Cervicogenic headache

Cervicogenic headache] (CGH) is defined as referred pain from various cervical structures innervated by the upper three cervicals spinal nerves.

Cervicogenic headaches of suboccipital headaches, retro-orbital pain, retro-auricular pain, or temporal pain may be associated with C2, C3, and C4 radiculopathies. The pain around scapula may be associated with C5, C6, C7, and C8 radiculopathies. However, there is insufficient evidence to make recommendations for the use in clinical practice because they did not evaluate sensitivity and specificity 1).

A comparison has been made between the cervicogenic headache criteria in the new IHS classification of headaches (3(rd) edition- beta version) and The Cervicogenic Headache International Study Group's (GHISG) criteria from 1998. In a more recent version, the CHISG criteria consist of 7 different items. While “core cases” of cervicogenic headache (CEH) usually fulfill all 7 criteria, the IHS classification - 3(rd) edition beta version- fulfills only 3 criteria. Although the new three beta version represents an improvement from the previous one, it does not quite seem to live up to the expectations for a diagnostic system for routine, clinical use 2).

Cervicogenic headache affects a significant portion of the entire population 3).

Include the atlantooccipital joint, atlantoaxial joint, C2-3 zygapophysial joint, C2-3 intervertebral disc, cervical myofascial trigger points, as well as the cervical spinal nerves. Various interventional techniques, including cervical epidural steroid injection (CESI), have been proposed to treat this disorder. And while steroids administered by cervical epidural injection have been used in clinical practice to provide anti-inflammatory and analgesic effects that may alleviate pain in patients with CGH, the use of CESI in the diagnosis and treatment of CGH remains controversial 4).

This type of headache especially with atypical presentation is often hard to diagnose and manage since its etiopathophysiology is not been yet well understood.

A notable portion of patients with cervicogenic headaches can have an atypical presentation mimicking a primary-type headache. However, cervicogenic headaches with atypical presentation can be difficult to diagnose and manage during the initial visit of the patients. Etiopathophysiology of this type of headache could be explained by the theories including discogenic, convergence and sensitization-desensitization theories. When cervicogenic headache is accompanied by CDD, performing ACDF or laminectomy would be the treatment of choice. Surgical intervention can also relieve the accompanying neck, shoulder and extremity pain with minimal complications. Lastly, outcomes of surgical intervention depending on the patients' morbidities including obesity, smoking, and depression 5).

The Cervical Flexion-Rotation Test (CFRT) is widely used in the assessment of upper cervical spine mobility impairments and in the diagnosis of cervicogenic headache (CGH) by physiotherapist. Many studies investigated its different properties, and the results show that the CFRT has good construct validity in the measurement of C1-C2 rotation as well as good to excellent reliability 6).

Suh BK, You KH, Park MS. Can axial pain be helpful to determine surgical level in the multilevel cervical radiculopathy? J Orthop Surg (Hong Kong). 2017 Jan;25(1):2309499016684091. doi: 10.1177/2309499016684091. PubMed PMID: 28176603.
Fredriksen TA, Antonaci F, Sjaastad O. Cervicogenic headache: too important to be left un-diagnosed. J Headache Pain. 2015 Dec;16(1):6. doi: 10.1186/1129-2377-16-6. Epub 2015 Jan 20. PubMed PMID: 25604994; PubMed Central PMCID: PMC4417107.
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Bir SC, Nanda A, Patra DP, Maiti TK, Liendo C, Alireza M, Chernyshev OY. Atypical presentation and outcome of cervicogenic headache in patients with cervical degenerative disease: A single-center experience. Clin Neurol Neurosurg. 2017 May 13;159:62-69. doi: 10.1016/j.clineuro.2017.05.016. [Epub ahead of print] PubMed PMID: 28550817.
Wang E, Wang D. Treatment of cervicogenic headache with cervical epidural steroid injection. Curr Pain Headache Rep. 2014 Sep;18(9):442. doi: 10.1007/s11916-014-0442-3. PubMed PMID: 25091129; PubMed Central PMCID: PMC4148620.
Paquin JP, Dumas JP, Gérard T, Tousignant-Laflamme Y. A perspective on the use of the cervical flexion rotation test in the physical therapy management of cervicogenic headaches. Arch Physiother. 2022 Dec 8;12(1):26. doi: 10.1186/s40945-022-00153-2. PMID: 36476405.
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