Introduction to Cervicogenic Headaches

Introduction

Headaches are highly prevalent and cause significant 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 the prevalence of current headache disorder (i.e. people who have been symptomatic at least once in the last year) is around 50 percent of the global population. 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 locations. 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, which inculdes migraine and tension-type headaches
• Secondary headaches, which includes cervicogenic headache
• Neuropathies, facial pain and other headaches

Other more serious causes of headache include:

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

Cervicogenic Headache

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

CGH is classified by the Cervicogenic Headache International Study Group as a: “side‐locked head pain worsened by neck movement or sustained improper positioning, restricted cervical range of motion and ipsilateral shoulder and arm pain.”

CGH begins in the neck or occipital region and can refer to the face and head. Any of the upper cervical joints and associated structures from C1 to C3 are implemented in cervicogenic headache. This includes:

• Suboccipital muscles
• Sternocleidomastoid
• Trapezius (especially upper trapezius)

These referral patterns are probably due to the convergence of the cervical and trigeminal nociceptive afferents in the trigemino-cervical complex (or dorsal horn of C1 and C2).  This convergence provides a neuro-anatomical explanation for this referred pain (i.e. pain originating in the neck can be perceived as coming from the head and pain originating in the head can be perceived as coming from the neck).

Distinguishing between migraine, tension-type headache and cervicogenic headache

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.

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 present with one type of headache (e.g. migraine or tension), but also have features of CGH. Thus, headaches are not always exclusive. Moreover, 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 trigemino-cervical complex as discussed above).

Assessment

It is important to find out about a patient’s headache intensity, frequency and duration. These points should be re-assessed to determine if management strategies are effective.

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 ligament)

Other red flags include:

• Sudden onset of a new, severe headache
• Headache this 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 very prevalent worldwide and cause significant disability
• There are many different types of headaches, but some are amenable to physiotherapy management, particularly those referring from the cervical spine
• Diagnosis of headache types is difficult despite 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.