Misconception 1 of 10

Upper Cervicogenic Dysfunction

That (upper) cervicogenic dysfunction does not play a causal role in primary headache (i.e. migraine, tension and cluster headache, hemicrania continua, menstrual migraine etc) syndromes – wrong!

Research continues to support the concept that the many and varied forms of headache and migraine1-7 – migraine, tension-type headache, cluster headache (that takes care of the 3 primary headache conditions and their numerous sub-types!) and menstrual migraine share a common disorder and that disorder is a sensitised brainstem – this is widely accepted.

It is surprising how often noxious upper cervical afferents are the reason for sensitisation – the majority of migraine (including menstrual migraine) is unilateral and alternating – and alternating headache is a cervicogenic headache – it is a musculoskeletal event – this feature alone confirms headache or cervical origin. (Discussed later)

Furthermore, if temporary reproduction of headache when examining upper cervical structures is a key diagnostic criterion of cervicogenic headache, what is the conclusion from a recent study which has shown reproduction occurs in 100 per cent tension headache patients and 94 percent of migraineurs (all with alternating headache)?8

Reproduction is either not indicative of cervicogenic headache or that noxious upper cervical afferents are involved in the VAST majority of migraine and tension headache.

The latter interpretation is in accordance with Rothbart: “Approximately 800 new headache patients per year are examined at our clinic. An estimated 80% of these patients are diagnosed with cervicogenic headache. Of these patients, almost none are referred with this diagnosis. Physicians are not taught to consider or explore neck structures when investigating headaches. This results in a rarely diagnosed but common condition.” 9

Why is it that modulating upper cervical afferents either by anaesthetic blocks10-16 or nerve stimulators17-20 prevents migraine, tension headache, cluster headache, SUNCT, hemicrania continua? (only as long as the anaesthetic lasts or the machine is switched on because these interventions do not address the cause of noxious afferents!)


  1. Kaube H, Katasavara Z, Przywara S, Drepper J, Ellrich J, Diener HC. Acute migraine headache. Possible sensitization of neurons in the spinal trigeminal nucleus? Neurology 2002; 58:1234-1238
  2. Katsavara Z, Lehnerdt G, Duda B, Ellrich J, Diener HC, Kaube H. Sensitization of trigeminal nociception specific for migraine but not pain of sinusitis. Neurology 2002; 59:1450-1453
  3. Katsavara Z, Giffin N, Diener HC, Kaube H. Abnormal habituation of ‘nociceptive’ blink reflex in migraine – evidence for increased excitability of trigeminal nociception. Cephalalgia 2003; 23:814-819
  4. Sandrini G, Cecchini AB, Milanov I, Tassorelli C, Buzzi MG, Nappi G. Electrophysiological evidence for trigeminal neuron sensitisation in patients with migraine. Neurosci Lett 2002; 317:135-138
  5. Nardone R, Ausserer H, Bratti A, Covi M, Lochner P, Marth R, Florio I, Tezzon F. Trigemino-Cervical Reflex Abnormalities in Patients with Migraine and Cluster Headache. Headache 2008; 48(4):578-585
  6. Nardone R, Tezzon F. The trigemino-cervical reflex in tension-type headache. European Journal of Neurology 2003; 10(3):307-312
  7. Varlibas A, Erdemoglu Ak. Altered trigeminal system excitability in menstrual migraine patients. The Journal of Headache and Pain 2009; 10(4):277-282
  8. Watson DH, Drummond PD. Head Pain Referral During Examination of the Neck in Migraine and Tension-Type Headache. Headache 2014;54:1035-1045
  9. Rothbart P. The cervicogenic headache: A pain in the neck. Can J Diagnos 1996; 13: 64–71.
  10. Takmaz AS, Inan N, Ucler S, Yazar MA, Inan L, Basar H. Greater occipital nerve block in migraine headache: Preliminary results of 10 patients. 2008 Jan;20(1):47-50
  11. Yi X et al Cervicogenic headache in patients with presumed migraine missed diagnosis or misdiagnosis? J Pain. 2005 Oct;6(10):700-3
  12. Young WB, Marmura M, Ashkenazi A, Evans RW. Expert opinion: Greater occipital nerve and other anesthetic injections for primary headache disorders. 2008;48:1122-1125
  13. Rozen T. Cessation of hemiplegic migraine auras with greater occipital nerve blockade. Headache 2007;47:917-928
  14. Peres MF, Stiles MA, Siow HC. Greater occipital nerve blockade for cluster headache. Cephalalgia 2002;22:520-522
  15. Porta-Etessam J, Cuadrado ML, Galán L, Sampedro A, Valencia C. Temporal response to bupivacaine bilateral great occipital block in a patient with SUNCT syndrome. J Headache Pain 2010 Apr;11(2):179
  16. Tobin J,Stephen Flitman S. Nerve Blocks: When and What to Inject? Headache 2009;49(10):1479-85
  17. Pascual J. Treatment of hemicrania continua by occipital nerve stimulation with a bion device. Curr Pain Headache Rep 2009 Feb;13(1):3-4
  18. Jasper JF, Hayek SM. Implanted occipital nerve stimulators. Pain Physician 2008 Mar-Apr;11(2):187-200
  19. Goadsby PJ. Neurostimulation in primary headache syndromes. Expert Rev Neurother 2007 Dec;7(12):1785-9
  20. Burns B, Watkins L, Goadsby PJ. Treatment of hemicrania continua by occipital nerve stimulation with a bion device: Long term follow-up of a crossover study. Lancet Neurol 2008;7:1001-1012
  21. de Tommaso M, Guido M, Libro G, Sciruicchio V, Puca F. Zolmitriptan reverses blink reflex changes induced during the migraine attack in humans. Neurosci Lett 2000 Jul 28;289(1):57-60
  22. Hoskin KL, Kaube H, Goadsby PJ. Sumatriptan can inhibit trigeminal afferents by an exclusively neural mechanism. Brain1996; 119:1419-28
  23. Kaube H, Katasavara Z, Przywara S, Drepper J, Ellrich J, Diener HC. Acute migraine headache. Possible sensitization of neurons in the spinal trigeminal nucleus? Neurology 2002; 58:1234-1238
  24. Watson DH, Drummond PD Cervical Referral of Head Pain in Migraineurs: Effects on the Nociceptive Blink Reflex. Headache 2014;54:1035-1045
  25. Rozen TD, Haynes GV, Saper JR, Sheftell FD. Abrupt onset and termination of cutaneous allodynia (central sensitization) during attacks of SUNCT. Headache 2005;45:153-155
  26. Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Med 2007;8:344-353
  27. Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. Headache1998; 38: 442–5.!
  28. Sjaastad O1, Fredriksen TA. Cervicogenic headache: criteria, classification and epidemiology. Clin Exp Rheumatol. 2000; 18(2 Suppl 19): S3-6.
  29. Headache Classification Subcommittee of the International Headache Society.The International Classification of Headache Disorders, 2nd edn. Cephalalgia 2004; 24 (Suppl. 1): 1–151.!
  30. Porter RW, Miller CG. Back pain and trunk list. Spine. 1986;11:596–600.
  31. McKenzie RA, May S. Mechanical Diagnosis and Therapy: The Lumbar Spine. 2nd ed. Waikanae, NZ: Spinal Publications; 2003.
  32. Suk KS, Lee HM, Moon SH, Kim NH. Lumbosacral scoliotic list by lumbar disc herniation. Spine. 2001;26: 667–671.
  33. Mercer S, Bogduk N. The ligaments and anulus fibrosus of human adult cervical intervertebral discs. Spine 1999;24: 619–626!
  34. Mercer SR, Jull GA. Review: morphology of the cervical intervertebral disc: implications for McKenzie’s model of the disc derangement syndrome. Manual Therapy 1996; 2: 76–81
  35. Pfaffenrath V, Dandekar R, Mayer ETh, Hermann G, Pöllmann W. Cervicogenic Headache: Results of Computer-Based Measurements of Cervical Spine Mobility in 15 Patients Cephalalgia, March 1988; vol. 8, 1: pp. 45-48.
  36. Sizer PS, Phelps V, Azevedo E, Haye A, Vaught M. Diagnosis and Management of Cervicogenic Headache. Pain Pract 2005 Sep;5(3):255-74

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.

Watson Headache
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