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Cervicogenic headache

Cervicogenic headache
Literature review current through: Jan 2024.
This topic last updated: Aug 10, 2023.

INTRODUCTION — Cervicogenic headache is a condition characterized by head pain that occurs as referred pain due to joint dysfunction in the upper neck. Cervicogenic headache can be challenging to diagnose because associated neck pain and cervical muscle tenderness occurs with many other headache disorders. In addition, symptoms of cervicogenic headache may be similar to those of tension-type headaches from cervical myofascial pain without joint dysfunction or to migraine headaches associated with neck pain.

Establishing the causal relationship between cervical joint dysfunction and headache can be challenging, leading some experts to question the existence of cervicogenic headache as a distinct clinical disorder [1-5].

This topic will review the pathogenesis, clinical features, diagnosis, and treatment of cervicogenic headache.

Other common forms of headache that may be associated with neck pain are discussed separately.

(See "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults".)

(See "Tension-type headache in adults: Etiology, clinical features, and diagnosis".)

(See "Evaluation of headache in adults", section on 'Specific features suggesting a secondary headache source'.)

The causes and evaluation of other conditions associated with neck pain are discussed elsewhere. (See "Evaluation of the adult patient with neck pain".)

PATHOGENESIS

Anatomy – Upper cervical joint dysfunction is regarded as the primary source of referred pain in cervicogenic headache [4]. Implicated joints include:

The C2-3 zygapophyseal joint is the most frequent source of cervicogenic headache, accounting for up to 70 percent of cases [4,6-10]. The evidence implicating this joint as the source of cervicogenic headache is derived from studies of patients with a history of neck injury or trauma [4]. As an example, one series of 100 patients who had chronic neck pain following whiplash found that the prevalence of headache was 27 percent [6].

The atlanto-axial (C1-2) joint is probably the second most common source of cervicogenic headache, but the true frequency is unknown [4,8]. Patients with rheumatoid arthritis may present with C1-2 cervicogenic headache due to the associated risk of subluxation and arthropathy of the atlanto-axial joint.

Less common sources of cervicogenic headache include the C3-4 zygapophyseal joint, upper cervical intervertebral discs, or intraspinal processes (eg, disc herniation) affecting the upper cervical roots (C1, 2, and/or 3). Lower cervical zygapophyseal joints are an uncommon source of cervicogenic headache. When implicated, they may cause occipital and suboccipital pain but are unlikely to cause headache more anteriorly [7,11,12].

The upper cervical joints are innervated by the first three cervical spinal nerves and their rami that can refer pain to the head (figure 1). These include:

C1 spinal nerve (suboccipital nerve) that innervates the atlanto-occipital (C0-C1) synovial joint.

C2 spinal nerve and its dorsal root ganglion located adjacent to the lateral capsule of the atlanto-axial (C1-2) joint and that innervates both the atlanto-axial (C1-2) and C2-3 zygapophyseal joints.

Dorsal ramus of C3 (third occipital nerve) located adjacent to and innervates the C2-3 zygapophyseal joint. Dysfunction at the C2-3 zygapophyseal joint may lead to referred pain in the occipital, frontotemporal, and periorbital regions of the head ("third occipital headache").

Pathophysiology – The anatomic locus for cervicogenic headache is the trigeminocervical nucleus in the upper cervical spinal cord, where sensory nerve fibers in the descending tract of the trigeminal nerve (trigeminal nucleus caudalis) are believed to interact with sensory fibers from the upper cervical roots (figure 2) [13]. This functional intersection of upper cervical and trigeminal sensory pathways is thought to allow the bidirectional transmission of pain signals between the neck and the trigeminal sensory receptive fields of the face and head [3].

Causes – Cervicogenic headache is commonly associated with a variety of conditions that can produce cervical joint dysfunction such as trauma-induced muscle strain or cervical arthropathy [14]. In addition, several other conditions have also been reported in patients with cervicogenic headache including spondylosis, disc herniation, radiculopathy, tumors, and osteochondritis [15-18]. However, the relationship between these conditions and cervicogenic headache may be uncertain in the absence of a temporal trigger because they may also occur in other patients without headache. Careful evaluation for alternative causes and use of anesthetic blockade to confirm the diagnosis are warranted. (See 'Diagnosis and evaluation' below.)

EPIDEMIOLOGY — Available data suggest that the prevalence of cervicogenic headache in the general population is 0.4 to 4 percent [19-22]. However, it may represent up to 53 percent of headaches presenting after whiplash [6] and almost 18 percent of severe headaches [23]. The mean age at presentation is approximately 43 years old and cervicogenic headache appears more common among females [22]. However, the true prevalence is uncertain as there have been no rigorous, large scale epidemiologic studies.

CLINICAL FEATURES

Character of head pain – Cervicogenic headache is characterized by unilateral head pain of fluctuating intensity that is increased by movement of the head [1,24-26]. Pain may be restricted to the cervical and occipital regions of the neck and head but may also radiate from occipital to frontal regions. The pain in cervicogenic headache is typically nonthrobbing, nonlancinating, of moderate to severe intensity, and of variable duration. The headache may radiate from posterior to anterior but does not shift from side to side. Pain is precipitated by neck movement or sustained awkward head positioning.

Cervicogenic headache may be constant or intermittent and recurrent. Initial transient symptoms provoked by neck movement (eg, head turning to look over the shoulder while driving) may become persistent over time as the underlying pathology progresses.

Neck symptoms – Patients with cervicogenic headache often have restricted neck range of motion, and some may also have ipsilateral neck, shoulder, or arm pain. Many patients also have cervical muscle tenderness.

Resolution of symptoms by anesthetic blockade helps to confirm symptoms are due to a suspected source of pain in one or more cervical joints [27]. (See 'Diagnostic anesthetic blockade' below.)

DIAGNOSIS AND EVALUATION — The diagnosis of cervicogenic headache should be considered in patients with headaches that are provoked by neck movement or associated with cervical dysfunction such as muscle strain. A clinical diagnosis of cervicogenic headache is confirmed by diagnostic evaluation that either identifies a cervical disorder attributable to headaches or demonstrates resolution of symptoms following anesthetic blockade.

However, there is no global consensus on how to establish the diagnosis of cervicogenic headache as two conflicting viewpoints are widely recognized [27]:

One approach employs a definition that relies on clinical features, as proposed in 1983 with introduction of the term "cervicogenic headache" [24]. The diagnosis of cervicogenic headache is made in patients with unilateral head pain of fluctuating intensity that is increased by movement of the head and radiates from occipital to frontal regions. (See 'Clinical features' above.)

A clinical diagnostic paradigm avoids anesthetic blockade or imaging that may not be readily available in some areas. However, a problem with this definition is that the proposed clinical features of cervicogenic headache overlap with those commonly associated with primary headache disorders that may have associated neck pain, such as tension-type headache, migraine without aura, and hemicrania continua [28]. Clinically based diagnostic criteria have low specificity for cervicogenic headache [4].

Another approach relies on establishing the diagnosis by demonstrating a cervical source of head pain and confirming the diagnosis by anesthetic blocks that pinpoint sources of pain in the upper cervical joints [27]. This approach offers greater diagnostic specificity for cervicogenic headache but may not be practical in settings where clinicians experienced in performing this technique are unavailable [29]. These anesthetic blocks require specialized skills and facilities, a limitation that adds to the difficulty of confirming the diagnosis. (See 'Diagnostic anesthetic blockade' below.)

Diagnostic criteria — The International Classification of Headache Disorders, 3rd Edition (ICHD-3) criteria for cervicogenic headache are as follows [15]:

A) Any headache fulfilling criterion C

B) Clinical and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck, known to be able to cause headache

C) Evidence of causation demonstrated by at least two of the following:

Headache has developed in temporal relation to the onset of the cervical disorder or appearance of the lesion

Headache has significantly improved or resolved in parallel with improvement in or resolution of the cervical disorder or lesion

Cervical range of motion is reduced, and headache is made significantly worse by provocative maneuvers

Headache is abolished following diagnostic blockade of a cervical structure or its nerve supply

D) Not better accounted for by another ICHD-3 diagnosis

Of note, headaches due to cervical myofascial pain are not considered cervicogenic and should be diagnosed as tension-type headache [15]. (See 'Tension-type headache' below.)

The utility of the ICHD-3 criteria for cervicogenic headache appears to be limited by the reliance on somewhat nonspecific clinical features. Several features associated with cervicogenic headache are not specific for the diagnosis, including focal neck tenderness, mechanical exacerbation of pain, unilaterality, posterior-to-anterior radiation of pain, nausea, vomiting, and photophobia [15]. In addition, clinical features of cervicogenic headache do not necessarily establish a causal relationship between the disorder and the source of the headache. A critical review of cervicogenic headache diagnostic criteria concluded that although neck structures play a role in the pathophysiology of some headaches, clinical patterns indicating a neck-headache relationship have not been adequately defined [2,5].

Our approach — The diagnostic evaluation of cervicogenic headache starts with a careful history and physical examination including provocative maneuvers and a complete neurologic assessment. (See 'Clinical evaluation' below.)

For all patients, we obtain cervical radiographs to establish a potentially causal cervical disorder and exclude alternative causes to symptoms. (See 'Imaging' below and 'Differential diagnosis' below.)

Additional diagnostic testing varies by symptom severity and response to initial treatment:

For patients with mild (intermittent, nondisabling) symptoms and evidence of a potentially causal disorder on cervical radiographs, we start with a trial of physical therapy for initial treatment. (See 'Initial treatment' below.)

For patients with more severe symptoms and those with mild symptoms that do not respond to initial treatment, we suggest anesthetic blocks of cervical structures or their nerve supply. These blocks should be performed by an experienced specialist with imaging guidance. (See 'Diagnostic anesthetic blockade' below.)

For patients unable to undergo anesthetic block, those with a partial response to cervical nerve block, those with atypical symptoms such as neurologic signs of cervical dysfunction at presentation, we also perform three-dimensional neuroimaging to identify a bony or soft tissue cause of cervicogenic headache and to exclude alternative etiologies. (See 'Imaging' below.)

Advanced neuroimaging is also required for patients with refractory symptoms who may be candidates for interventional treatment options.

Clinical evaluation — Clinical evaluation includes:

History to elicit cervical pathology related to the onset of headache, such as whiplash or other musculoskeletal trauma.

Physical examination of the head and neck to identify evidence of a restricted range of motion or pain that provokes or worsens symptoms with palpation of the upper cervical joints.

Neurologic assessment to exclude alternative causes to symptoms such as occipital neuralgia or vertebral artery dissection. An alternative diagnosis is likely in the presence of an abnormal finding on neurologic examination, such as the presence of Horner syndrome or fixed numbness in the distribution of a nerve. (See 'Differential diagnosis' below.)

Limited evidence suggests that the presence of a combination of physical measures such as palpably painful upper cervical joints, restricted range of neck extension, and muscle impairment characterized by reduced electromyographic activity in the deep neck flexors can distinguish cervicogenic headache from migraine and tension-type headache [30]. However, the diagnostic utility of this method has not been validated, and its use requires specialized skills and use of diagnostic equipment during the clinical evaluation. In addition, clinical features alone are not specific to cervicogenic headache, as other conditions can present with pain with palpation and a restricted range of motion. One study that evaluated 71 patients with chronic neck pain and headache found no distinguishing history or examination features that confirmed a definitive diagnosis of third occipital headache before nerve blocks [6].

Imaging — We perform routine cervical spine radiographs on all patients with clinical features suggestive of cervicogenic headache.

We also perform three-dimensional imaging of the cervical spine and soft tissues of the neck to help identify a cervical source to headache if diagnostic blockade is unavailable or when response to blockade is incomplete and for patients with atypical symptoms such as neurologic signs of cervical dysfunction accompanying the neck and head pain. Imaging is required for patients with refractory symptoms who may be candidates for interventional procedures and is also used to identify secondary causes of pain that may require surgery or other forms of treatment [14].

We typically perform magnetic resonance imaging (MRI) of the cervical spine with contrast. Computed tomography (CT) of the cervical spine and soft tissues of the neck may be performed as an alternative. Adjunctive imaging modalities that may be helpful for selected patients include CT myelography and ultrasound.

Cervical spine imaging may identify candidate structures that could cause cervicogenic headache such as asymmetric facet arthropathy (image 1) or rheumatoid changes around the atlanto-axial (C1-2) joint (image 2). However, abnormal imaging findings alone cannot confirm the diagnosis of cervicogenic headache because they may also be found in patients without headache and incidentally in those with other headache syndromes [31,32]. Abnormal findings in the upper cervical spine must be correlated with headache and/or neck symptoms to support the diagnosis of cervicogenic headache.

Diagnostic anesthetic blockade — Anesthetic blocks of cervical structures or their nerve supply are used to confirm the clinical diagnosis of cervicogenic headache. Cervical blocks help to localize upper cervical joints and nerves as the source of the pain and have a greater diagnostic specificity than clinical evaluation alone [4]. We typically perform anesthetic blocks for patients with severe symptoms and those with mild symptoms that do not respond to initial treatment. (See 'Our approach' above.)

Diagnostic anesthetic blocks for cervicogenic headache are not generally performed as routine office procedures. They typically require interventional pain medicine or spine consultation and may not be available in all areas [29]. These procedures should be performed with imaging guidance by an experienced specialist and require specialized skills and facilities, which are limitations that add to the difficulty of confirming the diagnosis.

Injection sites – Determining the specific level for anesthetic blockade starts by identifying the site that triggers or exacerbates pain on history and examination. As examples, pain with head rotation may suggest C1-2 joint etiology while pain with head extension and rotation or by palpation overlying the joint may suggest C2-3 or C3-4 joint etiology.

Clinical features that correspond to diagnostic imaging findings (eg, facet arthropathy) should be assessed first. However, if that initial block is ineffective, other upper cervical pain generators should be considered and assessed with diagnostic blocks.

Diagnostic anesthetic blockade for the evaluation of cervicogenic headache may be directed to several anatomic structures (figure 1) [4,6,33]:

The lateral atlanto-axial (C1-2) joint, by intraarticular blocks

The C2-3 zygapophyseal joint by intraarticular blocks or preferentially by blocking the medial branches of the C2 and C3 dorsal rami and the third occipital nerve where it crosses the joint

The C3-4 zygapophyseal joint, by intraarticular blocks or preferentially by blocking the medial branches of the C3 and C4 dorsal rami

Mid-cervical structures (the C4-5 and C5-6 zygapophyseal joints) more commonly refer pain to the neck and shoulders than to head but can sometimes refer to the occipital region and could be considered for diagnostic blockade with posterior predominant headaches. Patients whose headaches emanate from mid-cervical structures will not have frontal or orbital pain, as these mid-cervical structures do not have sensory input into the trigeminocervical nucleus, unlike upper cervical pain generators. This population is therefore often excluded from strict definitions of cervicogenic headache but remains important to consider clinically [28].

Of note, anesthetic blockade directed toward the soft tissues surrounding the greater or lesser occipital nerves (eg, at the superior nuchal line or at the level of C2 in the plane above the inferior obliquus capitis) is associated with occipital neuralgia, a condition distinct from cervicogenic headache. (See 'Occipital neuralgia' below.)

Technique – Anesthetic blocks are performed with imaging guidance (using fluoroscopy, CT, or ultrasound) to assure accurate and specific localization of the pain source [34-36].

The procedure should be performed in a blinded fashion using saline or other appropriate controls in order to identify true-positive cases and exclude placebo responders [37,38]. Because of ethical concerns with performing placebo saline injections, differential local anesthetic blocks are often utilized in clinical practice to differentiate false-positive (ie, placebo) responses from true-positive responses. Two diagnostic blocks of the suspected pain generator are performed at different times, using a short-acting anesthetic for one block and a long-acting local anesthetic for the next. The patient is blinded to the anesthetic used. The response is interpreted by both the degree of improvement and the duration of improvement, which should be concordant with the local anesthetic used.

Selection of anesthetic agent varies by duration of intended action and availability (table 1).

Adverse effects – Anesthetic nerve blocks are generally well tolerated. However, adverse effects may include dizziness, syncope, injection site pain, and bleeding [39]. Uncommon serious adverse effects include nerve injury or inadvertent arterial puncture. Injections directed at the C1-2 joint carry an elevated risk of adverse effects due to the proximity of the vertebral artery lateral to the joint and the C2 dorsal root ganglion at the dorsal mid-joint. Vertebral artery injury after transforaminal injection has been reported causing stroke and in some cases coma and death [40,41]. In addition, injury of the C2 dorsal root ganglion may cause worsening pain or sensory loss. Complications of cervical injections are discussed in greater detail separately. (See "Treatment and prognosis of cervical radiculopathy", section on 'Epidural glucocorticoid injections'.)

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of cervicogenic headache includes other headache conditions that may present with associated or incidental neck pain as well as structural conditions of the head and neck that can cause headaches.

Other headaches and cranial neuralgias — Common primary headache disorders may present with head and neck pain, including migraine and tension-type headache. In addition, some patients may have both a primary headache disorder or cranial neuralgias and an unrelated cause of neck pain, such as cervical spondylosis, due to the high prevalence of these conditions. In this situation, the headache and the neck disorder typically wax and wane independent of one another.

Migraine headache — Neck pain and muscle tension are common symptoms of a migraine attack [42-45]. In one study of 50 patients with migraine, neck pain or stiffness associated with the migraine attack was reported by 32 patients (64 percent) [42]. Referred pain into the ipsilateral shoulder was present in seven (14 percent). In another report of 144 patients, neck pain associated with migraine attacks was noted by 108 patients (75 percent) [44]. Of these 108 patients, the pain was described as tightness by 69 percent, stiffness by 17 percent, and throbbing by 5 percent. The neck pain was unilateral in 57 percent, among whom it was ipsilateral to the side of headache in 98 percent.

However, aura is not a feature of cervicogenic headache, and the presence of prominent nausea, vomiting, photophobia, and phonophobia are also more suggestive of migraine. By contrast, patients with migraine do not typically report provocation or worsening of headache during physical examination maneuvers such as palpation of upper cervical joints or range of motion exam [30]. (See 'Clinical evaluation' above.)

The clinical features and diagnosis of migraine are discussed in detail separately. (See "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults".)

Tension-type headache — Muscle tenderness in the posterior head and upper neck is common in tension-type headache. However, tension-type headaches are typically bilateral in location and the pain may be described as "band-like" or pulsatile, unlike the head pain with cervicogenic headache.

In addition, the neck pain and palpatory tenderness is typically myofascial in tension-type headache, whereas neck pain with cervicogenic headaches is due to cervical joint dysfunction [15].

Tension-type headache is discussed in detail separately. (See "Tension-type headache in adults: Etiology, clinical features, and diagnosis".)

Occipital neuralgia — Occipital neuralgia is a pain disorder that may present with posterior head and neck pain, similar to cervicogenic headache. The clinical distinction between occipital neuralgia and cervicogenic headache may be difficult despite careful evaluation of clinical features and thorough examination. A cervicogenic headache lesion affecting the C2 nerve root may have a similar distribution of symptoms as a more distal lesion of the occipital nerve as it traverses the posterior neck musculature or crosses the nuchal ridge to produce occipital neuralgia. However, occipital neuralgia is clinically characterized by paroxysmal jabbing pain in the distribution of the occipital nerves, sometimes accompanied by diminished sensation or dysesthesia in the affected area. Some patients with occipital neuralgia report constant deep or burning occipital pain with superimposed paroxysms of shooting pain.

Anesthetic nerve blockade may temporarily reduce or abolish pain both in occipital neuralgia and cervicogenic headache. Occipital neuralgia may arise from the greater occipital nerve, a peripheral nerve extension of the medial branch of the dorsal ramus of the C2 cervical spinal nerve. Cervicogenic headache arises from the upper zygapophyseal joints or from upper cervical nerves, including the C2 nerve root. In such cases, the use of image-directed anesthetic blockade of the occipital nerve can usually identify a peripheral source of pain to permit an accurate diagnosis. Occipital nerve blockade is performed close to where the nerve crosses the superior nuchal line or at the level of C2 in the plane above the inferior obliquus capitis muscle (with ultrasound guidance), beyond which the nerve supplies the scalp of the occipital region.

Occipital neuralgia is discussed in detail separately. (See "Occipital neuralgia".)

C2 spinal nerve lesions — Two distinctive clinical syndromes caused by lesions or injury affecting the C2 spinal nerve that may be confused with cervicogenic headache [4]:

C2 neuralgia is characterized by a paroxysmal, sharp or shock-like pain centered in the occipital region due to nerve dysfunction [46-48]. Ipsilateral eye lacrimation and conjunctival injection are common associated signs. These features contrast with the dull aching pain associated with cervicogenic headache [4]. Arterial or venous compression of the C2 spinal nerve or its dorsal root ganglion has been implicated as a cause for C2 neuralgia in some cases [46,49-51]. Meningioma has been rarely implicated [52].

Neck-tongue syndrome is precipitated when rapid head turning causes subluxation of the posterior atlanto-axial joint and C2 spinal root compression [53-55]. The symptoms include neck pain, occipital pain, or both, often associated with ipsilateral tongue sensory symptoms. Onset is typically during childhood or adolescence.

Cranial and cervical structural conditions — Several structural conditions of the neck or craniocervical junction can present with interrelated neck and head pain. These conditions may be suspected by clinical features or associated neurologic deficits and identified by imaging. These conditions include:

Internal carotid or vertebral artery dissection (see "Cerebral and cervical artery dissection: Clinical features and diagnosis")

Posterior fossa or spinal tumor (see "Overview of the clinical features and diagnosis of brain tumors in adults" and "Spinal cord tumors" and "Clinical features and diagnosis of neoplastic epidural spinal cord compression")

Spinal nerve tumor (see "Peripheral nerve tumors")

Chiari malformations (see "Chiari malformations")

Arteriovenous malformation (see "Brain arteriovenous malformations" and "Arteriovenous malformations of the extremities")

Cervical disc herniation (see "Clinical features and diagnosis of cervical radiculopathy")

Cervical arthropathy (eg, zygapophyseal arthropathy) (see "Clinical manifestations of axial spondyloarthritis (ankylosing spondylitis and nonradiographic axial spondyloarthritis) in adults", section on 'Low back pain and neck pain')

TREATMENT — Treatment of cervicogenic headache is directed at the cervical source of pain. Noninvasive options are generally preferred for initial therapy and for patients with mild symptoms. Combination therapy including use of local injections may be beneficial for patients with more severe or persisting symptoms. Interventional and surgical approaches are reserved for patients with severe and refractory symptoms and a diagnosis confirmed by anesthetic blockade and/or imaging.

Initial treatment — We suggest physical therapy as initial treatment for patients with cervicogenic headache. For patients with an inadequate response to physical therapy, we switch to or add alternative options such as pharmacotherapy or local injections.

Physical therapy — Available evidence suggests physical therapy with exercise reduces intensity and frequency of cervicogenic headaches. These modalities are generally well tolerated. The specific techniques used vary by patient symptoms as well as local experience and protocols, but may include cervical and thoracic spinal manipulation, massage with myofascial release, and neck and shoulder exercises [56].

We recommend not using high-velocity manipulation therapy due to the associated risk of vertebral artery dissection and stroke. This issue is discussed separately. (See "Spinal manipulation in the treatment of musculoskeletal pain", section on 'Serious adverse events'.)

In addition, limited evidence suggests that manipulation has no advantage over exercise therapy and the intensity of headache may initially worsen during or after physical therapy, especially if it is vigorously applied. Physical treatment is generally better tolerated when initiated with gentle muscle stretching and/or manual cervical traction. Therapy can be slowly advanced as tolerated to include strengthening and aerobic conditioning. Using anesthetic blockade for temporary pain relief may enhance patient tolerance of physical therapy.

Early efficacy – Some evidence suggests physical therapy may provide initial pain relief during the course of treatment. An open-label, controlled trial of spinal manipulation therapy (SMT) randomly assigned 256 patients with chronic cervicogenic headache to 0, 6, 12, or 18 SMT visits [57]. Patients received a brief, light massage as control. After four weeks, the number of cervicogenic headache days was reduced by one-third in the control massage group and by one-half in the SMT group. There was a linear dose-response with a reduction of one headache day/four weeks for every additional six SMT sessions. No treatment-related serious adverse events were reported. Another trial enrolled 65 adults (50 to 75 years of age) with recurrent headaches associated with neck pain and musculoskeletal dysfunction, irrespective of headache classification [58]. The patients were randomly assigned to 14 physiotherapy sessions over 10 weeks or to usual care; physiotherapy sessions included low-velocity cervical mobilization and low-load therapeutic exercises of cervical flexors, axioscapular muscles, and postural correction exercises. Those receiving physiotherapy reported a reduction in headache frequency at the end of treatment (-1.6 days per week) and at six-month follow-up (-1.7 days per week) compared with usual care.

Longer-term efficacy – Physical therapy may also provide long-term improvement for cervicogenic headache, but the conclusions of different systematic reviews have differed about the strength of the effect size and the quality of the evidence. A 2013 systematic review of clinical trials found good quality evidence supporting the use of cervical manipulation and mobilization, along with exercise, for the treatment of cervicogenic headache [56]. In the largest of the six included trials, which evaluated 200 patients with cervicogenic headache, treatment was unblinded and assessment was blinded [59]. Compared with controls who received no treatment, those assigned to six weeks of active treatment with either manipulative therapy, low-load endurance exercise therapy, or a combination of both therapies had a significant reduction in headache frequency at 12 months. The effect size was reported as moderate and clinically relevant. Combined treatment was not significantly better than either manipulative therapy or exercise alone.

A 2016 systematic review and meta-analysis that included four trials found that physical therapy led to reduced pain, frequency, and duration of cervicogenic headache over placebo or usual care [60]. However, the benefits did not necessarily achieve a clinically important effect size, and the quality of the evidence was considered low due to methodologic limitations of the trials.

Alternative options — Clinical experience and limited evidence suggest oral medications and local injections may provide benefit for some patients with cervicogenic headache. These options may be used along with or in place of physical therapy. Oral medications may be preferred as a noninvasive option while local injections may be preferred to reduce the risk of systemic adverse effects and by those with a good response to diagnostic anesthetic blockade.

Pharmacologic treatments — Medications used for cervicogenic headache include agents used for other headache disorders and cranial neuralgias. For most patients, we typically use pregabalin or duloxetine based on limited data for cervicogenic headache and extrapolation of efficacy data for other musculoskeletal disorders. Alternative options include gabapentin, amitriptyline, or other tricyclic antidepressants. However, the selection of medication for cervicogenic headache is largely based on patient comorbidities and contraindications, prior experience, and cost as efficacy data for this condition are limited.

Pregabalin was found to be effective in a small placebo-controlled trial of 41 patients with cervicogenic headache [61]. Most patients were treated with 450 mg per day (split twice a day), but dosing was variable and based on patient tolerance. Patients assigned to pregabalin had 10 fewer headache days per month while those assigned to placebo had no reduction in headache days per month. This benefit was evident at the end of a 12-week treatment trial but was not seen at the end of the first four weeks of treatment during which time patients were titrating the dosage up. There have been no follow-up studies on longer-term efficacy of pregabalin.

Duloxetine has been approved by the US Food and Drug Administration for chronic musculoskeletal pain. Cervicogenic headache by definition is generated by upper axial spine musculoskeletal joints.

Other medications commonly used for headache disorders (eg, tricyclic antidepressants, gabapentin) are often and reasonably trialed in patients with cervicogenic headache, but they have not been systemically studied in this patient population.

Local injections — Local injections can provide pain relief for some patients with cervicogenic headache who have a cervicogenic pain generator identified by imaging and/or response to diagnostic anesthetic blockade.

The available evidence suggests that botulinum toxin injections are not beneficial [62].

Glucocorticoid injection — Limited data from small retrospective studies suggest that some patients may obtain relief from intraarticular glucocorticoid injections. Procedures are typically performed by using fluoroscopic guidance by clinicians experienced with these techniques. An anesthetic agent is administered along with a glucocorticoid agent such as betamethasone or triamcinolone.

Zygapophyseal joint injections with glucocorticoids may be repeated if symptoms recur, up to every three to four months. However, more durable treatment options such as radiofrequency neurotomy may be preferred and are likelier to be covered by insurance than serial glucocorticoid injections. (See 'Radiofrequency neurotomy' below.)

Glucocorticoid injections are typically well tolerated when performed by clinicians trained in the procedure. Adverse symptoms include pain at the injection site, bleeding, and infection. Less common complications include inadvertent puncture of the vertebral artery or dorsal root ganglion. Injection at the C1-2 joint should be reserved for patients with severe exacerbations of pain previously shown to be from C1-2 pathology, due to elevated risk of injury to the adjacent vertebral artery at this site. (See 'Diagnostic anesthetic blockade' above.)

Relief after glucocorticoid injection may be immediate, but longer-term effects appear variable. In one study of 32 patients cervicogenic headache related to atlanto-axial joint pain confirmed with diagnostic block, immediate pain relief was noted by 82 percent [63]. However, at six months, the pre- and postprocedure pain scores were similar. In another report, 18 patients with cervicogenic headache had fluoroscopically guided therapeutic intraarticular glucocorticoid injections at the C2-3 zygapophyseal joint. At 19 months after injection, reduced headache frequency was noted for 11 patients (61 percent), and freedom from pain for two (11 percent) [64]. A third report included 31 patients who were treated with standardized injections of local anesthetic and glucocorticoid directed to multiple potential cervicogenic headache pain generators (C1-2 and C2-3 facet joint injections, the C2 dorsal ramus, and the C3 dorsal and ventral rami) in one procedural appointment [65]. Treatment was associated with >50 percent headache relief in 90 percent of patients, sustained for an average duration of 22 days [65].

Anesthetic blockade — Anesthetic injections typically performed during the diagnostic evaluation of cervicogenic headache may be repeated for short-term benefit while pharmacotherapy is being titrated, to allow greater participation in physical treatments, and for patients awaiting surgical procedures. (See 'Diagnostic anesthetic blockade' above.)

Treatment options for refractory symptoms — When cervicogenic headache symptoms are refractory to initial treatment options, we refer patients for interventional and surgical evaluation. Radiofrequency neurotomy (RFN) is the most well studied procedure, but the specific technique used varies by underlying cervical lesion, clinician experience, and local protocols. Prerequisites to interventional and surgical procedures include identification of a specific surgical target, demonstration of near-complete or complete temporary pain relief with diagnostic anesthetic blockade, and inadequate response to nonsurgical management.

Radiofrequency neurotomy — Percutaneous RFN is typically performed for patients with refractory cervicogenic headache arising from the C2-3 or C3-4 zygapophyseal joint. The benefit of RFN for other sources of cervicogenic headache is unknown.

RFN involves the use of multiple sources of radiation oriented to converge at a target lesion. Percutaneous techniques use imaging-guided needles directed to the pain-generating target to deliver focused radiofrequency currents to the tip of the ablation needle. This creates a thermal lesion at the branch of cervical root that innervates the target zygapophyseal joint.

Cervical RFN has been well validated as effective for treating mechanical neck pain from spondylotic zygapophyseal arthropathy in properly selected patients [66]. Pain relief is typically sustained for several months until treated nerve branches begin to regenerate.

Evidence of efficacy of RFN for cervicogenic headache is limited to small trials and observational data, some with methodologic flaws. A 2020 systematic review [66] of RFN and pulsed radiofrequency therapy for cervicogenic headache identified four studies [67-70] that utilized clinical features alone to diagnose cervicogenic headache and to define which levels to target with RFN. This meant there was a lack of specificity for the diagnosis or certainty of the treatment target. Additionally, some of these targeted lower cranial nerve roots (eg, C3-6) that have been implicated as the cause to other pain syndromes are atypical for cervicogenic headache.

Limited observational data of patients with cervicogenic headache confirmed with diagnostic blockade also support the efficacy of RFN for cervicogenic headache. In a prospective, observational study of 49 patients with blockade-confirmed cervicogenic headache, complete relief at six months was reported by 67 percent [71]. In a retrospective study of 30 patients with cervicogenic headache confirmed with positive diagnostic blocks, pain relief ≥75 percent at six months was reported by 77 percent [72].

A small trial of 30 patients with refractory cervicogenic headache that compared greater occipital nerve block with glucocorticoids with RFN reported similar improvement in pain scores at three-month follow-up in both groups, but only the group assigned to RFN showed sustained pain relief at nine-month follow-up [73].

Coblation — Coblation is a bipolar technique that passes radiofrequency energy at low temperatures through a conductive medium to produce a plasma field causing tissue destruction, but this procedure is only infrequently used as a pain intervention. One retrospective, single-center study treated 26 patients with cervicogenic headache of at least moderate severity with ultrasound-guided C2 nerve root coblation [74]. At 24 weeks of follow-up, treatment was associated with a decrease in pain scores by ≥50 percent in 92 percent of patients. This technique requires further study.

Neuromodulation — Electrical stimulation pain modulation through spinal cord and peripheral nerve stimulation (ie, neuromodulation) is used in the treatment of refractory neuropathic pain conditions. A three-year retrospective study evaluated occipital nerve stimulation for 16 patients with refractory cervicogenic headache who were implanted between 2011 and 2013 [75]. At one year, treatment was associated with a ≥50 percent improvement in headache pain scores for 11 patients (69 percent); at three years postimplant, a similar level of improvement was noted for six patients (38 percent) [75].

Several neuromodulation stimulation protocols may be used, including stimulation frequency and burst stimulation programming [75]. In addition, peripheral nerve stimulation techniques offer less invasive and burdensome opportunities to stimulate the occipital nerves compared with traditional neuromodulation techniques. Neuromodulation allows the ability to do test stimulation to judge efficacy prior to an outpatient surgical implantation. Further validation of this technique is necessary in cervicogenic headache.

Surgery — We reserve open surgical procedures for cervicogenic headache for patients with compelling evidence of a surgically amenable lesion on imaging causing the cervicogenic headache (ie, confirmed to be the pain generator by local anesthetic diagnostic blocks) that is refractory to all reasonable nonsurgical treatments. Several surgical interventions have been performed for presumed cases of cervicogenic headache, including neurolysis and upper cervical arthrodesis.

Specific causes of cervicogenic headache that may be amenable to surgery include:

C2 spinal nerve compression by vascular/ligamentous structures

Osteoarthritis of the lateral atlanto-axial joint

Upper cervical intervertebral disc pathology

Evidence of efficacy for surgery for cervicogenic headache is limited to small retrospective studies. Surgical decompression and microsurgical neurolysis of the C2 spinal nerve were reported in one series of 31 patients who met clinical criteria for cervicogenic headache, including headache relief from diagnostic block of the C2 spinal nerve [50]. Treatment was associated with complete pain relief in 14 patients (45 percent) and "adequate improvement" in 16 (52 percent). Arthrodesis of the lateral atlanto-axial joint was reported effective in three studies that reported a total of 24 patients, with complete pain relief or an "excellent result" reported in almost all patients, with benefit lasting two or more years [76-78].

Intensification of pain and anesthesia dolorosa are potential adverse outcomes that must be considered when contemplating the use of surgical interventions.

PROGNOSIS — The prognosis of cervicogenic headache appears to be bimodal, with some patients reporting a milder, self-limited course that may resolve spontaneously or with physical therapy and others reporting chronic symptoms associated with chronic degenerative changes of the cervical spine that may require multiple or repeated treatment options for pain relief [56,79].

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SUMMARY AND RECOMMENDATIONS

Definition and causes – Cervicogenic headache is a condition described as head pain that occurs as referred pain due to dysfunction in the upper cervical joints (figure 1). It may be associated with a variety of common neck pathologies such as trauma-induced muscle strain or cervical arthropathy as well as less common causes such as spondylosis, disc herniation, radiculopathy, tumors, and osteochondritis. (See 'Introduction' above and 'Pathogenesis' above.)

Headaches due to cervical myofascial pain without joint dysfunction are not considered cervicogenic and should be diagnosed as tension-type headache.

Clinical features – Cervicogenic headache is characterized by unilateral, nonthrobbing head pain of fluctuating intensity that is increased by movement of the head. Patients may have restricted neck range of motion, and some may also have ipsilateral neck, shoulder, or arm pain. (See 'Clinical features' above.)

Diagnosis – A diagnosis of cervicogenic headache is made clinically in patients with compatible clinical features and confirmed by diagnostic evaluation that either identifies a cervical disorder attributable to headaches or demonstrates resolution of symptoms following anesthetic blockade. (See 'Diagnosis and evaluation' above.)

Cervical radiographs – For all patients with clinical features of cervicogenic headache, we obtain cervical radiographs to establish a potentially causal cervical disorder and exclude alternative causes to symptoms. (See 'Imaging' above.)

Anesthetic blockade – We suggest anesthetic blocks of cervical structures or their nerve supply to confirm the diagnosis for patients with mild symptoms that do not respond to initial treatment and for those with more severe symptoms. These blocks should be performed with imaging guidance by an experienced specialist. (See 'Diagnostic anesthetic blockade' above.)

Additional imaging – We perform MRI of the cervical spine and soft tissues of the neck with contrast if diagnostic blockade is unavailable or when response to blockade is incomplete and for patients with atypical symptoms such as neurologic signs of cervical dysfunction accompanying the neck and head pain. (See 'Imaging' above.)

Differential diagnosis – The differential diagnosis of cervicogenic headache includes other headache conditions that may present with associated or incidental neck pain such as migraine headache, tension-type headache, and occipital neuralgia as well as structural conditions of the head and neck that can cause headaches such as cervical artery dissection, tumor, Chiari malformation, arteriovenous malformation, disc herniation, and cervical arthropathy. (See 'Differential diagnosis' above.)

Management

Initial physical therapy – We suggest physical therapy with exercise as initial treatment for patients with cervicogenic headache (Grade 2C). Evidence suggests physical therapy with exercise may reduce the intensity and frequency of cervicogenic headaches and is generally well tolerated. (See 'Physical therapy' above.)

Alternative treatment options – For patients with an inadequate response to physical therapy, we switch to or add alternative options such as pharmacotherapy or local injections. Some patients may prefer oral medications as a noninvasive option while others may prefer local injections to reduce the risk of systemic adverse effects. Local injections may also be preferred by those with a good response to diagnostic anesthetic blockade. (See 'Alternative options' above.)

-Pharmacotherapy – Medications used for cervicogenic headache include agents used for other headache disorders and cranial neuralgias such as pregabalin or duloxetine. Alternative agents include gabapentin, amitriptyline, and other tricyclic antidepressants. (See 'Pharmacologic treatments' above.)

-Local injections – Intraarticular glucocorticoid injections are typically performed by using fluoroscopic guidance by clinicians experienced with these techniques. An anesthetic agent is administered along with a glucocorticoid agent such as betamethasone or triamcinolone. (See 'Glucocorticoid injection' above.)

Interventional and surgical options for refractory symptoms – For patients with cervicogenic headache symptoms refractory to initial treatment options, we suggest referral for interventional and surgical evaluation. Prerequisites to interventional and surgical procedures include identification of a specific surgical target, demonstration of near-complete or complete temporary pain relief with diagnostic anesthetic blockade, and inadequate response to nonsurgical management. (See 'Treatment options for refractory symptoms' above.)

Prognosis – The prognosis of cervicogenic headache appears to be bimodal, with some patients reporting a mild, self-limited course and others reporting chronic symptoms that may require multiple or repeated treatment options for pain relief. (See 'Prognosis' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge Zahid H Bajwa, MD, who contributed to earlier versions of this topic review.

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