Atlantooccipital and Atlantoaxial Joint Block for Cervicogenic Headache

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Chapter 9 Atlantooccipital and Atlantoaxial Joint Block for Cervicogenic Headache

Kyung-Hoon Kim, MD, PhD, Seong-Wan Baik, MD, PhD

Cervicogenic headache

Cervicogenic headache is defined a unilateral headache defined by the following characteristics:

▪ Triggered by movements of head or neck or certain head posture

▪ Triggered by pressure in the neck

▪ Spreading to the neck or possibly the homolateral shoulder or arm

Diagnostic Criteria for Cervicogenic Headache

Tables 9.1and 9.2 summarize the various levels of criteria and the minimum requirements for the diagnosis of cervicogenic headache.

Table 9.1 Sensitivity and Specificity of Diagnostic Criteria in Patients Fulfilling the Criteria for Cervicogenic Headache

Diagnostic Criteria	Specificity	Sensitivity
Major Symptoms and Signs
Unilateral headache	0	1.00
Pain triggered by neck movements and/or sustained awkward head positioning	0.75	0.44
Pain elicited by external pressure over the greater occipital nerve (GON) or the ipsilateral upper, posterior neck region C2-C3	1	0.17
Ipsilateral neck, shoulder and arm pain of a rather vague, nonradicular nature	0.88	0.65
Reduced range of motion in the cervical spine	0.38	0.91
Pain Characteristics
Pain episodes of varying duration or fluctuating continuous pain	0.88	0.78
Moderate, nonexcruciating pain, usually of a nonthrobbing nature	0.86	0.91
Pain starting in the neck, eventually spreading to the oculofrontotemporal area	0	1.00
Other Important Criteria
Anesthetic blockades of the GON or C2 root	1.0	0.18
Patient has sustained neck trauma a relatively short time prior to the onset	0.88	0.65
Minor, More Rarely Occurring, Nonobligatory Symptoms and Signs
Rarely occurring nausea, vomiting, and photophobia and phonophobia	0.88	0.48
Ipsilateral edema and, less frequently, flushing, mostly in the periocular area	0.88	0.09
Dizziness	0.75	0.26
“Blurred vision” in the eye ipsilateral to the pain	1.00	0.22
Difficulty on swallowing	0.88	0.09

Table 9.2 Summary of Minimum Requirements for Diagnosis of Cervicogenic Headache

Definitive for cervicogenic headache (CGH)	Precipitating factors as described by patient and observed by physician Positive result of anesthetic blockade Unilateral pain without side shift
Combination of factors provisional/tentative for CGH	Reduced range of neck motion; ipsilateral shoulder/arm pain Positive result of anesthetic blockade Unilateral pain without side shift

The major criteria of cervicogenic headache are as follows:

1. Symptoms and signs of neck involvement, such as the following:

a. Similar head pain can be precipitated by neck movement and/or sustained awkward head positioning and/or by application of external pressure over the upper cervical or occipital region on the symptomatic side.

b. Restriction of the range of motion in the neck.

c. Ipsilateral neck, shoulder, or arm pain of a rather vague nonradicular nature or, occasionally, arm pain of a radicular nature.

2. Confirmatory evidence from diagnostic anesthetic blockades.

3. Unilaterality of the head pain without side shift.

Characteristics of headache may be described as follows:

▪ Moderate to severe, nonthrobbing, and nonlancinating pain, usually starting in the neck

▪ Episodes of varying duration

▪ Fluctuating, continuous pain

Other important characteristics are as follows:

▪ Indomethacin has only marginal or no effect.

▪ Ergotamine and sumatriptan have only marginal or no effect.

▪ The patient is female.

▪ Not infrequently, history reveals occurrence of head or indirect neck trauma, usually of more than medium severity.

Other features of lesser importance.

The following attack-related phenomena are rare and moderate when present:

▪ Phonophobia and photophobia

▪ Ipsilateral “blurred vision”

▪ Difficulties in swallowing

▪ Ipsilateral edema, mostly in the periocular area

Clinical Characteristics of Cervicogenic Headache

Cervicogenic headache has the following clinical characteristics:

▪ Head or face pain is unilateral. Pain may be on the contralateral side, but there should be profound unilateral dominance; pain may occasionally be bilateral (if structures on both sides are affected).

▪ Pain starts in the neck or occipital region, which may spread to oculotemporofrontal areas and where maximum pain may be perceived.

▪ Pain is of generally a deep, nonthrobbing, and constant character.

▪ Intermittent attacks last hours to days, or pain is constant with superimposed attacks of more severe pain.

▪ Pain is triggered by neck movement or a sustained awkward neck posture.

▪ There is ipsilateral nonradicular neck, shoulder, or arm pain.

▪ Range of motion of the neck is reduced.

▪ Headache pain may be reproduced upon palpation of neck structures.

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