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Cervicogenic Headache

Cervicogenic headache is defined as unilateral or bilateral pain localised to the neck and occipital region which may project to regions on the head and/or face. Head pain is precipitated by neck movement, sustained awkward head positioning, or external pressure over the upper cervical or occipital region on the symptomatic side.

Although cervicogenic headaches can occur at any age, it is commonly seen in patients between the ages of 20 and 60 and affects between 0.4-2.5% of the general population.

The condition's pathophysiology has been debated, but the pain is likely referred from one or more of the muscular, neurogenic, osseous, articular or vascular structures in the neck (Bogduk N., 1992).

Clinical features of cervicogenic headache are very similar to that of migraine and tension-type headaches, making it difficult to distinguish. Common features of cervicogenic headache are:

  • Generally pain is unilateral without sideshift
  • Pain localised to occipital, frontal, temporal or orbital regions
  • Moderate to severe, non-throbbing and non-lanciating pain usually starting in the neck
  • Precipitation of head pain by neck movement , external pressure over the occipital or upper cervical regions (C2/C3/C4) or Valsalva
  • Restriction in neck active ROM and passive ROM
  • Ipsilateral neck, shoulder or arm pain in a diffuse, non-radicular nature
  • Episodes of varying duration from hours to days
  • Fluctuating, continuous pain

Occassionally the following features are also present:

  • Nausea
  • Photophobia and phonophobia
  • Dizziness
  • Ipsilateral "blurred vision"
  • Difficulties on swallowing
  • Ipsilateral oedema, mostly in the periocular area

(Biondi et al, 2000)

Mechanisms
The main theory behind the possible mechanism of cervicogenic headache is that of convergence. This theory states that there is a convergence of trigeminal and cervical afferents in the trigeminocervical nucleus which allows referral of pain from neck origins to the head.

The trigeminocervical nucleus is a region of the upper cervical spinal cord where sensory nerve fibres in the descending tract of the trigeminal nerve are believed to interact with sensory fibres from the upper cervical roots. This functional convergence of upper cervical and trigeminal sensory pathways allows the bidirectional referral of painful sensations between the neck and trigeminal sensory receptive fields of the face and head. A functional convergence of sensorimotor fibres in the spinal accessory nerve (CN XI) and upper cervical nerve roots ultimately converge with the descending tract of the trigeminal nerve and might also be responsible for the referral of cervical pain to the head (Fitzgerald M.J., 1982 & Bremner-Smith A.T., 1999).

A second theory is that of dural tension. It has been proposed that at the atlanto-occipital junction, a connective tissue attachment exists between the rectuscapitus posterior minor muscle and the posterior spinal dura. This can therefore increase dural tension through dysfunction within the upper cervical spine (Hack et al 1995, Rutten et al 1997).

Diagnosis
To help with the diagnosis of cervicogenic headaches, a set of diagnostic criteria have been recommended by Olesen et al in 2004:

  • Pain localised in the neck and occiput, which can spread to other areas in the head, such as forehead, orbital region, temples, vertex, or ears, usually unilateral.
  • Pain is precipitated or aggravated by specific neck movements or sustained postures.
  • At least one of the following:
    • Resistance to or limitation of passive neck movements
    • Changes in neck muscle contour, texture, tone, or response to active and passive stretching and contraction
    • Abnormal tenderness of neck musculature 
  • Radiological examination reveals at least one of the following:
    • Movement abnormalities in flexion/extension
    • Abnormal posture
  • Fractures, congenital abnormalities, bone tumours, rheumatoid arthritis, or other distinct pathology (not spondylosis or osteochondrosis)


Management

A multifaceted approach should be taken when treating cervicogenic headaches using pharmacologic, non-pharmacologic, manual therapy, anaesthetic and rarely surgery. Manual treatment such as Chiropractic, Physiotherapy and Osteopathy have been shown to be effective and should include spinal manipulation, massage techniques, stretch and exercise techniques, traction, posture and ergonomic assessment. Also helpful is the use of hot/cold packs, electrotherapy, stress management, relaxation therapy and supportive pillows (Biondi D., 2005). For the prophylactic treatment of cervicogenic headache, there is evidence that both neck exercise (low-intensity endurance training) and spinal manipulation are effective in the short and long term when compared to no treatment. There is also evidence that spinal manipulation is effective in the short term when compared to massage or placebo spinal manipulation (Bronfort G. et al, 2009).

Injections
Diagnostic anaesthetic blockade is helpful in the definitive diagnosis of cervicogenic headaches of different origins. Cervical Epidural steroid injections are indicated in patients with multilevel disc or spine degeneration (Reale C., 2000) and trigger point injections can also provide patients with relief. If diagnostic blockade is successful for temporary alleviation of symptoms, then radiofrequency facet joint denervation is indicated for longer term relief (Blume H.G., 2000). Occipital nerve block injections can also help to relieve the resulting headaches. A course of physical therapy and rehabilitation is recommended after injection procedures to enhance functional restoration and effect a longer lasting analgesic benefit.

Contributing Author: 
Shelley Doole, DC MChiro

References
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