Cervicogenic Headache

Cervicogenic Headache

Relevant Anatomy

Cervicogenic Headache, or pain felt in the head that is referred from structures in the cervical spine, occurs due to converging of trigeminal and cervical afferents in the trigeminocervical nucleus.  This convergence in the trigeminocervical nucleus occurs in the upper cervical spinal cord.¹

Mechanism of Injury/Pathologic Process

There is some evidence that multiple structures in the upper cervical spine can be the pain generating structure that is referring pain into the head.  Structures innervated by C1, C2, and C3 have the ability to create referred pain in the head.  This may include the joints, disc, ligaments, and musculature.¹  The lower cervical spine may play an indirect role in pain production if dysfunctional, but there is no evidence of a direct referral pattern.¹

Clinical Presentation

Cervicogenic headaches can be challenging to diagnose clinically.  In a 2002 study evaluating the efficacy of manual therapy and exercise in treating cervicogenic headaches, Jull et al² included headache patients with a unilateral or unilateral dominant headache that was exacerbated by neck movement or postures and had tenderness at the level of the upper three cervical spine joints.  Excluded were those with a bilateral headache or symptoms that typify migraine headaches.²

Diagnostic Procedures

Diagnostic pain block injections guided fluoroscopically may be utilized in order to determine if the pain generator causing the headache is in the cervical spine.¹

Outcome Measures

Neck Disability Index

Headache Disability Index

Northwick Park Neck Pain Questionnaire

Numeric Pain Rating Scale

Pain visual analog scale

Headache frequency and duration

Management/Interventions

Jull et al² reported that a six week physiotherapy program including manual therapy and exercise interventions was an effective treatment option for reduction of cervicogenic headache symptoms and decreasing medication intake in both the short term and at one-year follow-up.

Differential Diagnosis

Patients presenting with headaches should be screened for serious medical pathologies potentially creating the symptoms.  Differential diagnosis among the various headache types including tension type, migraine, and cluster should follow in order to determine if the patient's headache has a cervicogenic component.  The International Headache Society³ has developed classification criteria to aid in differential diagnosis among headache types.

Recent Case Studies

J Man Manip Ther. 2007;15(1):10-24.

Orthopaedic manual physical therapy including thrust manipulation and exercise in the management of a patient with cervicogenic headache: a case report.
van Duijn J, van Duijn AJ, Nitsch W.

Resources

1. Diagnosis and management of cervicogenic headache.

   Sizer PS Jr, Phelps V, Azevedo E, Haye A, Vaught M.

   Pain Pract. 2005 Sep;5(3):255-74.

2. The diagnostic validity of the cervical flexion-rotation test in C1/2-related cervicogenic headache.

   Ogince M, Hall T, Robinson K, Blackmore AM.

   Man Ther. 2007 Aug;12(3):256-62.

3. Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache.

   Hall T, Chan HT, Christensen L, Odenthal B, Wells C, Robinson K.

   J Orthop Sports Phys Ther. 2007 Mar;37(3):100-7.

4. Clinical evaluation of cervicogenic headache: a clinical perspective.

   Fernández-de-Las-Peñas C.

   J Man Manip Ther. 2008;16(2):81.

References

1. Bogduk N, Govind J.  Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. Lancet Neurol 2009; 8: 959–68.

2. Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A randomized controlled   trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002;27:1835–1843.

3. http://ihs-classification.org/en/02_klassifikation/