Cervicogenic Headaches

Description

Cervicogenic headache pain arises from the anatomic structures of the neck. These include the atlanto-occipital joint and the upper cervical joints. The presentation can be similar to primary headache syndromes often resulting in a misdiagnosis.

Causes

Any abnormality of the cervical vertebrae can cause cervicogenic headaches. The roots of the upper three cervical spinal nerves share a nerve pain pathway with a major sensory nerve in the face known as the trigeminal nerve. Because of this shared pathway, the pain associated with these headaches is sensed as arising in the head even though the origin is in the bones of the neck. Cervicogenic headaches can arise secondary to chronic wear and tear in the neck vertebrae or after trauma such as whiplash after a car accident.

Symptoms

More often observed in females, cervicogenic headaches present with one-sided pain. The pain can episodic or continuous and resemble the pain of tension headaches or migraine headaches. Motion at the neck is limited. Sensitivity to light or sound, nausea and vomiting are not as common as they are in other headache syndromes. The pain is provoked with movement at the neck or by applying pressure at tender points in the neck.

Diagnosis

The diagnosis starts with a careful history and physical exam. Tenderness, including at the base of the skull, and worsening of pain with motion of the head and neck are relevant in establishing the diagnosis. The radiographic workup may include x-rays of the neck in multiple positions, x-rays of the head, a CT scan and an MRI scan. Several diagnostic nerve blocks performed one at a time to pinpoint the anatomic location of the pain may be necessary as well.

Management

Treating cervicogenic headaches varies according to severity and the presentation of the patient. Medications include over-the-counter and prescription pain medications. Some of these include:

  • NSAIDs or non-steroidal anti-inflammatory medications such as aspirin or ibuprofen

  • Muscle relaxants

  • Anti-seizure medications

  • Antidepressants

Physical therapy can be beneficial as well as it is a useful treatment modality for many musculoskeletal problems. The physical therapist evaluates the patient and formulates a custom treatment program that can include stimulating the soft tissues and joints to alleviate painful symptoms.

Transcutaneous electrical nerve stimulation is therapeutic modality in which small (non-painful) electrical signals are transmitted through the skin using electrodes. These stimulate nerves near the source of the pain and can alleviate symptoms at least temporarily.

Nerve blocks are injected by the physician near pain sensing nerves and into joints that are suspected to be the source of the pain. The nerve block may include a small amount of steroid medication to reduce inflammation at and near the source of the pain. They provide relief for short to intermediate periods of time and can be repeated if and when the pain returns.

Radiofrequency ablation uses radio waves to heat the tip of a needle that is applied to a sensory nerve responsible for transmitting pain from the source. The nerve is essentially destroyed and can no longer transmit pain. Since it is not a motor nerve, there are typically no resultant deficits in movement or motion resulting from the procedure.

If all else fails, surgery can be considered. Neuromodulation surgery involves placing electrodes on the back of the neck. These electrodes are then connected to a pulse generator. The generator delivers electrical stimulation via the electrodes to the occipital nerve, reducing pain by interfering with nerve signal transmission.