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Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 5-7

Cervicogenic Headache

Daradia – The Pain Clinic, Kolkata, West Bengal, India

Date of Submission18-Oct-2020
Date of Decision27-Oct-2020
Date of Acceptance02-Feb-2021
Date of Web Publication08-Mar-2021

Correspondence Address:
Mary Benita Jeyakumar
Daradia – The Pain Clinic, Kolkata, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrap.jrap_10_20

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Cervicogenic headache is a secondary headache that occurs due to referred pain from the cervical region, perceived in the trigeminal nerve distribution. It is a rare entity which is often seen in patients following whiplash injuries belonging to the early 30s age group. The pain generators are facet joints, atlanto-occipital joint, intervertebral discs, neck muscles, and cervical nerves from various pathologies. Clinically, it is a side-locked headache worsened by abnormal neck postures and neck strain. The flexion–rotation test is positive in most cases. Diagnosis is made based on the ICHD-3 criteria. The mainstay of treatment involves physical therapy for 6 weeks along with psychological therapy and pain medications. Interventional pain therapy options include cervical epidural steroid injections, trigger point injections, selective nerve root injections, and radiofrequency thermal neurolysis.

Keywords: Headache, pain management, trigeminal nerve

How to cite this article:
Das G, Jeyakumar MB. Cervicogenic Headache. J Recent Adv Pain 2020;6:5-7

How to cite this URL:
Das G, Jeyakumar MB. Cervicogenic Headache. J Recent Adv Pain [serial online] 2020 [cited 2022 Aug 13];6:5-7. Available from: http://www.jorapain.com/text.asp?2020/6/2/5/310950

  Definition Top

Cervicogenic headache (CGH) is a chronic headache classified under secondary headache by the International Headache Society (IHS). It is, in essence, referred pain from certain pathologies of the cervical region.[1] It is a side-locked dull headache with ipsilateral shoulder and arm pain with restricted range of movements of the neck.[2]

  Epidemiology Top

It is a rare entity accounting for 1%–4% of all headaches. The prevalence of CGH is 2%–14% of population.[3] The age of onset is the early 30s, and it affects males and females equally.[2]

  Predisposing Factors Top

There are multiple predisposing factors to experience CGH. (1) Occupational hazards: Hairstylists, carpenters, drivers, and other occupations which involve abnormal head posture while working may predispose to CGH. (2) Strenuous activities: Activities such as weight lifting can produce CGH. (3) Forward head posture: Holding the head out in a forward position such as working on a computer on a continual basis may pose a risk for CGH.[4]

  Etiology Top

One or more of the following may be the source of pain in CGH: (1) facet joints, (2) atlanto-occipital joint, (3) intervertebral discs, (4) neck muscles, and (5) cervical nerves. The causes of pain from the sources of pain mentioned above are the following – (1) trauma: Whiplash injury from rear-end car accidents causing zygoapophyseal joint injury accounts for 53% of CGH.[5] Fall or sports injury causing facet joint dislocation and fractures can be other traumatic causes for CGH. (2) Inflammatory conditions: Rheumatoid arthritis and cervical disc disease also produce CGH. (3) Degenerative conditions: Cervical degenerative disc disease and osteoarthritis of the facet joints are the degenerative causes of CGH. (4) Neoplastic conditions: Malignant or benign tumors of the neck can cause compression of the spinal nerves leading to CGH.[4]

  Pathophysiology Top

The trigeminocervical nucleus receives afferents from the trigeminal nerve as well as the cervical spinal nerves C1–C3, and through the efferent trigeminothalamic tract, the pain impulses originating from the cervical region get transmitted to the trigeminal sensory distribution of the face.[6]

  Types Top

There are three different types of CGH – (1) occipital CGH, (2) occipito-temporo-maxillary CGH, and (3) supraorbital CGH which is the most frequent type. There can be mixed presentations of these types.[3]

  Clinical Features Top

On eliciting history, a patient belongs to the early 30s. The typical pain characteristics are unilateral dominant headache, which originates in the neck and radiates to the eye, the temple, and the ear. It is intermittent initially and becomes continuous eventually. It is a dull ache – mild to moderate in intensity. It may be associated with pain in the ipsilateral shoulder and arm with reduced neck flexibility, blurriness, and swelling of the eye. Abnormal postures of neck and neck strain such as pressure on the neck, weightlifting, coughing, and sneezing can aggravate the pain.[7],[8] Local anesthetic blockade of selective nerve roots relieves the pain.[9] A history of trauma may be present. Clinical examination reveals tenderness over C1–C3 joints, spasm and trigger points in the upper trapezius, levator scapulae, scales and suboccipital extensors, weakness of the deep flexors of the neck, increased activity of the superficial flexors, and atrophy of the suboccipital extensors.[10],[11] The flexion–rotation test is positive in most cases. It is performed during the patient's pain-free period. The neck of the patient is passively held in complete flexion followed by rotation of the neck to each side until they feel resistance or until the patient complains of pain. The range of movement is assessed. The test is considered positive when the estimated range is reduced by 10° or more from the anticipated normal range (44°).[12]

  Diagnosis Top

The diagnostic criteria are as follows as described by the IHS:

  1. Any headache fulfilling criterion C
  2. Clinical, laboratory, and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck, known to be able to cause headache
  3. Evidence of causation demonstrated by at least two of the following:

    1. Headache has developed in temporal relation to the onset of the cervical disorder or appearance of the lesion

    2. Headache has significantly improved or resolved in parallel with improvement in or resolution of the cervical disorder or lesion
    3. Cervical range of motion is reduced and headache is made significantly worse by provocative maneuvers
    4. Headache is abolished following diagnostic blockade of a cervical structure or its nerve supply.

  4. Not better accounted for by another ICHD-3 diagnosis.[13]

  Differential Diagnosis Top

This syndrome can be confused with other side-locked headaches such as migraine without aura, hemicrania continua, and also cluster headache which makes eliciting proper history, a very important step in diagnosis of CGH. Other conditions that can present similarly include cervical arterial dysfunction, cervical myelopathy, intracranial pathology, cervical instability, and occipital neuralgia.

  Management Top

Management is interprofessional involving physical therapists, psychologists, and pain specialists. Physical therapy options are cervical spine manipulation or mobilization, deep flexor strengthening and upper quarter strengthening exercises, thoracic spine thrust manipulation exercises, C1–C2 self-sustained natural apophyseal glide,[14],[15],[16],[17] trigger point therapy, sensorimotor training, and re-education of posture. Physical therapy options are recommended for 6 weeks and have been found to decrease analgesic requirement considerably.[10] Psychological interventions such as biofeedback, relaxation, and cognitive-behavioral therapy have proven beneficial in patients with behavioral changes.[18] Medical pain management options include low-dose tricyclic antidepressants, centrally acting muscle relaxants, and botulinum toxin injection to reduce hypertonia of muscles. Interventional pain management options that can be offered would be cervical epidural steroid injections, trigger point injections, selective nerve root injections, and radiofrequency thermal neurolysis. Surgical options such as release of occipital nerve from entrapment in the trapezius muscle and transection of the greater occipital nerve can offer minimal benefit with the potential adverse effect, anesthesia dolorosa.[18]

  Red Flags Top

The red flags that alert the pain physician would be (1) a sudden-onset severe new headache; (2) a worsening pattern of a preexisting headache without any precipitating factors; (3) headache associated with fever, neck stiffness, skin rash, and with a history of cancer, HIV, or other systemic illness; (4) headache associated with focal neurologic signs other than typical aura; (5) moderate or severe headache triggered by straining; and (6) new-onset headache during or following pregnancy.

Patients with one or more red flags should be referred for an immediate medical consultation and further investigation.[12]

  Management Algorithm Top

The management algorithm is summarized in [Figure 1].
Figure 1: Courtesy – ScienceDirect[19]

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Conflicts of interest

There are no conflicts of interest.
  References Top

Goodman CC, Fuller KS. Pathology: Implications for the physical therapist [Internet]. St. Louis, Mo.: Saunders/Elsevier; 2009. Available from: https://search.ebscohost.com/login.aspx?direct=true&scope=site&db=nlebk&db =nlabk&AN=1167593. [Last accessed on 2020 Oct 10].  Back to cited text no. 1
Al Khalili Y, Ly N, Murphy PB. Cervicogenic Headache. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020. Available from: http://www.ncbi.nlm.nih.gov/books/NBK507862/. [Last accessed on 2020 Oct 10].  Back to cited text no. 2
Das G. Clinical Methods in Pain Medicine. CBS publishers: New Delhi; 2014.  Back to cited text no. 3
Do ZM. Cervicogenic Headache Causes and Risk Factors [Internet]. Spine-health. Available from: https://www.spine-health.com/conditions/neck-pain/cervicogenic-headache-causes-and-risk-factors. [Last accessed on 2020 Oct 09].  Back to cited text no. 4
Bogduk N, Govind J. Cervicogenic headache: An assessment of the evidence on clinical diagnosis, invasive tests, and treatment. Lancet Neurol 2009;8:959-68.  Back to cited text no. 5
Cervicogenic Headache [Internet]. Physiopedia. Available from: https://www.physio-pedia.com/Cervicogenic_Headache. [Last accessed on 2020 Oct 02].  Back to cited text no. 6
Jull GA, Stanton WR. Predictors of responsiveness to physiotherapy management of cervicogenic headache. Cephalalgia 2005;25:101-8.  Back to cited text no. 7
Haas M, Spegman A, Peterson D, Aickin M, Vavrek D. Dose response and efficacy of spinal manipulation for chronic cervicogenic headache: A pilot randomized controlled trial. Spine J 2010;10:117-28.  Back to cited text no. 8
Becker WJ. Cervicogenic headache: Evidence that the neck is a pain generator. Headache 2010;50:699-705.  Back to cited text no. 9
Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine (Phila Pa 1976) 2002;27:1835-43.  Back to cited text no. 10
Page P. Cervicogenic headaches: An evidence-led approach to clinical management. Int J Sports Phys Ther 2011;6:254-66.  Back to cited text no. 11
Hall TM, Briffa K, Hopper D, Robinson KW. The relationship between cervicogenic headache and impairment determined by the flexion-rotation test. J Man Physiol Ther 2010;33:9.  Back to cited text no. 12
Gobel H. 11.2.1 Cervicogenic headache [Internet]. ICHD-3 Beta The International Classification of Headache Disorders 3rd edition (Beta version). Available from: https://beta.ichd-3.org/11-headache-or-facial-pain-attributed-to-disorder-of-the-cranium-neck-eyes-ears-nose-sinuses-teeth-mouth-or-other-facial-or-cervical-structure/11-2-headache-attributed-to-disorder-of-the-neck/11-2-1-cervicogenic-headache/. [Last accessed on 2020 Oct 09].  Back to cited text no. 13
Fritz JM, Brennan GP. Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Phys Ther 2007;87:513-24.  Back to cited text no. 14
Cleland JA, Mintken PE, Carpenter K, Fritz JM, Glynn P, Whitman J, et al. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a general cervical range of motion exercise: Multi-center randomized clinical trial. Phys Ther 2010;90:1239-50.  Back to cited text no. 15
Luedtke K, Allers A, Schulte LH, May A. Efficacy of interventions used by physiotherapists for patients with headache and migraine-systematic review and meta-analysis. Cephalalgia 2016;36:474-92.  Back to cited text no. 16
Hall T, Chan HT, Christensen L, Odenthal B, Wells C, Robinson K. Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache. J Orthop Sports Phys Ther 2007;37:100-7.  Back to cited text no. 17
Biondi DM. Cervicogenic headache: A review of diagnostic and treatment strategies. J Am Osteopath Assoc 2005;105:16S-22.  Back to cited text no. 18
Bir SC, Nanda A, Patra DP, Maiti TK, Liendo C, Minagar A, et al. Atypical presentation and outcome of cervicogenic headache in patients with cervical degenerative disease: A single-center experience. Clin Neurol Neurosurg 2017;159:62-9.  Back to cited text no. 19


  [Figure 1]


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