Cervicogenic headache is a clinically defined headache syndrome originating from the cervical nociceptors of the cervical structures. The structures responsible for the pain are still unknown. It is hypothesised that all cervical structures (facet joints, discs, muscles and ligaments) that are innervated by segment nerves C1, C2 and C3 could be source of cervicogenic headache. Cervical segmental dysfunction encountered in musculoskeletal medicine is most important cause.
Up until now, the cause of cervicogenic headache remains unknown. Cervicogenic headache is seen after neck trauma, but is not the same as whiplash associated disorders (WAD).
Signs and symptoms
Headache irradiating from the neck is the reason patients seek help. During establishing the medical history, general questions should be asked, such how long the complaints last, frequency, localisation of the headache, provoking factors, symptoms of migraine, traumas, medication, previously applied treatment, medical family history, etc.
The headache has a nagging and non-pulsating character. It may present as an attack, varying in duration from some hours to a few days. The duration of an attack is unpredictable. The pattern of the attacks can change into a chronic headache with a fluctuating course.
Symptoms that illustrate involvement of the cervical spine are essential, such as motion restriction in the neck, provocation of neck pain/headache during motion and after static load. If present, migraine-like symptoms such as nausea, vomiting and photophobia, are mild in character. A positive effect from a diagnostic test block with local anaesthetic of an upper cervical nerve root confirms the diagnosis.
Physical examination of the cervical spine consists of a number of elements:
- Motion analysis of the cervical spine: passive forward flexion, backward flexion, lateral flexion and rotation has to be judged with respect to motion restriction.
- Segmental palpation of the upper, mid and lower cervical facet joints.
- Judgement of the next 'pain pressure point':
a. greater occipital nerve (occipital temporal part of the skull)
b. lesser occipital nerve (skull insertion of sternocleidomastoid muscle)
c. third cervical nerve root (facet joint C2/C3)
d. edges of the trapezius muscle
Additional Somatic Diagnostics
The relationship between X-ray abnormalities and pain is unclear and certainly not unambiguous. Therefore, standard X-ray examination is not suitable for confirming or excluding involvement of the cervical spine. In the case of 'red flags', additional examinations are mandatory, such as MRI and CT scans.
Additional Psycho-cognitive Diagnostics
- RAND-36 (quality of life)
- VAS-Pain (maximal, minimal, actual, average/week)
- PCS (catastrophising)
- HADS (fear and depression)
Whether or not somatic treatment is indicated is based on the pain diagnosis. Based on the findings of the pain questionnaires, additional diagnostics and/or multidisciplinary treatment comprising various non-somatic treatments may be necessary.
- Non-steroid Anti-inflammatories (short period)
Interventional Pain Treatments
Up until now, no generally accepted interventional pain treatment for cervicogenic headache is available. This is due to the fact that the aetiology of cervicogenic headache is unknown. Therefore, many treatments are symptomatic in character.
- Single injection with corticosteroids of the occipital nerves
- PRF treatment occipital nerve
- Facet joint blocks
- Test block of upper cervical nerve roots
- PRF treatment of upper cervical nerve roots