Upper Cervical 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!)
- 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
- 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
- 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
- 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
- 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
- Nardone R, Tezzon F. The trigemino-cervical reflex in tension-type headache. European Journal of Neurology 2003; 10(3):307-312
- Varlibas A, Erdemoglu Ak. Altered trigeminal system excitability in menstrual migraine patients. The Journal of Headache and Pain 2009; 10(4):277-282
- Watson DH, Drummond PD. Head Pain Referral During Examination of the Neck in Migraine and Tension-Type Headache. Headache 2014;54:1035-1045
- Rothbart P. The cervicogenic headache: A pain in the neck. Can J Diagnos 1996; 13: 64–71.
- 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
- Yi X et al Cervicogenic headache in patients with presumed migraine missed diagnosis or misdiagnosis? J Pain. 2005 Oct;6(10):700-3
- 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
- Rozen T. Cessation of hemiplegic migraine auras with greater occipital nerve blockade. Headache 2007;47:917-928
- Peres MF, Stiles MA, Siow HC. Greater occipital nerve blockade for cluster headache. Cephalalgia 2002;22:520-522
- 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
- Tobin J,Stephen Flitman S. Nerve Blocks: When and What to Inject? Headache 2009;49(10):1479-85
- Pascual J. Treatment of hemicrania continua by occipital nerve stimulation with a bion device. Curr Pain Headache Rep 2009 Feb;13(1):3-4
- Jasper JF, Hayek SM. Implanted occipital nerve stimulators. Pain Physician 2008 Mar-Apr;11(2):187-200
- Goadsby PJ. Neurostimulation in primary headache syndromes. Expert Rev Neurother 2007 Dec;7(12):1785-9
- 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