Cervicogenic headache

The connection between headache and the cervical spine has been a theme of debate for decades. Cervicogenic headache is a headache related to the cervical spine that often is misdiagnosed and treated inadequately because of confusing and varying terminology. In this article, we discuss our experience in diagnosing and treating cervicogenic headache.     

Cervicogenic headache

Eleven female patients with cervicogenic headache (mean age, 43 years; range, 25-59 years) have been examined with the pupillometer. The pupillary diameter was examined in the basal state (that is, the status before pharmacologic stimulation) and after topically administered tyramine (2%), phenylephrine (1%), and hydroxyamphetamine (1%). A total of 51 tests were performed, 35 in the asymptomatic period and 16 during pain attacks. In a control group consisting of 26 age-matched women a total of 39 tests were carried out. Before pharmacologic stimulation (that is, in the "basal state") the pupils were smaller in the asymptomatic (pain-free) period than during pain attacks in the patients and also as compared with that of control individuals. The anisocoria (the difference in pupillary size in the same individual) observed was not significantly different between the patient group and control individuals either in the basal state (before pharmacologic stimulation) or after pharmacologic stimulation. The mydriasis resulting from the instillation of the three sympathicomimetic drugs was symmetrical in both controls and patients both during and between the pain attacks. This finding is in clear contrast to what is found in cluster headache, in which there is a "Horner-like" syndrome on the symptomatic side. These two headaches thus seem to differ essentially with regard to this variable.     

Cervicogenic headache: invasive procedures

A review of the most important invasive treatment options for cervicogenic headache is given. The methods are briefly described and discussed.     

Cervicogenic headache: Manual and manipulative therapies

This article reviews current literature on the role of manual medicine in the diagnosis and treatment of cervicogenic headache. Manual diagnostic procedures and treatment procedures are described for the cervical spine. Emphasis is placed on accurate diagnosis using a biomechanical model and precise localization of forces. Muscle energy technique is suggested as a safe and effective treatment when somatic dysfunction of the cervical spine is found in association with the diagnostic criteria for cervicogenic headache. Lastly, a suggested clinical approach to this problem from a manual medicine perspective is given.     

Cervicogenic headache: long-term postoperative follow-up

The patient, a 50-year old female had been suffering from right-sided head- and neck pain since she was 31 years of age. It started in connection with an indirect neck trauma. Analgesics were of little or no avail and operative procedures, including liberation of the greater occipital nerve (GON) (n = 2) and decompression of the C2 ganglion/root, had only a transitory effect. At 42, a magnetic resonance scan of the cervical spine demonstrated a degenerated disk C5-C6, with encroachment on the foramina and the cord. At 42 years of age, a stabilization operation at C5-C6 (Robinson-Smith) alleviated her discomfort--only some motor complaints in the ipsilateral upper extremity remaining and only in the first 12-18 months.     

Cervicogenic headache: The forehead sweating pattern

Forehead sweating in 11 patients with cervicogenic headache was tested with the Evaporimeter. All were studied during heating experiments, 2 patients during exercise, and 10 patients after pilocarpine stimulation. Five patients were studied during spontaneous attacks. The evaporation during spontaneous attacks was symmetrical. This was also the case after heating, exercise, and pilocarpine stimulation. These findings differ clearly from the situation in cluster headache. These observations indicate that cervicogenic headache and cluster headache differ fundamentally with regard to autonomic involvement.     

"Cervicogenic headache": Clinical manifestation

The main criteria of "cervicogenic headache" are considered to be as follows: relatively rare and long-lasting unilateral attacks of severe headache, although seemingly of a non-excruciating character, signs of neck involvement, and lack of "cluster pattern". In the present communication, the clinical manifestations in 11 patients fulfilling these criteria are described. All 11 patients selected in accordance with these criteria proved to be females, the age at onset ranging from 6 to 40 years (mean, 30 years). The mean duration of symptoms was 13 years. Six patients had had previous head/neck injuries. All patients had pain periorbitally, in the temporal region, and in the low occipital region (nape of the neck); less frequent were frontal, parietal, and facial pain and pain in the upper part of the occipital region. The duration of attacks was from 3 h to 3 weeks, and the interval between attacks lasted from 2 days to 2 months. The commonest accompanying phenomena were phonophobia, dizziness, ipsilateral eyelid edema, ipsilaterally blurred vision, and irritability. Some of the patients also had nausea (n = 7) and vomiting (n = 6). On physical examination, slight to moderate reduction of movements in the neck was noted, and five patients had ipsilaterally reduced sensation for touch in the trigeminal area. All the patients except one were severely afflicted. Attacks could, in addition to occurring spontaneously, be precipitated in all patients by head movements or by pressure at specific points in the neck.     

Cervicogenic headache: Diagnostic evaluation and treatment strategies

Cervicogenic headache is a chronic, hemicranial pain syndrome in which the source of pain is located in the cervical spine or soft tissues of the neck but the sensation of pain is referred to the head. The trigeminocervical nucleus is a region of the upper cervical spinal cord where sensory nerve fibers in the descending tract of the trigeminal nerve converge with sensory fibers from the upper cervical roots. This convergence of upper cervical and trigeminal nociceptive pathways allows the referral of pain signals from the neck to the trigeminal sensory receptive fields of the face and head. The clinical presentation of cervicogenic headache suggests that there is an activation of the trigeminovascular neuroinflammatory cascade, which is thought to be one of the important pathophysiologic mechanisms of migraine. Another convergence of sensorimotor fibers has been described involving intercommunication between the spinal accessory nerve (CN XI), the upper cervical nerve roots, and ultimately the descending tract of the trigeminal nerve. This neural network may be the basis for the wellrecognized patterns of referred pain from the trapezius and sternocleidomastoid muscles to the face and head. Diagnostic criteria have been established for cervicogenic headache but its presenting characteristics may be difficult to distinguish from migraine, tension-type headache, or hemicrania continua. A multidisciplinary treatment program integrating pharmacologic, nonpharmacologic, anesthetic, and rehabilitative interventions is recommended. This article reviews the clinical presentation of cervicogenic headache, its diagnostic evaluation, and treatment strategies.     

Cervicogenic headache after whiplash injury

Cervicogenic headache (CEH) with pain radiating from the neck to the forehead is a common finding after whiplash injury. In most whiplash studies, the whiplash headaches are not defined. Post-whiplash CEH typically is a moderate headache with a benign, but often prolonged course. It probably is unilateral and bilateral. Reduced neck mobility does not seem to be as common after whiplash as in chronic CEH in general. Post-whiplash CEH is accompanied by great disability and high use of medication. Although the natural course seems favorable for unilateral CEH during the first postinjury years, some patients will need specific treatment for their headaches. There is a lack of controlled studies to guide practitioners to choose investigations and treatment for chronic CEH.     

Cervicogenic headache: lack of influence of pregnancy

The influence of pregnancy upon the head pain of cervicogenic headache (CEH) has been studied in 14 patients (number of pregnancies 25). Migraine was used as control group (n = 49; number of pregnancies 116). CEH was diagnosed according to The Cervicogenic Headache International Study Group guidelines. Migraine was diagnosed according to International Headache Society (IHS) guidelines; a further requirement was that at least eight of nine solitary IHS diagnostic requirements of migraine were present. In 79%-or more-of CEH patients, attacks seemed to appear just as usual during pregnancy; in one patient, attacks stopped completely, and in two there may have been a minor reduction of attacks. A significantly lower number of migraine patients (up to 18%) were more or less uninfluenced by pregnancy (CEH vs. migraine P < 0.0001, chi2 test). The lack of response to pregnancy may be a sort of biological marker in CEH. It may also help in clinically distinguishing CEH from migraine when CEH starts early in life, i.e. prior to pregnancies.     

Cervicogenic Headache Part 1: An Anatomic and Clinical Overview

Abstract

Cervicogenic headache is a headache arising from painful dysfunction of the upper cervical spine. This paper reviews current literature on the anatomy, etiology, clinical presentation and differential diagnosis of cervicogenic headache. Lower cervical spine levels and cervical soft tissue components will be incorporated where they have a direct influence on the upper three segments.     

Cervicogenic headache: locus of control and success of treatment

BACKGROUND: A number of extraneous factors have been implicated in the effectiveness of treatment of headache, including patient beliefs about aspects of the treatment or persons delivering the treatment. OBJECTIVE: The concept of external locus of control for headaches refers to patients with a high level of belief that headache and relief are influenced primarily by health care professionals. The aim of this study was to examine whether external locus of control is associated with a reduction in frequency of cervicogenic headaches among patients treated by a physiotherapist. DESIGN: A recent randomized controlled trial of the effectiveness of physiotherapy among 200 patients with headache enabled a test of this relationship. Treatment consisted of manipulative therapy, therapeutic exercise, or a combination of the 2. Analysis of relative change in headache frequency was conducted after 6 weeks of treatment and at 3- and 12-month follow-up appointments. RESULTS: Results of the analysis indicated that participants with relatively high external Headache-Specific Locus of Control scores were more likely to achieve a reduction in headache frequency if they received the combined manipulative therapy and exercise therapy, compared with those who received no treatment. This was not determined for the group who received manipulative therapy, which is a treatment received passively by the patient. CONCLUSIONS: The interpretation of these findings is considered in the context of nongeneralization to the other physiotherapy treatment groups and sustained reduction in headache frequency following withdrawal of treatment. The pattern of findings suggests that characteristics of the therapy were more pertinent than characteristics of the therapist.     

Cervicogenic headache: Interventional,anesthetic, and ablative treatment

Cervicogenic headache is becoming an accepted clinical syndrome in which headache pain is thought to originate from the cervical spine. Unfortunately, there are no diagnostic imaging techniques of the cervical spine and associated structures that can determine the exact source of pain. Therefore, diagnosis and treatment are based on the major accepted criteria of clinical presentation and the use of diagnostic nerve blocks to identify the source of the pain generator before considering further interventional or neuroablative treatment. This suggests that consistent reproducible anatomic and neurophysiologic pathways exist for the reproduction of typical clinical pain patterns and the ability of neuroblockade to consistently interrupt these pain pathways. This article describes the essential anatomy required to understand the use of diagnostic nerve blocks, and their predictive value in anticipating response to neuroablative and interventional therapy with a review of the major interventional, anesthetic, and ablative techniques for cervicogenic headache.