Cervicogenic Headaches

The pain of cervicogenic headaches is thought to start in the neck and then spread into the back of the head. When severe cervicogenic headaches can affect the entire head as well as structures served by several cranial nerve nuclei.

Cervicogenic Headaches is the currently preferred term to describe a group of chronic headaches including occipital neuralgia with symptoms in the distribution of the greater and lesser occipital nerves. Initially the pain is episodic and primarily one sided. Patients describe the pain as beginning in the area of the occipital protuberance and then spreading to involve the entire scalp on the affected side. The headache is commonly associated with neck pain that is aggravated by turning the head to the affected side. In severe cases the pain will spread across the midline and forward to an area deep behind the eye. In particularly severe cases patients will report symptoms referable to the fifth cranial nerve, including temperomandibular joint (TMJ) pain, tooth pain, maxillary or mandibular pain and/or the eighth cranial nerve, commonly a sense of fullness in the ear, mastoid pain, nausea, dizziness and even true vertigo.

 

For years the site of primary pathology was felt to be in the upper cervical facet joints and/or their innervating cervical branches. There is often a history of trauma, most commonly vehicular. In most cases imaging studies will demonstrate upper cervical facet joint arthritis, most commonly at C2-3. Many have begun to doubt this as the pathophysiologic mechanism for a number of reasons. A history of trauma is not always obtainable and the degree of arthritis and its location is poorly correlated with the severity of symptoms. In addition joint injections at C2-3 are sometimes effective at relieving the associated neck pain and movement limitations, but relief the headache is often transient.

 

The diagnosis of cervicogenic headaches begins with a careful history and supporting findings on the physical exam. Diagnostic nerve blocks such as greater and lesser occipital blocks or cervical median branch blocks are often the next step. In cases where a prolonged response to diagnostic injection is observed the blocks can be repeated with complete resolution of symptoms. In other cases ablative treatments such as radiofrequency ablations (RFA) are often effective initially, but tend to fail as the disease progresses. In its later neuropathic stages the stimulation is the treatment of choice. For people with intermittent symptoms, individual attacks can sometimes be broken with a TENS unit, but anatomical factors (primarily hair and muscle mass) related to lead placement and stability of the leads limits the application of this technique to more continuous pain syndromes. For these cases a trial of spinal cord stimulation is warranted. Occipital nerve and cervical field stimulation is extremely effective in treating cervicogenic headaches.

 

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