Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment

doi:10.1016/S1474-4422(09)70209-1

The Lancet Neurology

Volume 8, Issue 10, October 2009, Pages 959-968

https://doi.org/10.1016/S1474-4422(09)70209-1 Get rights and content

Summary

Cervicogenic headache is characterised by pain referred to the head from the cervical spine. Although the International Headache Society recognises this type of headache as a distinct disorder, some clinicians remain sceptical. Laboratory and clinical studies have shown that pain from upper cervical joints and muscles can be referred to the head. Clinical diagnostic criteria have not proved valid, but a cervical source of pain can be established by use of fluoroscopically guided, controlled, diagnostic nerve blocks. In this Review, we outline the basic science and clinical evidence for cervicogenic headache and indicate how opposing approaches to its definition and diagnosis affect the evidence for its clinical management. We provide recommendations that enable a pragmatic approach to the diagnosis and management of probable cervicogenic headache, as well as a rigorous approach to the diagnosis and management of definite cervical headache.

Introduction

Cervicogenic headache is pain referred to the head from a source in the cervical spine. Unlike other types of headache, cervicogenic headache has attracted interest from disciplines other than neurology, in particular manual therapists and interventional pain specialists, who believe that they can find the source of pain among the joints of the cervical spine. Neurologists differ in their acceptance of this disorder. The International Headache Society recognises cervicogenic headache as a distinct disorder¹ and one chapter in a leading headache textbook acknowledges that injuries to upper cervical joints can cause headache after whiplash,² although another chapter indicates that this concept is not fully accepted.³

In terms of basic sciences, cervicogenic headache is the best understood of the common headaches. The mechanisms are known, and this headache has been induced experimentally in healthy volunteers. In some patients, cervicogenic headache can be relieved temporarily by diagnostic blocks of cervical joints or nerves. However, a matter that remains contentious is how cervicogenic headache should be diagnosed. Some neurologists maintain that this headache can be diagnosed on clinical features; others are not convinced of the validity of such diagnosis. Manual therapists use manual examination of vertebral motion segments, whereas interventional pain specialists use fluoroscopically guided diagnostic blocks.

In this Review, we provide a synopsis of the available evidence on cervicogenic headache. We summarise the basic mechanisms, analyse the evidence on diagnosis and treatment, and provide recommendations on management.

Section snippets

Mechanism of pain referral

Cervicogenic headache is referred pain from the cervical spine. Physiologically, this pain is analogous to pain felt in the shoulders, chest wall, buttocks, or lower limbs that is referred from spinal sources; hence its familiarity to pain specialists.

The mechanism underlying the pain involves convergence between cervical and trigeminal afferents in the trigeminocervical nucleus (figure 1).4, 5 In this nucleus, nociceptive afferents from the C1, C2, and C3 spinal nerves converge onto

Epidemiology

Estimates of the prevalence of cervicogenic headache differ according to the populations studied and the criteria used to make the diagnosis. When clinical criteria have been used, the prevalence of cervicogenic headache has been estimated to be 1%, 2·5%,¹⁷ or 4·1%¹⁸ in the general population and as high as 17·5% among patients with severe headaches.¹⁷ The prevalence is as high as 53% in patients with headache after whiplash.¹⁹

Diagnosis

The diagnosis of cervicogenic headache has been driven by two schools of practice. The clinical diagnosis approach arose in Europe and was based on the belief that cervicogenic headache had distinctive clinical features by which it could be diagnosed. The approach of interventional diagnosis by pain medicine arose in Australia and North America and was based on establishing a cervical source of pain in patients with headache by use of controlled diagnostic blocks.

Treatment

Although there have been many treatments suggested for cervicogenic headache, few have been tested and even fewer have been proven successful. Among the determinants of effectiveness are whether the headache was diagnosed clinically or whether a cervical source was proven.

A pragmatic clinical approach

The degree to which practitioners might manage cervicogenic headache depends on the facilities available to them. If clinicans can undertake fluoroscopically guided diagnostic blocks, they can establish a cervical source of pain and thereby fulfil the diagnostic criteria for cervicogenic headache as set by the International Headache Society.¹ If physicians are restricted to clinical diagnosis only, they cannot fulfil those criteria. Nevertheless, a working diagnosis of possible or probable

Conclusions

Neurologists are accustomed to diagnosing headache on the basis of clinical features, supplemented in some cases by medical imaging or other tests. Cervicogenic headache does not lend itself to this approach. As a result, tensions and controversies have arisen within the field. On the one hand, some experts have insisted that cervicogenic headache can be defined by clinical criteria, but the evidence shows otherwise. Consequently, owing to the absence of valid clinical criteria, some

Search strategy and selection criteria

References for this Review were identified from the personal libraries of the authors, supplemented by the reference lists of recent reviews and book chapters and by a search of PubMed with the search terms “cervicogenic headache”, “cervical headache”, “headache”, “cervical vertebrae”, and “neck pain”, between 1950 and July, 2009. Papers published in English, French, German, Italian, Spanish, and Slavic languages were reviewed. Seminal articles that introduced new concepts or provided

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