Headaches affect up to 15.8% of the world’s population every day.1 Among those who experience chronic headaches, it is estimated that 15-20% of cases are “cervicogenic headaches” (CGH). CGH are defined by pain referred to the head from the bony structures or soft tissues of the neck. Risk factors for CGH include occupations and activities which put the head and neck in strenuous positions such as a prolonged forward head posture. Degenerative changes and injury to upper cervical structures also increase the risk of CGH. A literature review showed that the symptoms of CGH tend to be chronic, with a mean age of presentation of 42.9 years and a 4:1 female disposition.2
The first three cervical spinal nerves (C1-C3) are the primary peripheral nerve structures that refer pain to the head via the trigeminocervical nucleus (region of the upper cervical spinal cord that relays sensory information). The C1 spinal nerve (suboccipital nerve) innervates the atlanto-occipital (A-O) joint, and pathology at this joint refers pain to the occipital region of the head. The C2 spinal nerve innervates the atlanto-axial (C1-C2) joint, and pathology at this joint results in unilateral occipitocervical and parietal skull pain. The third occipital nerve (TON), which is the superficial medial branch of the C3 dorsal ramus, innervates the C2-3 facet joint, and pathology at that joint refers pain to the occiput, frontotemporal, and periorbital regions of the head.3 Finally CHG may also arise from the C3-4 facet joint which is innervated by the medial branches of C3 and C4 dorsal rami. Notably, the C2-3 facet joint is the most common cause of CGH, accounting for around 70% of cases, while the C1-2 joint is the second most common.4
Diagnosis of CGH can be established with a combination of history, physical exam, imaging, and diagnostic spinal blocks as defined by the Cervicogenic Headache International Study Group (CHISG) and the International Classification of Headache Disorders, 3rd edition (ICHD-3).
CGH typically presents as unilateral headaches that are precipitated by neck movement. These headaches usually are non-throbbing and do not shift from side to side. Patients may have ipsilateral pericranial muscle tenderness either at the base of the skull or in the upper cervical paraspinal muscles.5
It is important to rule out other common causes of headache such as migraine (unilateral, gradual onset, aura, light and sound sensitivity), sinus (frontal, nasal congestion, allergies), tension (bilateral pressure, waxes and wanes), and cluster headaches (unilateral, sudden onset, nasal discharge, red or tearing eyes).6 It is important to note, however, that CGH may occasionally present with similar features to other common causes of headache.
Assessment should always include a careful evaluation for “red flag” signs such as sudden onset, worsening or extreme severity of pain, focal neurologic signs (weakness, numbness, vision changes), or systemic signs (fevers, night sweats) which may be indicative of more dangerous causes of headache such as brain aneurysm, stroke, cancer, or infection.7
A thorough physical exam including a neurologic assessment is an important part of the workup of CGH. Common findings include pain with palpation of the upper cervical joints, restricted neck range of motion (ROM), and reduced activation of the deep neck flexors.8 A 2021 systematic review and meta-analysis found that, compared to individuals without CGH, CGH patients generally had reduced flexion, lateral flexion, and flexion-rotation ROM, reduced cervical lordosis angle, and decreased neck flexion and extension strength.9
X-ray, CT scan, or MRI imaging may identify pathology in structures which are associated with CGH, such as arthritic changes in the A-O, C1-2 and C2-3 joints. Imaging also helps rule out secondary causes of pain which may be more dangerous such as a mass or infection.
While history, physical exam, and imaging help diagnose CGH, definitive diagnosis is often confirmed via controlled, fluoroscopically-guided anesthetic blocks of the upper cervical structures. The block is generally considered diagnostic if there is ≥80% pain relief. These include:
- The lateral C1-2 joint, by intra-articular block
- The C2-3 facet joint, by blocking the TON
- The C3-4 facet joint, by medial branch blocks (MBB) of the C3 and C4 dorsal rami10
Physical therapy- A 2013 systematic review found good quality evidence supporting the use of exercise, cervical manipulation, and mobilization to treat CGH.11
Pharmacologic treatment– Due to limited studies, current evidence suggests that pharmacologic therapy does not show clear benefit for treatment of CGH, however, anti-inflammatory and neuropathic pain medications can be trialed. A small randomized controlled trial found that pregabalin (Lyrica), a type of nerve pain medicine, was effective in decreasing the frequency of CGH.12
- Steroid injection- Results from small, retrospective studies suggest that steroid injections at the lateral C1-2 joint provide short term relief for patients with CGH, however frequent steroid injections may lead to increased joint degeneration and osteoporosis.13
- Radiofrequency ablation– For patients with cervical facet arthritis who have diagnostic pain relief with initial and confirmatory MBB, the next step is treatment with radiofrequency ablation (burning of the pain nerves), which can provide >50% pain relief for 9 months or longer.14
- Neuromodulation- Advances in pain modulation using spinal cord and peripheral nerve stimulation may present new treatment options for those who suffer from CGH. A small study using occipital nerve stimulation for patients with refractory CGH found that 69% had ≥50% pain relief at one year .15
Surgery- Surgery is generally not recommended for treatment of CGH unless the patient has failed non-operative management. In these cases, some studies show potential benefit of C2 spinal nerve decompression and fusion for lateral C1-2 joint arthritis.16 17
Cervicogenic headaches can become chronic and debilitating if left untreated. If you are experiencing headaches associated with neck pain, please call to schedule an appointment at Desert Spine and Sports Physicians so that our team of physiatrists can help diagnose and treat your issue. We offer appointments and in-office procedures at all of our Phoenix, Scottsdale, and Mesa locations, and we look forward to helping decrease your pain and improve your function.
- Stovner LJ, Hagen K, Linde M, Steiner TJ. The global prevalence of headache: an update, with analysis of the influences of methodological factors on prevalence estimates. J Headache Pain. 2022;23(1):34. Published 2022 Apr 12. doi:10.1186/s10194-022-01402-2
- Haldeman S, Dagenais S. Cervicogenic headaches: a critical review. Spine J. 2001;1(1):31-46. doi:10.1016/s1529-9430(01)00024-9
- Bogduk N. Cervicogenic headache: anatomic basis and pathophysiologic mechanisms. Curr Pain Headache Rep. 2001;5(4):382-386. doi:10.1007/s11916-001-0029-7
- Bogduk N, Govind J. Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. Lancet Neurol. 2009;8(10):959-968. doi:10.1016/S1474-4422(09)70209-1
- Pöllmann W, Keidel M, Pfaffenrath V. Headache and the cervical spine: a critical review. Cephalalgia. 1997 Dec;17(8):801-16. doi: 10.1046/j.1468-2982.1997.1708801.x. PMID: 9453267.
- Wootton JR. Evaluation of headache in adults. UpToDate. https://www.uptodate.com/contents/evaluation-of-headache-in-adults. Accessed June 18, 2022.
- Red flags in headache-what if it isn’t migraine? American Headache Society. https://americanheadachesociety.org/news/red-flags-in-headache-what-if-it-isnt-migraine/. Published July 16, 2021. Accessed June 11, 2022.
- Jull G, Amiri M, Bullock-Saxton J, Darnell R, Lander C. Cervical musculoskeletal impairment in frequent intermittent headache. Part 1: Subjects with single headaches. Cephalalgia. 2007 Jul;27(7):793-802. doi: 10.1111/j.1468-2982.2007.01345.x. PMID: 17598761.
- Anarte-Lazo, E., Carvalho, G.F., Schwarz, A. et al. Differentiating migraine, cervicogenic headache and asymptomatic individuals based on physical examination findings: a systematic review and meta-analysis. BMC Musculoskelet Disord 22, 755 (2021). https://doi.org/10.1186/s12891-021-04595-w
- Watson JC. Cervicogenic headache. UpToDate. https://www.uptodate.com/contents/cervicogenic-headache. Accessed June 19, 2022.
- Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine (Phila Pa 1976). 2002 Sep 1;27(17):1835-43; discussion 1843. doi: 10.1097/00007632-200209010-00004. PMID: 12221344.
- Boudreau GP, Marchand L. Pregabalin for the management of cervicogenic headache: a double blind study. Can J Neurol Sci. 2014 Sep;41(5):603-10. doi: 10.1017/cjn.2014.2. PMID: 25373811.
- Narouze SN, Casanova J, Mekhail N. The longitudinal effectiveness of lateral atlantoaxial intra-articular steroid injection in the treatment of cervicogenic headache. Pain Med. 2007 Mar;8(2):184-8. doi: 10.1111/j.1526-4637.2006.00247.x. PMID: 17305689.
- Kapural L, Mekhail N. Radiofrequency ablation for chronic pain control. Curr Pain Headache Rep. 2001;5(6):517-525. doi:10.1007/s11916-001-0069-
- Eghtesadi M, Leroux E, Fournier-Gosselin MP, Lespérance P, Marchand L, Pim H, Artenie AA, Beaudet L, Boudreau GP. Neurostimulation for Refractory Cervicogenic Headache: A Three-Year Retrospective Study. Neuromodulation. 2018 Apr;21(3):302-309. doi: 10.1111/ner.12730. Epub 2017 Nov 27. PMID: 29178511.
- Pikus HJ, Phillips JM. Characteristics of patients successfully treated for cervicogenic headache by surgical decompression of the second cervical root. Headache. 1995 Nov-Dec;35(10):621-9. doi: 10.1111/j.1526-4610.1995.hed3510621.x. PMID: 8550364.
- Schaeren S, Jeanneret B. Atlantoaxial osteoarthritis: case series and review of the literature. Eur Spine J. 2005 Jun;14(5):501-6. doi: 10.1007/s00586-004-0856-4. Epub 2005 Feb 4. PMID: 15692824; PMCID: PMC3454662.