Cervicogenic headache

What is cervicogenic headache?

A headache caused by problems of the cervical spine is called a cervicogenic headache (CHA).  CHAs are seen in about three percent of the general population, but make up 20% of the headaches seen in an interventional pain clinic.  CHAs are also 4 times more common in women. CHAs can be caused by trauma to the head and neck, osteoarthritis of the cervical spine joints, and  motor vehicle accidents.

What are the findings?

The symptoms of a CHA can mimic those of a migraine, making the diagnosis difficult.  However, there are some subtle differences.The pain of CHAs is usually on one side of the head and doesn’t change sides, is triggered by neck movement, or sustained or awkward neck positions (particularly looking up and behind).

Unilateral head or face pain without sideshift; the pain may

occasionally be bilateral

 

Pain localized to the occipital, frontal, temporal or orbital

regions

 

Moderate to severe pain intensity

 

Intermittent attacks of pain lasting hours to days, constant

pain or constant pain with superimposed attacks of pain

 

Pain is generally deep and nonthrobbing; throbbing may

occur when migraine attacks are superimposed

 

Head pain is triggered by neck movement, sustained or

awkward neck postures; digital pressure to the suboccipital, C2,

C3, or C4 regions or over the greater occipital nerve; valsalva,

cough or sneeze might also trigger pain

 

Restricted active and passive neck range of motion; neck stiffness

 

Associated signs and symptoms can be similar to typical migraine

accompaniments including:

— nausea;

— vomiting;

— photophobia, phonophobia,  and dizziness;

— others include ipsilateral blurred vision, lacrimation and conjunctival injection or ipsilateral neck, shoulder  or arm pain

On physical examination, pressure on the base of the head and upper cervical spine joints causes considerable pain and may trigger headaches. Loading the neck joints by pushing down on the head while it is extended and twisted, will reproduce neck pain and may also reproduce headaches.

There is also associated stiffness in the neck and decreased range of motion.CHAs are also associated with shoulder pain and occasionally arm pain on the side of the headache.

X-rays will often show degeneration or collapse of the disc and arthritic joints of the cervical spine called facet joints.The arthritic facet joint is the primary cause of CHAs, and the most amenable to treatment.   Pain from each inflamed cervical joint is referred (felt at a site distant from the source of pain) to a specific place on the head, neck or shoulders.

If the exam, history and x-ray films suggest facet joint pain, then diagnostic testing can be performed to determine the precise location of pain.Facet joint or medial branch injection can be performed to numb the joint(s) in question.  A small amount of local anesthetic is placed on the nerve (called the medial branch), which transmits pain signals from the facet joint.  If the pain is relieved and the range of motion is improved after an injection, then that specific joint(s) is most likely the cause of the pain.

The duration of relief can be either short or long term.  A good response to diagnostic blocks of the facet joints predict a good response to radiofrequency ablation of the facet joint nervesRadiofrequency ablation utilizes a special needle, which heats the tissue around the needle tip.  This creates a small “burn” over the nerve to the painful facet joint.

The painful joint is semi-permanently anesthetized or numbed,  and symptoms may not return until 9 to 18 months when the nerve grows back.  Aside from reduction in pain intensity, the nerve blocks allow for greater participation in physical therapy and rehabilitation.

Sustained long-term improvements in pain reduction, and improved function require consistent attention to body mechanics, posture, and muscle reeducation