Talking About Cervicogenic Headache

Introduction

‘Cervicogenic’ refers to ‘neck-related’, and therefore, the cause of ‘Cervicogenic Headache’ lies in the neck; more specifically, research has shown that the cause will be found in the top three spinal segments or joints.¹

Consequently, head pain is referred from musculoskeletal misbehaviour or disturbance of any structure supplied by the top three spinal nerves. These structures include an intervertebral disc, small muscles, joints and their associated ligaments and capsules.¹

How does a neck disorder refer pain to the head?

Head pain occurs when normal signals from structures within the head and face and abnormal signals from the upper neck merge in an area within the top of the spinal cord –in the lower brainstem. Together, the normal and abnormal information is then relayed to the brain. The brain incorrectly interprets abnormal information (which comes from the neck) as coming from inside the head, producing head pain.¹

Imagine the brainstem as a juicer.  Fresh blueberries (from inside the head) and apples (from the neck) blend, but the apples were picked too late and consequently bitter.  The result is a bitter juice that is drunk by the brain.  However, the brain cannot identify the source of the bitterness and blames the blueberries and head pain is produced.

How can I tell if my neck is the cause?

A confusing situation is that Cervicogenic Headache can impersonate Migraine, Tension Headache or even Cluster Headache.^2-5

So, even though your headache may have been diagnosed as Migraine, Tension Headache, Cluster Headache, etc., it may be a ‘Cervicogenic Headache’.

Whilst the location of the pain of Cervicogenic Headache does not differentiate it from other forms of headache, there are behaviours of head pain that confirm that the upper neck is responsible for head pain.

Three examples of behaviour are characteristic of Cervicogenic Headache.

Firstly, suppose your headache is exclusively a one-sided headache, which, for example, occurs on the left, and the next episode is on the right exclusively. In that case, that is, it swaps sides between episodes. Sometimes, the side of a headache may swap sides within the same episode. For example, let’s assume that an episode lasts for three days.  On day 1, it occurs on the right; on day 2, it swaps to the left; swapping back to the right on day three and on day four, it has gone.  This is a fundamental behaviour of Cervicogenic Headache.

Secondly and similarly, if you experience headache on both sides of the head simultaneously but more intense on the left and other times on the right, this also confirms that musculoskeletal misbehaviour in the upper neck is responsible for headache.^3,4

Thirdly, if your headache starts on one side (and it usually begins on the same side consistently) and then, as it progresses, spreads to include the other side without leaving the side it started on, that is, the headache is felt on both sides simultaneously. This is another pattern of Cervicogenic Headache.

However, Cervicogenic Headache can also present as a one-sided headache that is always on the same side, a headache on both sides simultaneously that is even, or a headache that is ‘all over’.

Another characteristic of CGH is headache accompanied by neck symptoms, stiffness/tightness, discomfort/ache, and/or similar symptoms in the area between your lower neck and shoulder or radiating downwards toward your scapula (shoulder blade).  Ironically, though, many with Cervicogenic Headache present without these symptoms, i.e. an absence of these symptoms does not rule out disorders of the upper neck being responsible for headache.

Other characteristics suggestive of Cervicogenic Headache are:

1. If your headache started soon after (within two to three months) or at the time of head and or neck trauma, for example, whiplash, concussion, falls, etc.
2. If your headache started soon after (within two to three months) or gradually increased in frequency after a change in occupation, for example, from an active, outdoor occupation to being deskbound/screen-based or since starting/altering a gym program.
3. If sustained postures trigger your headache, typically flexion (forward bending of the head and neck) or a forward head or poking chin posture
4. Headache that is gradually (over the years) increasing in frequency

But, the medical model’s perspective of Cervicogenic Headache is that if it does exist, it is scarce.  This is frustrating for many who know their neck is the issue.

Where does this leave you?

Unfortunately, many with headache presenting as migraine, for example, who know that their neck is the issue, are told that because it is a ‘migraine’, the neck cannot be involved; i.e., despite the cause of migraine being unknown, it cannot be a Cervicogenic Headache.

My perspective has been aptly and succinctly described by Dr Peter Nathan, Neurologist, and I paraphrase, ‘Trust the patient; they are telling the truth, it is up to you to find out why. If your patient tells you that their neck is causing their migraine, it is, even if you cannot understand it, or it doesn’t fit your paradigm.’

Assessment of the upper cervical spine requires specific training and experience. Sound knowledge of current examination and treatment protocols and a firm grasp of the affected anatomy are vital in identifying relevant issues in the upper neck. Respectfully, those within the medical profession are not trained – nor can we expect them to be – in examining the upper neck.⁶

It is becoming increasingly recognised that a skilled, informed examination of the upper cervical spine becomes an essential course of action when investigating headache conditions, irrespective of the diagnosis.

Examination of the upper cervical spine could prevent a lifetime of medication because a Migraine could be a Cervicogenic Headache, and a Cervicogenic Headache can be treated.

 References

1. Bogduk N. Headaches and the cervical spine. Cephalalgia. Mar 1984;4(1):7-8.
2. Rothbart PJ. The cervicogenic headache: A pain in the neck. Can J Diagnos. 1996;13:64-71.
3. Watson DH, Drummond PD. Head pain referral during examination of the neck in migraine and tension-type headache. Headache. Sep 2012;52(8):1226-1235.
4. Watson DH, Drummond PD. Cervical referral of head pain in migraineurs: effects on the nociceptive blink reflex. Headache. Jun 2014;54(6):1035-1045.
5. Bartsch TGP. Anatomy and physiology of pain referral in primary and cervicogenic headache disorders. Headache Curr. 2005;2:42-48.
6. Becker WJ. Cervicogenic headache: evidence that the neck is a pain generator. Headache. Apr 2010;50(4):699-705.