Introduction to Cervicogenic Headaches

Original Editor - Jess Bell Top Contributors - Jess Bell, Kim Jackson, Tarina van der Stockt, Lucinda hampton, Nupur Smit Shah, Jorge Rodríguez Palomino and Ewa Jaraczewska

Introduction

Headaches are highly prevalent and are associated with significant disease burden for the individual and the wider community. Headache disorders are ranked as the third most disabling condition in people aged under 50 years old in the Global Burden of Disease Study.

It is estimated that 46 percent of the adult population has Active Headache Disorder. Between 1.7 and 4 percent of the world’s adult population report having a headache on 15 or more days each month. While there are regional variations, headaches affect people from all ages, ethnicities, socio-economic backgrounds and geographical areas. The highest rates for headache are found in North America with 85 to 90 percent of people reporting that they have experienced with headache at some point in time.

There are many different types of headache, which are discussed in more detail here.

Headaches are grouped into three main areas:

• Primary headaches (e.g. migraine, tension-type headaches, and trigeminal autonomic cephalalgias (including cluster headaches))
• Secondary headaches (e.g. cervicogenic headache)
• Neuropathies, facial pain and other headaches

Tension-Type Headaches

Tension-type headaches (TTH) are very common. Lifetime prevalence in the general population ranges from 30% and 78%.

The cause of TTH is not known, but peripheral pain mechanisms are believed to play a role in episodic TTH, whereas central pain mechanisms are implicated in chronic TTH.

The ICHD-3 notes that "pericranial tenderness is easily detected and recorded by manual palpation".

Further information on TTH is available here.

Migraine

Migraine also has high prevalence and socio-economic and personal burden. It was ranked as the third most prevalent disorder in the world in adults aged under 50 years. in the Global Burden of Disease Study.

There are two major types of migraine:

• Migraine with aura
• Migraine without aura

Further information on migraine is found here.

Other more serious causes of headache include:

• Concussion
• Brain tumour
• Aneurysm
• Substance abuse
• Withdrawal
• Infection
• Inflammatory disease

Primary headaches and serious causes of headaches are explained in the following video.

Cervicogenic Headache

Cervicogenic headache (CGH) is a chronic secondary headache that originates in the cervical spine. It affects 2.5 to 4.1 percent of the general population. However, this figure rises to 15 to 20 percent of people who report headaches. There is evidence to suggest that it has a similar impact on quality of life as migraine and episodic tension-type headache.

CGH is described by the ICHD-3 as "Headache caused by a disorder of the cervical spine and its component bony, disc and/or soft tissue elements, usually but not invariably accompanied by neck pain." Their full diagnostic criteria is available here.

CGH begins in the neck or occipital region and can refer to the face and head. The specific sources of CGH are any structures innervated by the C1 to C3 nerve roots, including:

• The upper cervical joints
• The upper cervical muscles
  • Suboccipital muscles
  • Sternocleidomastoid
  • Trapezius (especially the upper fibres)
• The C2-3 disc
• The vertebral and internal carotid arteries
• The dura mater of the upper spinal cord and posterior cranial fossa

This referral of pain to the head from the neck can be explained by the convergence of trigeminal afferents and afferents from the upper three cervical spinal nerves.

• The trigeminal nucleus caudalis descends down to C3 or C4. This nucleus borders the grey matter of the spinal dorsal horn (i.e. the trigeminocervical nucleus)
• The interneurons in the trigeminocervical nucleus enable sensory information to be exchanged between the upper cervical spinal nerves and the trigeminal nerve
• Through this exchange, nociceptive signals from the upper cervical spine can be referred to the areas supplied by the trigeminal nerve in the head and face

Most of this nociceptive information is exchanged through the ophthalmic division of the trigeminal nerve (cranial nerve V). Thus, pain generated in the cervical spine will most likely refer to the temple, orbit and forehead.

There is also some exchange of sensory information with the maxillary division of cranial nerve V, so pain generated in the upper cervical spine can also be referred to the face.

Neck muscles can also refer pain to the head and face.

Distinguishing Headache Types

Despite clear criteria to classify cervicogenic headache, it is difficult to diagnose this condition. The following points can be helpful when trying to distinguish between migraine, tension-type headache and CGH.

Location

CGHs are usually unilateral. Pain occurs more frequently in the suboccipital region, although they can also refer to the orbital and frontal regions.

Migraines also tend to be unilateral, but they can shift from side to side. Pain is more frequently in the frontal and temporal regions, although they can also be orbital. This means that there is some overlap with CGH.

Tension-type headaches tend to be more diffuse and people often describe it as a sense of pressure like a headband. They originate in the temporal region.

Type of Pain

CGHs tend to be non-throbbing and often start in the neck.

Tension-type headaches are described as a pressing or tightening pain, of mild to moderate intensity.

Migraines are described as a pulsating headache.

Triggers

CGHs are triggered by neck movements. There are multiple courses for tension headaches and migraines, but they are not typically related neck movements.

Additional Symptoms

Patients with CGH will more likely present with limited neck range of motion. Tension headache and migraines might present with sensitivity to light and sound (i.e. photophobia and phonophobia). Migraines may also have the additional symptoms of nausea and vomiting, as well as visual changes (aura) and can be aggravated by activity.

The following table, from Kaplan, provides a summary of these points.

	Cervicogenic Headache	Tension-Type Headache	Migraine
Location	Unilateral Occipital, orbital or frontal	Diffuse Can feel like a headband	Unilateral, but can shift sides Frontal, orbital, temporal
Pain type	Non-throbbing, usually starts in the neck	Dull or tightening, pressure	Throbbing, pulsating
Triggers	Neck movements	Multiple	Multiple
Additional Symptoms	Reduced neck range of motion	Photophobia, phonophobia	Nausea, vomiting. visual changes (aura), photophobia, phonophobia

Diagnostic Difficulties

While there are clear classification systems for headaches, it has been suggested that an incorrect headache diagnosis may occur in as much as 50 percent of cases.

In some instances, patients may be diagnosed with one type of headache (e.g. migraine or tension-type), but also have features of CGH. Thus, headaches are not always exclusive. Tension-type headaches can occasionally have some cervical components. And both migraine and tension-type headaches are often associated with neck pain (due to the convergence of the cervical and trigeminal nociceptive afferents in the trigeminocervical complex as discussed above).

Diagnosis of cervicogenic headaches is discussed in more detail here.

Red Flags

Certain red flag conditions can be associated with headache, including:

• Cranial artery dysfunction (i.e. cervical or carotid)
• Intracranial issues
• Upper cervical ligamentous laxity (i.e. transverse or alar ligaments)

Other red flags include:

• Sudden onset of a new, severe headache
• Headache that is described as the worst headache ever
• A worsening pattern of pre-existing headache in the absence of obvious predisposing factors
  • A headache of insidious onset over a period of six months will also heighten the index of suspicion
• Headache associated with fever or neck stiffness, rashes
• History of cancer or other systemic illness
• Headache associated with focal neurological signs
• Moderate or severe headache triggered by a cough, exertion or bearing down
• New onset of headache following pregnancy
• Headaches that begin after head injury
• Problems with vision or profound dizziness
• Any kind of sudden, severe, diffuse pain that causes an individual to wake from sleep. This sort of pain is often associated with elevated blood pressure
• Headaches that worsen with activity or when lying down - headaches that are musculoskeletal in origin, tend to improve when lying down
• Focal tenderness over the temporal artery
• Visual changes over the age of 60
• Anything that occurs with a sharp pain of short duration or minimal cause
• A severe pain around the sinuses and teeth.
• Headaches with altered mental faculties, visual changes and altered sensation
• The five Ds
• Episodes of blacking out
• Strength, coordination, balance and gait disturbances
• Loss of senses such as hearing, smell or taste
• Difficulty swallowing and or tingling around the lips
• Loss of voice and a chronic cough

In any of these cases, further medical review is necessary before treatment. Please click here for more information on headaches, dizziness and assessing the cervical spine.

Summary

• Headache disorders are highly prevalent and cause significant disability
• There are many different types of headaches. Some may respond to physiotherapy management, particularly those referring from the cervical spine
• Classifying and diagnosing headaches can be difficult despite the existence of classification systems
• Red flag conditions must be considered and ruled out prior to treatment

Further information on assessing and treating CGH can be found here.

Further information on headaches can be found here and here.