Occipital versus Non-Occipital Migraine Pain: Clinical Characteristics, Differential Diagnosis, Treatment Response, Anatomical, and Pathophysiological Perspectives

Introduction: In this study, we aimed to compare clinical characteristics and treatment responses in patients with migraine with occipital pain and those with non-occipital pain. We hypothesized that the area of pain could influence clinical features and treatment responses. Methods: We conducted a retrospective review of patients diagnosed with episodic or chronic migraine who attended a Neurology (Headache) outpatient clinic between January 2022 and December 2024. Patients were divided into two groups: Group 1 (People with migraine with occipital pain) and Group 2 (People with migraine with non-occipital pain). Data were collected on demographic characteristics, clinical features, and treatment responses. Results: A total of 100 patients were enrolled, with 50 included in Group 1 [39 patients (78%) with episodic migraine; 40 (80%) females], and 50 patients included in Group 2 [40 patients (80%) with episodic migraine; 43 (86%) females]. No significant difference was found in gender distribution (p=0.603), age of migraine onset (p=0.904), or time until diagnosis (p=0.205). Group 1 had more frequent bilateral pain (50% vs 38%, p=0.003) and a higher mean of migraine days per month (11 vs 6, p=0.004). Similar proportions of patients started oral preventive treatment (70% vs 80%, p=0.248). In Group 1, the most prescribed drug was amitriptyline, while in Group 2, it was topiramate. Group 1 had higher treatment failure rates than Group 2 (70% vs 31%, p<0.001). After adjusting for monthly migraine frequency, occipital pain remained independently associated with a poorer response to preventive treatment (adjusted OR = 0.33; 95% CI: 0.14–0.77; p=0.01). Conclusion: Patients with occipital migraine experience more bilateral pain, migraine frequency, and higher treatment failure rates. These findings suggest the need for tailored treatment strategies based on migraine pain localization.