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

▪ 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:

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:

▪ Nausea

▪ Phonophobia and photophobia

▪ Dizziness

▪ 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.

▪ The headache may be accompanied by nausea, vomiting, photophobia, phonophobia, dizziness, ipsilateral blurred vision, lacrimation, and conjunctival irritation, making its clinical differentiation from other types of headache difficult.

Atlantooccipital and atlantoaxial joint pain

Atlantooccipital (AO) and atlantoaxial (AA) joint pain is defined as pain arising from the atlantooccipital and atlantoaxial joints. Patients typically present with occipital headaches, which are often associated with suboccipital pain and aggravated by lateral rotation, flexion, and/or extension of the cervical spine (Figs. 9-1 and 9-2) [1].

Figure 9–1 The cervicotrigeminal interneuronal relay: A potential overlap of central neuronal connections occurs between the spinal nucleus of the trigeminal and the upper cervical cord neurons. The trigeminal nucleus develops from the pyramidal decussations and descends to the level of vertebra C2, and perhaps to that of C4, as the nucleus caudalis, which primarily subserves pain and temperature function to the head and neck. This trigeminal nucleus is morphologically and functionally associated with the upper cervical segments, and its cells form a column continuous with the column of cells that form the posterior horn in the cervical cord. CNV, cranial nerve V; V1, ophthalmic division of cranial nerve V; V2, maxillar division of cranial nerve V; V3, mandibular division of cranial nerve V.

From Silverman SB: Cervicogenic headache: Interventional, anesthetic, and ablative treatment. Curr Pain Headache Rep 2002;6:308-314.

Figure 9–2 Referral pain patterns for the atlantooccipital joint (AOJ) (A) and the lateral atlantoaxial joint (AAJ) (B). OA, occipito-atlantal joint; T1, first thoracic vertebra.

Common causes of pain in the AO and AA joints caused by inflammation and adhesion are as follows:

▪ Whiplash-associated disorder (WAD)

▪ Blunt head trauma

▪ Osteoarthritis of the upper cervical spine

Resolution of AO and AA joint pain is often achieved over a 2 to 4 weeks with conservative management. Interventional pain management procedures may be indicated when chronicity sets in and resolution is difficult to achieve with conservative measures.

Box 9.1 summarizes the clinical presentation of AO and AA joint pain.

The mechanisms of AO and AA join pain are summarized in Table 9.4.

Table 9.4 Mechanisms of Atlantooccipital and Atlantoaxial Joint Pain

Atlantooccipital joint pain

▪ Inflammation of joints (degenerative, traumatic, infectious, rheumatoid, etc.)

▪ Synovial joint adhesions

▪ A combination of inflammation, joint adhesions, and loss or reduction of cartilage thickness of joint in advanced cases

▪ Capsular irritation and inflammation leading to sensitivity to stretch (nodding)

▪ Referred pain to the occipital and suboccipital region (headaches)

▪ Referred pain to the temporal region that can extend to the preauricular area to the temporomandibular joint region

Atlantoaxial joint pain

▪ Inflammation (degenerative, traumatic, infectious, rheumatoid)

▪ Intra-articular chondral adhesions

▪ Chronic degenerative loss of intra-articular cartilage in combination with inflammation and/or intra-articular chondral adhesions

▪ Capsular inflammation and irritation due to increase of sensitivity with stretch

▪ Pain referred mostly to the suboccipital region

▪ Possibility of occipital headache (and pain)

▪ Referred pain through C1 to C3 dorsal rami that converge with the trigeminal afferent via the trigeminal afferent via trigeminocervical nucleus; may cause maxillary area V2 pain in the preauricular region

▪ Periauricular muscle spasm (hypertonus and hypertonicity)

▪ Possibility of 60 degrees of horizontal rotation around the odontoid

▪ Possibility of isolated 10 degrees of extension and 5 degrees of flexion of the atlantoaxial joint

Table 9.5 lists the disorders in the differential diagnosis of AO and AA joint pain.

Table 9.5 Differential Diagnosis of Atlantooccipital and Atlantoaxial Joint Pain

Vascular	Vertebral artery aneurysm Temporal arteritis Basilar artery spasm (migraine)
Central nervous system	Inflammation of dura by blood or infection C1-C3 nerve root irritation Arnold-Chiari malformation
Intracranial	Tumor Arteriovenous malformation Hemorrhage
Musculoskeletal	Discopathy of upper cervical spine, e.g., C2-C3 degenerative disc disease and C2-C3 herniation Atlantooccipital and atlantoaxial inflammatory arthropathy (facet) Tender muscle ligaments C2-C3 facet arthropathy