OrthoNeuroSpine & Pain Institute
Cervicogenic (say: SUR-vico jen-IK) headache is not a single disorder. It means that the source of headache is a problem in the neck. This can come from a wide range of other causes, from traumatic injury to arthritis. The International Headache Society is responsible for classifying headaches and deciding what to call them. They consider headache coming from whiplash injuries or myofascial pain as different headaches, but they have similar symptoms, and are treated in the same way. Cervicogenic headaches happen to about 1% (1 out 100) of the general population. They are a common cause of headache that happens daily.
Signs and symptoms
- Pain is most often on one side of the head only.
- It is often a dull or piercing pain, starting in the back of the head or the neck, and moving forward to the forehead or temples.
- Headache can occur with pain and stiffness in the neck.
- Headache can occur with pain or stiffness in the shoulder and arm on the same side.
- Some people have some mild sensitivity to light and sound, and even nausea and vomiting with severe pain. This can cause confusion between headache and migraine.
A stated above, there are many causes of cervicogenic headache. We think that the reason neck pain causes headache is that there is a place in the upper part of the spinal cord where sensory nerve fibres from the neck meet sensory nerve fibres from the trigeminal nerve. This nerve transmits signals related to headache. This results in what we call referred pain. In this case, pain caused by structures in the neck is felt in the head.
There is a set of diagnostic criteria established by the International Headache Society. It. includes a number of the signs and symptoms listed above. Sometimes, an injection of local anaesthetic can be done into the muscles in the back of the head. This temporarily blocks the greater occipital nerve. This results in a decrease in pain for many people with cervicogenic headache. The results are temporary, so this is a diagnostic test, not a treatment strategy. Other injections such as facet joint injections or medial branch blocks can help to diagnose the problem in a similar way.
There is a lot of debate about the best way to treat a cervicogenic headache. Researchers are trying to find the best approach. Treatment should be aimed at the problem in the neck if possible. In most cases, this will involve physiotherapy and exercise to strengthen the deep, spine-stabilizing muscles.
There are no medicines that are specific to cervicogenic headache. Sometimes, over-the-counter medicines such as anti-inflammatories or acetaminophen can stop or reduce the intensity of a headache. In cases of severe headache affecting function, opioids can be considered. However, be careful not to use any of these medicines on more than 10 days per month. Doing so can cause you to develop a medication overuse headache.
There is often some overlap between the symptoms of migraine and cervicogenic headache Migraine sufferers often describe neck pain as a trigger for migraine. In those cases, migraine medicines might be tried for a headache that seems to come from a problem in the neck.
Many researchers have studied injections of many types to treat cervicogenic headache. These include steroids, local anaesthetics, and botulinum toxin (Botox) injected into various structures in the neck. In very severe cases, spinal surgery has been tried as well. There are no convincing studies that show an improvement in headache after surgery.
Studies have shown that non-drug therapies can help to reduce pain levels and enhance pain coping. These include:
- activity pacing
- cognitive behavioural therapy
Cervicogenic headache is classified as a secondary headache.
Classifying what type of headache you have can be vitally important, as it will help your physiotherapist to determine the best course of treatment for you. Not bothering to identify the type of headache you have, and more importantly its cause, could be a costly mistake. It’s really a matter of being safe rather than sorry!
What is the cause of a cervicogenic headache and how is it diagnosed?
Cervicogenic headache (CGH) is usually characterized by pain that is referred to the head from the cervical spine (the neck region). Clinical studies have shown that pain from the upper
cervical joints and muscles can often refer pain into the head. Strangely, if these pain sensitive structures become irritated we can often feel pain that is more prominent in the head than it is in the neck.
￼Medical experts believe that the reason neck pain can cause a headache is due to the ‘convergence’ (the coming together) of sensory nerve fibres from the neck and sensory nerve fibres from the trigeminal nerve (the nerve that supply’s the sensation of the face and scalp). This convergence effectively makes it very difficult for the brain to interpret where exactly the pain is coming from and effectively transmits signals related to what we typically feel when we have a headache. This is why it is often called referred pain.
A whiplash injury or poor sitting posture is one common cause of this type of headache. Arthritis can be a contributing factor. There are as many as 20 muscles in the neck region as well and a dysfunction in how these muscle work collectively in controlling head and neck movement can often cause significant problems.
Some other facts regarding CGH:
- In the general population, around 1% or 2% suffer from cervicogenic headaches.
- About 20% of those who have chronic headaches are diagnosed as having the cervicogenic type
- About 4 times as many women than men suffer from this type of headache
- The frequency and severity of a cervicogenic headache can vary greatly, but those who suffer from this type of headache often experience it on an almost daily basis.
With a cervicogenic headache, pain will often start of in the neck region first, whereas it normally starts in the head with Migraine’s and tension-type headache sufferers. Cervicogenic headaches are also side- specific and do not fluctuate from side to side like a migraine headache can.
“The presence of relevant physical signs in the musculoskeletal system is fundamental to the diagnosis of cervicogenic headache” (Classification Committee of the International Headache Society 1988).
How can Physiotherapy Assessment and Treatment help?
A patient’s history and clinical presentation is vital in helping your physiotherapist to know whether their symptoms are consistent with cervicogenic headache. They will often ask you questions such as the location, severity, frequency and duration of you headache symptoms. What movements and postures typically bring on a headache episode and what you can do to make things easier.
Two recent studies by Jull et al. (2) and Amiri et al. (3) have reported three measures that collectively have 100% sensitivity and 94% specificity in distinguishing cervicogenic headaches from migraine or tension- type headaches. The three measures are reduced range of motion of the cervical spine, especially for extension; the presence of painful joint dysfunction in the upper cervical joints (C0-3); and impairment in muscle function, specifically a lack of endurance in the deep flexors of the neck.
At Richmond Physiotherapy our team of highly experienced physiotherapists have been trained to recognize these findings and employ appropriate manual therapy techniques to the cervical spine and associated soft tissue structures to regain range of motion and restore normal joint mechanics to the cervical spine along with instructing patients in a specific and evidence based exercise program that addresses the deep neck flexors and the stabilising muscles of the scapular area. This will also help to stimulate the process of healing and repair by facilitating normal movement and loading stresses around the symptomatic joints. Studies have documented a 76% success rate with a combination of these treatment interventions, whereby patients reported a more than 50% decrease in headache frequency and 35% achieved complete resolution of symptoms following seven weeks of treatment (4)
Medication for Cervicogenic Headache:
Medication alone seldom serves as an adequate treatment for cervicogenic headache although medication can sometimes provide a measure of relief. When medication is prescribed, it typically is an antidepressant, and anti-inflammatory, an analgesic, or an antiepileptic drug. It takes an expert to determine the type of medication best suited and your physiotherapist will be able to both guide you and liaise with your GP.
Medication-induced headaches are more common that you may think and are caused by taking painkillers for migraines or headaches too regularly. In fact it is now recognized as the third most common cause of headache. By taking medication such as codeine, ibuprofen, paracetemol and Triptans (more specifically used for migraines) too frequently, your body becomes used to the effects of the drugs. A “rebound” or withdrawal headache may then develop if you do not take another one. As a result, you may end up getting stuck in a vicious cycle of having to rely on taking medication every day in order to keep the headache at bay.
What can I do to help prevent headaches?
- Maintain a good sitting posture
- Avoid prolonged periods of sitting or static postures in general
- Ask your employer about having an appropriate workstation assessment
- Avoid getting overtired to the point of exhaustion
- Keep yourself well hydrated throughout the day
- Exercise regularly to stimulate the circulation of blood to the head and to maintain neuro-musculoskeletal flexibility.
- Try not to sleep on your stomach. ither sleep on your side with your head supported so that it is level with your spine, or on your back with a small pillow or rolled up towel supporting your neck rather than your head.
What may cause cervicogenic headaches?
Any type of neck condition can result in these types of headaches, including; degenerative cervical spine disease (arthritis), a disc prolapse in the neck, or a whiplash injury.
What are the symptoms of cervicogenic headaches?
Cervicogenic headaches typically cause pain at the back of the head. This pain may spread to the top of the skull and sometimes to the forehead or temple. It may also be associated with pain or discomfort behind the eye.
There is often, but not always, associated neck pain or discomfort, and sometimes the neck pain and headaches become more or less severe at the same time.
Nausea, poor concentration and irritability are frequent symptoms.
What are the other possible diagnoses?
Cervicogenic headaches may resemble occipital neuralgia, which is a condition that causes localised pain and neurological abnormalities in the distribution of the occipital nerves at the back of the head.
Migraines may also be confused with cervicogenic headaches. An opinion from a neurologist is frequently sought to be more certain of the diagnosis.
How are cervicogenic headaches treated?
It is important to try to determine exactly which structures in the neck are causing the headaches. Once this has been done, an appropriate treatment may be prescribed.
Initially, cervicogenic headaches are treated with pain medications and physiotherapy. Avoidance of aggravating activities is important.
Constant cervicogenic headaches arising from the facet joints may respond to percutaneous radiofrequency denervation (where the nerves over the joints are damaged by controlled heating through a needle in the back of the neck). A facet joint block with local anaesthetic (and often steroids) is usually performed first to confirm the diagnosis.
C2 radiofrequency pulse ganglionotomy is another technique which may benefit some patients, particularly if C2 nerve root compression is thought to be involved in the production of the headaches.
Cervicogenic headaches secondary to cervical disc prolapse or nerve root compression often (but not reliably) improve with microsurgical discectomy and fusion.
Peripheral nerve stimulation of the greater and lesser occipital nerves (also known as occipital nerve stimulation) is an effective technique in patients with cervicogenic headaches (as well as migraines and occipital neuralgia). It appears that around 70% of patients who are resistant to other conventional therapies may benefit from this fairly low-risk surgical technique.