Examining the Upper Cervical Spine

In Trigeminal Autonomic Cephalalgias

It is refreshing to come across a case study which supports my clinical experience.

This study1 describes a woman with a cluster-like pattern of presumably [R] side-locked face and neck pain with associated periorbital and mandibular swelling, tearing, conjunctival injection, and allodynia which was ameliorated by third occipital nerve lesioning – the C2-3 facet joint.

The authors conclude ‘It represents a unique proof of principle in that not only trigeminal nerve pain but also presumed neurogenic inflammation can be relieved by blockade of cervical nociceptive inputs. Further investigation into shared mechanisms of headache pathogenesis is warranted.’

Furthermore, cluster headache (CH) is considered a unilateral headache2 (although there are exceptions3) and CH is second only to migraine in terms of alternation4,5 and we know what alternating unilaterality means… (?), I rest my case.

Of course, the sceptics will say, a TAC diagnosis must be incorrect because it responded to specific cervical intervention and cervical afferents are not involved. How can they it not be? Just refer to elementary neuroanatomy.

Clearly, the upper cervical spine needs to be skillfully examined for cervical relevancy in the TAC group of headaches.


1. Giblin K, Newmark JL, Brenner GJ, Wainger BJ. Headache plus: trigeminal and autonomic features in a case of cervicogenic headache responsive to third occipital nerve radiofrequency ablation. Pain Med. Mar 2014;15(3):473-478.

2. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. Jan 2018;38(1):1-211.

3. Bahra A, May A, Goadsby PJ. Cluster headache: a prospective clinical study with diagnostic implications. Neurology. Feb 12 2002;58(3):354-361.

4. Prakash S, Rathore C. Side-locked headaches: an algorithm-based approach. J Headache Pain. Dec 2016;17(1):95.

5. Ramon C, Mauri G, Vega J, Rico M, Para M, Pascual J. Diagnostic distribution of 100 unilateral, side-locked headaches consulting a specialized clinic. Eur Neurol. 2013;69(5):289-291.

Until next time

If you are new to Watson Headache®, welcome to the Watson Headache® Approach, an evidence-informed practice when considering the role of the neck in Cervicogenic and Primary Headache.

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