Cervicogenic Headache

Cervicogenic headache is a secondary headache caused by a disorder of the cervical spine and its bony, disc or soft tissue components, typically referred from the upper three cervical segments through the trigeminocervical nucleus to the head.

• Typically unilateral, side locked headache that begins in the neck and spreads to the occiput, frontal, temporal and periorbital regions.
• Causes: upper cervical facet joint arthropathy (C2/3 most common), whiplash, disc degeneration, trauma, myofascial trigger points, rheumatoid arthritis, ankylosing spondylitis, tumour, infection, and vertebral artery dissection.
• Prevalence is about 1 to 4 percent of the general population and about 15 to 20 percent of chronic headaches; more common in women aged 30 to 44.
• Often misdiagnosed as migraine or tension type headache; the distinguishing feature is reproduction by neck movement or pressure and reduced neck range of motion.

• Unilateral headache without side shift, moderate, non-throbbing, starting in the neck, lasting hours to days, aggravated by neck movement, sustained posture (desk work, driving, reading) or pressure over the upper cervical spine or greater occipital nerve.
• Reduced cervical range of motion, especially rotation; tenderness of upper cervical facet joints and suboccipital muscles; pain provoked by passive upper cervical segmental movement.
• Possible ipsilateral shoulder or arm pain, nausea, photophobia, phonophobia and blurred vision, which overlap with migraine.
• Neurological examination is normal in isolated cases.
• Features suggesting a serious cause: fever, weight loss, trauma, progressive neurological signs, myelopathy (gait disturbance, hand clumsiness, Hoffmann sign), dizziness with neck pain, severe sudden neck pain, and drop attacks (vertebral artery dissection).

• Clinical, based on neck linked onset, provocation and reduced range of motion; the flexion rotation test (rotation to one side limited to under 32 degrees in flexion, or by about 10 degrees compared with the other side) has good accuracy.
• Diagnostic confirmation: anaesthetic block of the C2/3 facet joint (medial branch of the third occipital nerve) or the greater occipital nerve with relief of headache of at least 80 percent.
• Imaging: cervical spine X-ray (including flexion extension views if instability is suspected) and MRI only for red flags, neurological signs, trauma, or planned intervention.
• Inflammatory markers (ESR, CRP) and rheumatoid factor when systemic disease is suspected.
• Differentials: migraine, tension type headache, occipital neuralgia, hemicrania continua, cluster headache, giant cell arteritis, Chiari malformation, temporomandibular disorder, intracranial mass.

First line (4 to 6 weeks)

• Education, posture correction, workstation adjustment, regular movement breaks and avoidance of prolonged neck flexion.
• Physiotherapy: manual therapy (mobilisation of the upper cervical segments), deep neck flexor and scapular stabilisation exercises, stretching; 6 to 8 sessions over 6 weeks. Avoid high velocity manipulation of the upper cervical spine (risk of vertebral artery dissection).
• Heat to the neck for 15 to 20 minutes.
• Analgesia: ibuprofen 400 mg orally three times daily with food for up to 2 weeks, or naproxen 500 mg twice daily with food, with omeprazole 20 mg daily for patients over 65 or with ulcer risk; paracetamol 1 g up to four times daily (maximum 4 g; 3 g if under 50 kg or with liver disease). Limit analgesic days to under 10 a month to avoid medication overuse headache.
• Avoid opioids and benzodiazepines.

Second line

• Amitriptyline 10 mg orally at night, increasing by 10 mg weekly to 30 to 50 mg (maximum 75 mg).
• Gabapentin 300 mg orally at night, increasing over 2 weeks to 300 mg three times daily and then to a maximum of 1800 mg daily in divided doses (renal dose adjustment required).
• Short term tizanidine 2 mg at night (increase to 4 mg three times daily) for associated muscle spasm; check liver function; avoid with ciprofloxacin and fluvoxamine.

Interventional (when pain persists after 6 to 12 weeks)

• Greater occipital nerve block: lidocaine 1 to 2 percent 2 to 3 mL with methylprednisolone 40 to 80 mg (or triamcinolone 40 mg); relief lasts 2 to 8 weeks.
• C2/3 facet joint injection or third occipital nerve radiofrequency ablation under imaging, after a positive diagnostic block; benefit may last 6 to 12 months.
• Surgical options (rare): cervical fusion or decompression for confirmed structural lesions.

Follow up

• Review at 6 weeks and refer if no improvement, neurological signs appear, or if intervention is required.
• Advise urgent review for sudden severe neck pain with dizziness, double vision, slurred speech or facial numbness (arterial dissection).