for lack of sufficiently high-quality double-blind controlled studies.¹¹
• Acupuncture / dry needling : data still insufficient specifically for ON.

Beyond the physical: how do you educate the patient and act on psychological factors?

Pain neuroscience education (PNE) is a cornerstone of management. It aims to reconceptualise pain as a modulable neurobiological phenomenon (Suzuki 2022, Treede 2008), to reduce fear of movement (kinesiophobia) and catastrophising, and to foster self-efficacy.¹²,¹³

Validated strategies:

• Explanation of the mechanisms (central sensitisation, trigeminocervical convergence, distinction between migraine/ON/CGH);
• Identification of personal triggers (prolonged posture, stress, lack of sleep);
• Relaxation and stress management techniques (cardiac coherence, mindfulness);
• Sleep hygiene (Finan 2013: sleep/pain relationship, PMID 24290442);¹⁴
• Cognitive behavioural therapy (CBT) in cases of comorbid catastrophising, anxiety or depression (Ehde 2014: Am Psychol, CBT chronic pain meta-analysis, PMID 24547801).¹⁵

Criticisms and controversies regarding treatment

🧐 The therapeutic field suffers from several limitations:

1. Few RCTs specifically dedicated to occipital neuralgia ; most of the literature is extrapolated from cervicogenic headaches or from migraines with occipital tenderness.¹,⁶
2. Heterogeneity of protocols (injected volumes, frequency of blocks, duration of PRF follow-up) limiting comparisons.
3. Low level of evidence for most interventions, for lack of dedicated trials (Deuel 2024¹; Martins 2026 for cervicogenic headache).
4. No standardised consensus on the threshold beyond which to move from conservative to invasive treatment (how many blocks? after how many months?).
5. Risk of iatrogenic harm that is not negligible with repeated interventions (systemic corticosteroids, ONS, surgery).

Long-term management goes beyond simple control of attacks. It aims to restore function, prevent recurrences and turn the patient into the main player in their musculoskeletal health.¹ The evidence on the durability of results remains limited (most studies have a follow-up of less than 12 months), but the rehabilitation principles for cervicogenic headache offer a robust, extrapolable framework. 🧘

How do you make the patient an active participant in their own recovery through self-management?

1. Pain neuroscience education (PNE). The Deuel 2024 review stresses that pain neuroscience education is a prerequisite for any effective rehabilitation in occipital neuralgia.¹ It includes explaining central sensitisation, distinguishing between neuralgia / migraine / cervicogenic headache, and deconstructing limiting beliefs (“I must protect my neck”, “the more it hurts, the more I'm damaging myself”).

2. Ergonomics and posture. Forward head posture increases the mechanical stress on the upper cervical segments and the cervicothoracic junction. The classic recommendations:

• Screen at eye height; arm's-length distance;
• Regular breaks (20-20-20: every 20 minutes, for 20 seconds, look at something 20 feet = 6 m away);
• Reduction of the cumulative time spent in cervical flexion on a smartphone (“text neck”);
• Choice of a pillow that allows neutral cervical alignment.

3. Home exercise programme. Structured on the principles of upper cervical physiotherapy (Jull 2002, Demont 2023):²,³

• Activation of the deep flexors (head nodding against biofeedback or in supine lying);
• Cervical extensor endurance (prone neck holds);
• Scapular strengthening (Y/T/W, rowing);
• Gentle stretches (upper trapezius, levator scapulae, suboccipitals), with no aggressive stretching if symptoms are in an active phase;
• Upper thoracic mobility (cat-camel, extensions over a foam roller).

4. Myofascial self-release. Using a massage ball or hook on the suboccipitals may provide symptomatic relief in some patients. The specific evidence remains weak, but safety and simplicity justify its inclusion.

5. Sleep hygiene and stress management. Finan 2013 (J Pain) firmly established the bidirectional link between sleep ↔ pain.⁴ Recommend:

• Regular schedules, cool and dark environment;
• Reduced screen use in the evening;
• Relaxation techniques (cardiac coherence, body scan, mindfulness);
• Regular physical activity (but not late in the evening);
• Limiting stimulants (caffeine after 2 pm).

When and how should a safe return to activities and sport be planned?

🏃 Return to activities should be guided by functional criteria, not by a fixed calendar time frame; there is no published standard specific to Arnold's neuralgia.

1. Resting pain < 3/10 on the VAS;
2. Pain-free functional cervical ranges of motion (rotation, flexion-extension);
3. Absence of symptoms during activities of daily living for 1-2 weeks.

• Phase 1 : Low-impact aerobic activity (walking, upright cycling); no cervical stress.
• Phase 2 : Sport-specific movements at moderate intensity and without impact (light jogging, swimming with a kickboard to limit cervical extension).
• Phase 3 : Progressive increase in complexity and intensity; introduction of specific strengthening. Non-aggravation rule: any significant increase in pain the next day → return to the previous phase.
• Phase 4 : Full return, without restriction, as soon as all sport-specific movements are tolerated at full intensity.

Sports with particular risk (combat, contact, gymnastics, horse riding, rugby) warrant specific attention to cervical motor control before resumption.

Criticism and controversy

🧐 The scientific literature has several limitations:

1. Considerable heterogeneity of rehabilitation protocols, most of them extrapolated from cervicogenic headaches or common neck pain.¹,³
2. Lack of longitudinal studies specific to the prevention of recurrences in occipital neuralgia.
3. No consensus on criteria for returning to sport or to high-risk occupational activities.
4. Underestimation of psychosocial factors in conventional therapeutic studies, a point widely stressed by Deuel 2024.¹

The study of cases that have actually been published (and not fictional illustrations) sheds light on the diversity of presentations and on diagnostic pitfalls. However, the level of evidence of a case report (CEBM level 5) calls for caution: a case illustrates, it never demonstrates efficacy, a fundamental point recalled by Nissen & Wynn (BMC Res Notes 2014).¹ 🧐

Analysis of a “classic” case: from assessment to conservative resolution.

The literature offers few rigorously published physiotherapy case reports on isolated Arnold's neuralgia. The Deuel 2024 review (Curr Pain Headache Rep), the first mechanistic synthesis devoted to physiotherapy management of ON, identifies no specific RCT but relies on extrapolation from cervicogenic headache data.²

The typical features of a successful conservative pathway (synthesised from Deuel 2024 and the Jull 2002 / Demont 2023 protocols):

• Phase 1 (weeks 1-2) : pain education, identification of triggers, ergonomics, gentle isometric neck exercises;
• Phase 2 (weeks 3-6) : manual therapy (C0-C2 mobilisations, suboccipital soft tissues), CCFT progression, scapular integration;
• Phase 3 (weeks 7-12) : full strengthening, global motor control, return to activities;
• Phase 4 (beyond) : autonomous maintenance, telephone follow-up or consultation every 3-6 months to adjust prevention.

When a GON block has been performed at the start of the pathway (diagnostic + therapeutic), it can initiate the window for effective rehabilitation by significantly reducing pain for several weeks.³,⁴

The diagnostic challenge: when Arnold's neuralgia mimics another condition.

🎯 Published case no. 1: Vascular compression of the GON and referred hemifacial pain. Son and Choi (Case Rep Neurol Med 2017, PMC5346380) report the case of a 53-year-old woman followed for 16 months for refractory left occipital neuralgia, in whom pain and hypoaesthesia of the left half of the face appeared, although brain and cervical MRI were normal.⁵ Surgical exploration found the GON caught between branches of the occipital artery; its decompression immediately abolished the occipital neuralgia, the facial pain and the sensory disturbance, with no recurrence at 12 months. This case illustrates the trigeminocervical convergence : pain in the face can arise from involvement of the GON.

🎯 Published case no. 2: Occipital neuralgia after COVID-19 vaccination. Several open-access case reports (2022-2023) have reported series of patients developing occipital neuralgia in the days following a second dose of an mRNA vaccine.⁶ The proposed mechanism is inflammatory / autoimmune, without formal causal proof. The evidence remains of low level (case series, reporting bias), but this signal deserves to be documented for pharmacovigilance surveillance.

🎯 Published case no. 3: Atypical presentation with maxillary radiation. The anatomical variations in the course of the GON (Cesmebasi 2015) explain why some patients present with radiation to distant territories (maxilla, external ear), which can wrongly point towards trigeminal neuralgia or an ENT condition.⁷

Study of a complex case: serious secondary causes.

🧬 Published case: Schwannoma of the C2 root. Krishnan et al. (J Neurosci Rural Pract 2015, PMID 26752925) report a 38-year-old man suffering for two years from pain in the right occipital region and below the right ear, with hypoaesthesia of the scalp on the right side and a deep mass painful on palpation of the upper part of the neck.⁸ The medications tried in succession had remained without effect; brain MRI was normal, and it was cervical MRI that revealed the mass, lateral to the lateral masses of C2 and C3. Excision of a benign schwannoma attached to the greater occipital nerve and originating from the C2 root made the pain disappear completely. This case is the paradigmatic illustration of the red flag “resistance to well-conducted treatment”.

🧬 Published case: C2 cavernoma. An intramedullary C2 vascular malformation (PMC5898127) was identified in a patient with refractory chronic ON, underlining that MRI must include the upper cord and the craniocervical junction.⁹

🧬 Published case: Chiari I malformation. The association of ON with Chiari I is documented (PMC5788399); management requires a dedicated neurosurgical approach.¹⁰

🧬 Published case: Metastasis to the occipital condyle. Arivazhagan et al. (Cureus 2023, PMC9985513) report a 66-year-old woman presenting with an occipital headache associated with tongue deviation.¹¹ MRI showed a mass compressing the occipital bone and the hypoglossal canal, and the work-up concluded a diagnosis of metastatic breast cancer, whose recurrence was revealed by this occipital condyle syndrome. This case confirms the importance of the red flag “history of cancer”: cranial nerve involvement associated with occipital pain falls outside the picture of Arnold's neuralgia.

🧬 Published case: Paediatric population. Villeneuve et al. (J Neurosurg Pediatr 2023, PMID 37548543) report a series of paediatric cases of ON requiring surgical management, illustrating that a secondary cause should be sought more systematically in children and young people.¹²

Criticism and controversy

🧐 Published clinical cases have inherent limitations:

1. Publication bias : spectacular cases (exceptional therapeutic successes, highly atypical presentations) are over-represented.¹
2. Low level of evidence : CEBM 5 / GRADE very low. A case illustrates, never demonstrates.
3. Absence of longitudinal cohorts on Arnold's neuralgia specifically: the Melchior 2025 meta-analysis underlines this gap.¹³
4. Heterogeneity of diagnostic criteria between published cases (some do not apply the ICHD-3, others have no confirmatory anaesthetic block).

Applying evidence-based recommendations is the bridge between science and patient outcomes. It requires a threefold competence: identifying situations that fall outside one's scope (medical referral), measuring the effect of interventions (PROMs), and overcoming the barriers to EBP in daily practice. 🤔

When should you refer, and to which other healthcare professionals?

Red flags call for rapid medical referral. The IFOMPT framework of Finucane et al. (JOSPT 2020, PMID 32438853) remains the French and international reference for spinal red flags;¹ the cervical vascular aspect falls under a second framework from the same federation (Rushton, JOSPT 2023).⁷ Verhagen et al. (Pain 2017, PMID 28708761) have, however, shown that most isolated red flags have a low positive predictive value, hence the need to interpret them as a cluster of converging findings.²

The Han 2023 Cochrane review (CD014461) confirms this probabilistic logic for vertebral fracture in low back pain: combining several flags significantly increases the post-test probability, whereas the absence of red flags makes it reasonable to rule out serious pathology.³

Specifically for Arnold's neuralgia, the situations calling for medical referral (GP, neurologist, pain specialist or emergency department depending on the context):

• Thunderclap or sudden-onset headache → subarachnoid haemorrhage, arterial dissection;
• Focal neurological deficit (paresis, ataxia, visual disturbances);
• Known history of cancer or unexplained weight loss;
• Fever + neck stiffness → infection;
• Resistance to well-conducted conservative treatment (4-6 weeks) → cervical + brain MRI;
• Recurrence after posterior cervical surgery → suspected post-operative fibrosis, iatrogenic lesion.

Yellow flags (kinesiophobia, catastrophising, anxiety, depression, poor social support) are major predictors of chronification and call for collaboration with a psychologist, a pain physician or a multidisciplinary team.

🩺 Interprofessional collaboration. The complexity of Arnold's neuralgia justifies the potential involvement of:

• General practitioner or neurologist (differential diagnosis, prescription, imaging);
• Pain specialist (nerve blocks, pulsed radiofrequency);
• Neurosurgeon (surgical cases: decompression, ONS);
• Psychologist or psychiatrist (CBT, management of comorbidities);
• Ergonomist / occupational physician (workstation adaptation).

How do you measure outcomes and overcome barriers to implementation?

📈 Measuring outcomes with validated PROMs. Standardised follow-up should combine:

• VAS / NRS for pain (at rest, on exertion, during an attack);
• Neck Disability Index (NDI) for cervical functional impact;
• HIT-6 or MIDAS for headache-specific impact;
• Pain Catastrophizing Scale (PCS) and Tampa Scale of Kinesiophobia (TSK-11) for psychological factors;
• Physical performance measures: cervical ranges of motion, CCFT score (mmHg of pressure held × seconds).

🚧 Overcoming barriers to EBP. Systematic reviews invariably identify three main obstacles to implementation: lack of time, lack of research skills, lack of organisational support. Effective strategies (beyond the simple passive dissemination of guidelines):

• Targeted continuing education on critical appraisal of articles and applied statistics;
• Use of evidence syntheses (Cochrane Reviews, BMJ Best Practice, Physio Learning syntheses) to save time;⁴
• Audit and feedback on one's own practice (rate of PROM use, adherence to recommendations);
• Clinical leadership and mentoring by “EBP champions”;
• Technological integration (patient record software integrating PROMs).

Criticism and controversy: beyond the checklist

🧐 Three critical tensions run through the application of EBP in practice:

1. Reductionism. Red flags can lead to an anxiety-provoking “pathology hunt”, neglecting the biopsychosocial context. Conversely, a PROM score captures only part of the human experience. Expert competence integrates these tools without being limited to them.
2. Knowing-doing gap. The barriers identified (time, skills, support) have remained surprisingly stable for 20 years. This suggests that the problem is not only individual: the health systems (reimbursement models, administrative burden, initial training) need to be rethought to foster EBP.
3. Standardisation vs personalisation. Core Outcome Sets and standardised care pathways are essential for research and quality, but may run counter to the patient-centred approach. Clinical art consists in reconciling the two poles.

Finally, the emergence of artificial intelligence in decision support raises opportunities (real-time access to evidence, suggestion of differential diagnoses) and risks (dehumanisation, deskilling, accountability). The balance between technological augmentation and the autonomy of clinical judgement will be the challenge of the next decade.