An occipital nerve block places local anaesthetic, sometimes with steroid, around the occipital nerves at the back of the head. It is used for occipital neuralgia and for headache arising from the upper cervical spine, and it is among the more straightforward blocks to perform.
Straightforward is not the same as trivial. There is one structure nearby that decides how the block is done.
Two nerves, not one
The block targets a pair. As Gisele J. Girault, MD describes the anatomy, there is the greater occipital nerve, which lies more medially, and the lesser occipital nerve, which lies more laterally.
Her practice is to block both. The territories overlap, the symptomatic distribution is often not cleanly one or the other, and blocking a single nerve in a patient whose pain arises from both produces a partial result that is difficult to interpret.
Both nerves are very superficial, which is what makes the block accessible without imaging.
The occipital artery, and why it governs the technique
The one anatomical caution that matters: the occipital artery runs in this territory, lateral to the greater occipital nerve.
That relationship is the block's defining safety consideration. Intravascular injection is the risk, and its consequences vary from an ineffective block to systemic anaesthetic toxicity depending on volume and agent.
The practical implications: know that the artery lies lateral to the greater occipital nerve, palpate for the pulse before injecting, aspirate before delivering anything, and inject slowly.
How the block is performed
Girault's setup is simple and worth describing because positioning does most of the work.
The patient sits in a chair. She stands on the left side to perform the left-sided block, then walks around to the right side for the right. Approaching each side from that side keeps the needle orientation and the landmark relationship consistent rather than reaching awkwardly across.
Her overall assessment is that it is “a fairly easy block to do” — because the nerves are superficial and the landmarks palpable.
As with the rest of this category, technique is learned under supervision. This guide carries no doses, volumes or depths.
When it is used
The presentation Girault describes most often is post-traumatic, and the mechanism is specific enough to recognise in a history: a patient in a road traffic collision where the airbag deployed, who “slammed their head against their neck rest” and injured the occipital nerve.
That mechanism — sudden forced extension driving the occiput against a headrest — is a common route to occipital neuralgia, and it is worth asking about directly in any patient with occipital headache following a collision.
Beyond trauma, the block is used for occipital neuralgia from other causes, for cervicogenic headache arising from the upper cervical segments, and diagnostically to establish whether pain is occipital in origin at all.
The diagnostic value, which is often the bigger one
Occipital pain, cervicogenic headache and migraine overlap considerably, and no imaging test separates them reliably.
A block that abolishes the pain for the duration of the local anaesthetic is meaningful information: it localises the source, whatever happens afterwards. That is frequently worth more than the therapeutic effect, and it should be documented against a baseline recorded beforehand in the same terms.
Girault's caution about trigger points applies here too — head and facial trigger points can mimic migraine and other headache syndromes, and she treats them sparingly for exactly that reason. A response to an occipital block is one piece of evidence, not a complete diagnosis.
Coding
Occipital nerve block does not necessarily share the general peripheral nerve block code. Girault uses 64450 for peripheral nerve blocks generally, and notes specifically that in her state “the occipital nerve has a different code than the 64450, even though they are peripheral nerves” — as does carpal tunnel.
Her standing caveat: these apply to South Carolina, codes vary by state and sometimes by area, and the CMS Physician Fee Schedule Lookup Tool is the reference to check, since many commercial insurers follow Medicare.
Check before building a service around an assumed reimbursement.
What patients should expect
Numbness across the back of the scalp for the duration of the local anaesthetic is expected, and patients should be told so — an unexpected numb scalp is alarming.
If steroid was included, Girault's general warning about steroid flare applies: increased pain over 24 to 48 hours occurs in roughly one in ten injections, settles over the following day or two, and does not warrant an emergency department visit, though the office should be called.
Scalp tenderness at the injection site for a day or two is usual. A spreading, hot, or increasingly painful area is not, and should be assessed.
Where it sits in the plan
An occipital block relieves pain and localises its source. It does not correct the upper cervical dysfunction, the posture or the unresolved injury driving it, and a block that works and then wears off without any change to the underlying problem is an argument for addressing that problem rather than for repeating the block indefinitely.
The wider set of peripheral nerve and joint targets is covered in the joint and extremity injection reference.
Learn blocks with your hands, not from a page
Empire’s Pain Management Training (THE Pain Show) is accredited for 25.25 AMA PRA Category 1 Credits™, jointly provided by AKH, Inc, and Empire Medical Training. For narrower peripheral work, Joint, Extremity and Non-Spinal Injection Training carries 6.75 credits for the complete in-person hybrid program, and Advanced Musculoskeletal Ultrasound Guided Injections builds the guidance skills above.
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