Cervicogenic Headache
Definition & Pathophysiology
| Key point | Details |
|---|---|
| Definition | Unilateral head pain arising from a disorder of the cervical spine (C1-C3) and its components (bone, disc, ligaments, muscles, zygapophyseal or atlanto-occipital/-axial joints). Pain is referred to the head via the trigeminocervical nucleus (TCN). |
| Anatomical basis | C1: atlanto-occipital joint → occiput. C2: atlanto-axial & C2-3 zygapophyseal joints → occiput, peri-/retro-orbital, frontotemporal. C3: C2-3 / C3-4 zygapophyseal joints → same distribution. |
| Typical age | Peak 30-44 y female > male. |
| Prevalence among headache patients | 0.4 – 4 %. |
Clinical Presentation (ICHD-3 diagnostic clues)
- ❯ Side-locked unilateral head pain without side-shift.
- ❯ Starts in the neck (sub-occipital or upper cervical) and may radiate to oculo-fronto-temporal region or eye.
- ❯ Provoked or worsened by neck movement or sustained awkward posture.
- ❯ Intensity moderate–severe, dull/pressure; not pulsatile or excruciating.
- ❯ Duration hours to days; may be continuous with fluctuating exacerbations.
- ❯ Associated signs
- ↓ Range of cervical motion.
- Ipsilateral trapezius/shoulder or arm ache.
- Possible scalp hypo-/hyper-aesthesia over C2 dermatome.
- ❯ Negative features (helpful for differentiation)
- Minimal or absent nausea, photophobia, phonophobia.
- Poor response to triptans, ergotamine, indomethacin.
Examination Findings
| Domain | Positive findings |
|---|---|
| Observation & ROM | Guarded posture; pain reproduced/↑ with active or passive cervical rotation/flexion. |
| Palpation | Reproduction of typical headache when pressing occipital nerve, upper cervical facet joints or paraspinal muscles. |
| Cervical Flexion-Rotation Test (CFRT) | ≤ 32° rotation toward painful side or pain reproduction ⇒ 91 % Sn / 90 % Sp for CGH. |
| Neurological | Usually normal; rule out myelopathy or radiculopathy. |
Differential Diagnosis
| Condition | Distinguishing pointers |
|---|---|
| Migraine without aura | Pulsatile, nausea, photophobia, responds to triptan; can switch sides. |
| Tension-type headache | Bilateral, band-like, mild-moderate, no neck-triggered reproduction. |
| Occipital neuralgia | Paroxysmal lancinating pain in C2 distribution, trigger points, responds to occipital nerve block. |
| Cluster / TACs | Strictly unilateral orbital pain + cranial autonomic features, male predominance, short attacks. |
| Vertebral artery dissection† | Acute neck pain + posterior headache, neuro deficits, Horner sign; consider in trauma. |
| structural mimics: – Upper cervical facet arthropathy – Discogenic neck pain – Rheumatoid atlanto-axial instability – Chiari malformation |
†Red-flag any acute CGH-like pain with neuro deficit, ataxia, or vascular risk factors.
Investigations (only if atypical, refractory, or red flags)
- Cervical spine X-ray → RA, degenerative change.
- MRI cervical spine/brain → tumour, Chiari, demyelination, dissection.
- CT angiography → vertebral artery dissection when suspected.
6. Management (eTG-aligned)
Non-pharmacological first-line
| Intervention | Evidence / eTG notes |
|---|---|
| Physiotherapist-led exercise (deep cervical flexor, scapular stabilisation) | Strong evidence for pain & disability ↓. |
| Manual therapy (mobilisation ± manipulation of C1-3 facets) | Short-term benefit; avoid high-velocity rotation in vascular risk. |
| Posture & ergonomics | Workplace assessment, avoid sustained neck flexion. |
| Education / reassurance | Explain cervical origin & chronicity, encourage active self-management. |
Pharmacological options (short courses, evidence modest)
| Drug | Dose (adult) | Notes |
|---|---|---|
| NSAID (e.g. ibuprofen) | 400 mg PO q6-8 h PRN (max 2.4 g/day) for ≤ 5 days. | eTG: consider gastroprotection if ≥ 65 y or GI risk. |
| Naproxen | 250-500 mg PO 12-hourly with food (≤ 1 week). | |
| Paracetamol | 1 g PO q6 h (max 4 g/day) – limited benefit alone. | |
| Adjuvant TCA (if chronic, sleep disturbance) | Amitriptyline 10-25 mg nocte; uptitrate to 50 mg if tolerated. | Off-label; monitor anticholinergic effects. |
| Muscle relaxant (short course) | Diazepam 2-5 mg nocte or PRN at night × ≤ 5 days to break spasm. | Avoid long-term use. |
Interventional (for refractory CGH)
- C2-3 or C3-4 medial branch diagnostic block → if ≥ 80 % pain relief, proceed to radiofrequency neurotomy (effective ≥ 6-12 months).
- Greater occipital nerve block (local anaesthetic ± corticosteroid) → simple, outpatient.
- Botulinum toxin A injections – variable evidence; may help when muscular trigger predominates.
- Surgical fusion / decompression – rare, only when clear structural lesion.
Follow-up & chronicity prevention
- Review at 4–6 weeks; reinforce exercise adherence.
- Escalate to multidisciplinary pain service if persisting > 3 months with functional limitation.
Prognosis
- Most improve with combined exercise + manual therapy (effect size ~0.5–0.6).
- Recurrence common if ergonomic factors persist; empower self-management.