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Cervicogenic headache

Cervicogenic headache has been described as the 'controversial headache' (Sjaastad 1992) and the 'headache challenge in our time', (Nillson 2000).

Headache caused by disease of the cervical spine has been described in the literature as early as 1860 (John Hilton) and is well accepted generally. The controversy is in the classification and terminology of this entity.

Sjaastad first used the term 'cervicogenic headache' in 1990 and his major criteria for the diagnosis were:

I. Unilateral headpain without sideshift.

II. Symptoms and signs of neck involvement.

- Provocation of attacks:
  • Pain, seemingly of a similar nature, triggered by neck movement and/or sustained awkward head positioning.

  • Pain similar in distribution and character to the spontaneously occurring pain elicted by external pressure over ipsilateral upper, posterior neck region or occipital Region.
- Ipsilateral neck, shoulder & arm pain of a rather vague, non radicular Nature.

- Reduced range of motion in the cervical spine.

The Internation Association on the Study of Pain (IASP, 1994) uses the term cervicogenic headache in its classification of headaches and in general agrees with Sjasstad's criteria but requires a positive block of the Greater Occipital Nerve as a diagnostic test. The International Headache Society (HIS,1998) on the other hand prefers to use the term 'Headache associated with disorder of the neck' and requires radiological evidence of abnormality. The problem is further compounded by the fact that a review of Sjaastad's major criteria by M Leone in 1998 with large series of patients found the criteria inconclusive and not entirely reliable.

The source of pain are the pain fibre innervated structures in the neck ranging from the cervical spine with its various structures and joints, the cervical muscles and their attachments, cervical nerve roots and vertebral arteries. The mechanism of pain referred to the head from the neck is believed to be through the convergence of the descending tract of trigeminal nerve and the sensory fibers of the upper cervical roots at the trigeminocervical nucleus in the upper cervical spinal cord. Convergence of the sensorimotor fibers of the spinal accessory nerves and the upper cervical nerve roots explain referral of pain from neck muscles to the head.

Management of these headaches can be complex as secondary pains mechanisms need to be treated as well. Besides conventional oral medical therapy and physiotherapy, trigger Point injections, diagnostic blocks and multiple procedures may be necessary. Depending On the result of diagnostic blocks, radiofrequency deervation of facet joints, percutaneous partial rhizotomy, radiofrequency lesion of the stellate ganglion and radiofrequency lesion of the sphenopalatine ganglion may be necessary. As a last resort, spinal cord stimulation of the upper cervical cord may be considered.


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