# Cervicogenic headache | Symptoms, Causes, Tests and Treatment | OSANG > Cervicogenic headache is a secondary headache caused by lesions in the joints, intervertebral discs, muscles, and ligaments of the upper cervical spine (C1-C3), which ar… - Official page: https://osns.co.kr/en/encyclopedia/cervicogenic-headache - Organization: OSANG Neurosurgery ## Page content Headache ## Cervicogenic headache Cervicogenic Headache · G44.841 Cervicogenic headaches are secondary headaches caused by structural abnormalities in the cervical spine or irritation of the upper cervical nerves, and are characterized by starting on one side of the head and worsening with neck movement. ## At a glance Cervicogenic headache is a secondary headache caused by lesions in the joints, intervertebral discs, muscles, and ligaments of the upper cervical spine (C1-C3), which are transmitted to the headache through the trigeminocervical nucleus. It accounts for approximately 15-20% of all headache patients and is characterized by pain that starts from the back of the head on one side and spreads to the forehead or around the eyes. It gets worse when you turn or tilt your neck or stay in the same position for a long time. It is easy to be confused with migraine or tension-type headache, so an accurate differential diagnosis is necessary. It can be effectively managed through physical therapy, nerve blocks, radiofrequency coagulation, manual therapy, and exercise therapy. - 01Definition and Overview - 02cause - 03symptoms - 04diagnosis - 05Differential diagnosis - 06treatment - 07life guide ## Definition and Overview Cervicogenic headache (CEH) is a secondary headache that originates from structural abnormalities in the bones, intervertebral discs, joints, muscles, and ligaments of the cervical spine. It was first proposed as an independent disease concept by Sjaastad et al. in 1983, and was later recognized as an official disease in the 3rd edition of the International Classification of Headache Disorders (ICHD-3) of the International Headache Society. It is estimated that approximately 15-20% of all chronic headache patients suffer from cervicogenic headaches. The prevalence in the general population is reported to be about 0.4-4.6%, with women showing a frequency about four times higher than men. The prevalence rate is higher in patients with whiplash injury after a traffic accident, with up to 53% reported. Cervicogenic headache is a disease with a clear pathophysiological mechanism that is distinct from simple ‘headache caused by stiff neck’. Pain signals originating from the upper cervical spine (C1-C3) converge with intracranial pain pathways through the trigeminocervical nucleus and are recognized as head pain. Understanding this mechanism is the starting point for accurate diagnosis and treatment. ## cause The pain source of cervicogenic headache is concentrated in the upper cervical spine (C1-C3) segment. Sensory nerves in this area converge in the trigeminal nucleus, which overlaps the subnucleus caudalis of the spinal nucleus of the trigeminal nerve and the dorsal horn of the upper cervical spine. Due to this convergence, pain signals arising from cervical lesions are transferred (referred pain) to pain in the forehead, around the eyes, and temporal areas controlled by the trigeminal nerve. The specific causal structures are as follows. The zygapophyseal joint (facet joint) is the most common source of pain. In particular, lesions of the C2-3 facet joint are most closely associated with cervicogenic headaches. Bogduk reported that the C2-3 facet joint was identified as the source of pain in approximately 70% of cervicogenic headaches. Causes include degenerative changes in the facet joints, post-traumatic damage, and synovial inflammation. Lesions of the atlanto-occipital joint (C0-1) and atlanto-axial joint (C1-2) also cause headaches. Since these joints are responsible for a significant portion of the neck's rotation and flexion-extension movements, they are vulnerable to degeneration or trauma. Headaches can occur when herniation or degenerative changes in the cervical intervertebral disc irritate the upper cervical nerve roots. C2-3 intervertebral disc lesions are the most common. Tension and shortening of the muscles around the upper cervical spine are also causes. Excessive tension or myofascial trigger points in the suboccipital muscles, upper trapezius, sternocleidomastoid muscle, and semispinalis capitis can cause or worsen headaches. Entrapment of the greater occipital nerve (C2) is also an important cause. The greater occipital nerve originates from the C2 dorsal ramus and runs through the suboccipital and upper trapezius muscles. When the nerve is compressed along this path, pain extending from the occipital region to the parietal region occurs. ## symptoms The most characteristic clinical feature of cervicogenic headache is pain that appears only on one side of the head. In principle, pain is unilateral and does not transfer to the other side. It starts from the back of the head (occipital area) and radiates to the same side of the head, forehead, and around the eyes. The nature of the pain is often dull and aching, and non-throbbing pain is more prevalent than throbbing. Pain intensity is moderate to severe, and severe, unilateral throbbing pain, as in migraines, is rare. Triggering and aggravation by neck movements are key diagnostic clues. Headaches occur or become worse when you turn your head (rotation), tilt it up (extend it), or tilt it to one side. Headaches also worsen after maintaining the same posture for a long time (computer work, reading, driving). It is often accompanied by pain in the neck, shoulder, or arm on the same side. Arm pain is a non-specific referred pain rather than radicular pain. Restrictions in neck range of motion are observed. In particular, rotation toward the symptomatic side is often limited. Other accompanying symptoms may include swelling around the eye on the same side, tearing, and blurred vision, but the typical nausea, light sensitivity, and sound sensitivity seen in migraine are relatively mild. However, in some patients, these autonomic symptoms accompany it, making it difficult to differentiate it from migraine. Headache attacks last from several hours to several days, appear intermittently, and then gradually increase in frequency, becoming chronic. ## diagnosis The diagnosis of cervicogenic headache is made through a combination of clinical criteria, physical examination, imaging studies, and diagnostic nerve blocks. ### Diagnostic criteria The diagnostic criteria proposed by Sjaastad et al. and established by the Cervicogenic Headache International Study Group (CHISG) are the most widely used. The main criteria are as follows: - Unilateral headache that will not switch to the other side - Headache may be triggered by neck movement, improper posture, or external pressure on the ipsilateral occipital or upper cervical region. - Non-radiating pain in the ipsilateral neck, shoulder, or arm - Diagnostic anesthetic blockade may temporarily relieve headaches. The diagnostic criteria for ICHD-3 require that there is clinical, imaging, and laboratory evidence of a cervical disease or lesion, that the lesion is recognized as the cause of the headache, and that the headache improves with treatment or improvement of the causative disease. ### physical examination Cervical spine examination identifies movement limitations and tenderness in the upper cervical spine segment. The cervical flexion-rotation test is a useful test to evaluate dysfunction of the C1-2 joint, and is reported to have a sensitivity of 91% and a specificity of 90%. Promotes tenderness and trigger points in the suboccipital, upper trapezius, and sternocleidomastoid muscles. Also check for tenderness at the outlet area of the greater occipital nerve (outside the occipital protuberance). ### imaging test Cervical spine alignment, degenerative changes, and instability are evaluated through simple X-ray imaging of the cervical spine. Cervical spine MRI is necessary to identify soft tissue lesions such as intervertebral disc lesions, nerve root compression, and ligament damage. However, cervicogenic headache cannot be confirmed based on imaging findings alone, and agreement with clinical findings is important. ### Diagnostic nerve block Diagnostic nerve block is the most definitive method for diagnosing cervicogenic headache. If the headache temporarily disappears by injecting a local anesthetic into the suspected pain source (facet joint, nerve root, greater occipital nerve), it can be confirmed that the structure is the source of pain. C2-3 facet joint block or greater occipital nerve block are most commonly performed. ## Differential diagnosis Cervicogenic headaches have many overlapping clinical features with other primary headaches, so accurate differentiation is essential. ### Differentiation from migraine Migraine is a pulsating pain on one side of the head that lasts for 4 to 72 hours, and nausea, light sensitivity, and sound sensitivity are evident. Unlike cervicogenic headaches, the headaches may appear alternately on the left and right sides, and may be accompanied by an aura. Cervicogenic headaches are more clearly triggered by neck movements and have a characteristic spreading direction from the occipital area to the frontal area. However, since many patients with chronic migraine are accompanied by cervical muscle tension, there are many cases where the two diseases coexist. ### Differentiation from tension-type headache Tension-type headaches are characterized by mild to moderate pain that feels like the head is being squeezed on both sides. Cervicogenic headaches are unilateral, have a clear association with neck movement, and are accompanied by referred pain to the ipsilateral shoulder or arm. In tension-type headaches, muscle tenderness in the frontal and temporal regions appears symmetrically on both sides, whereas in cervicogenic headaches, tenderness in the ipsilateral upper cervical and suboccipital muscles is prominent. ### Differentiation from occipital neuralgia Occipital neuralgia is a lancinating paroxysmal pain that occurs in the distribution area of the greater or lesser occipital nerve. In contrast to the dull, persistent pain of a cervicogenic headache, the electric-like momentary pain repeats for several seconds to several minutes. However, entrapment of the greater occipital nerve can be the cause of both diseases, so there is some overlap. ## treatment Treatment of cervicogenic headaches aims to directly intervene in the structures causing pain and restore function. It is applied step by step from conservative treatment to procedural treatment. ### physical therapy Physical therapy is recommended as the first-line treatment for cervicogenic headaches. Movement restrictions in the upper cervical spine are improved through joint mobilization, and hypertonic muscles are relieved through soft tissue release techniques. In a randomized controlled trial by Jull et al., headache frequency was reduced by more than 50% in 72% of patients who received physical therapy (manual therapy + exercise therapy), and this effect was maintained after 12 months. ### nerve block A greater occipital nerve block is a procedure that involves injecting a local anesthetic and a small amount of steroid around the greater occipital nerve. In addition to its diagnostic value, therapeutic effects can also be expected. Cervical facet joint block relieves pain by injecting a local anesthetic into the facet joint that has been identified as the source of pain. It is performed under the guidance of ultrasound or fluoroscopy, and long-term pain control is possible with repeated procedures. ### Radiofrequency thermocoagulation Radiofrequency neurotomy (RF) is a procedure that blocks nerve conduction by applying high-frequency heat energy to the medial branch of the posterior joint, which transmits pain. It is performed when the facet joint identified in the diagnostic block is the source of pain. In a randomized controlled trial by Lord et al., 58% of patients who received radiofrequency thermocoagulation showed complete pain relief 27 weeks (median) after the procedure, compared to only 8 weeks in the control group. Pain may recur after nerve regeneration, but reoperation is possible. ### manual therapy Manual therapy is a treatment that applies manual techniques to the cervical joints and surrounding soft tissues. It includes upper cervical high-velocity low-amplitude (HVLA) correction techniques and joint mobilization techniques. The effect is maximized when combined with physical therapy. ### exercise therapy Deep cervical flexor strengthening exercises are the key to managing cervicogenic headaches. Craniocervical flexion exercise improves the endurance and coordination of deep cervical muscles and increases cervical spine stability. Scapular stabilization exercises also contribute to reducing the load on the upper cervical spine. Exercise therapy is an effective strategy not only for short-term pain reduction but also for long-term recurrence prevention. ### medication There are no drugs specifically approved for cervicogenic headaches, but non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and tricyclic antidepressants (amitriptyline) are used as adjuvants. Drug treatment alone has limited effectiveness, and in principle, it should be combined with physical therapy and procedures. ## life guide Posture correction is the basis for preventing cervicogenic headaches. When using a computer, adjust the height so that the top of the monitor is at eye level, and place the keyboard and mouse in a position where your elbows are maintained at 90 degrees. When sitting in a chair, press your lower back against the backrest and lightly pull your chin so that your head is aligned with your shoulder. Correct turtle neck (forward head posture). Every time the head moves forward by 1 cm, an additional load of about 1 to 1.5 kg is placed on the cervical spine. When using a smartphone, avoid raising it to eye level or using it for long periods of time. Perform neck stretches every 30 to 40 minutes. Slowly turn your head left and right, tilt your ear toward your shoulder, and pull your chin for 15 to 20 seconds each. Avoid sudden neck rotation or excessive extension. Adjust the height of the pillow when sleeping. When lying on your side, the appropriate height is to ensure that your head, neck, and spine are in a straight line, and to maintain neck lordosis when lying on your back. A pillow that is too high or too low puts a strain on the cervical joints. Perform regular aerobic exercise (walking, swimming, cycling) 3 to 5 times a week for at least 30 minutes. Repeat deep cervical flexor strengthening exercises (chin pulling exercises) 10 to 15 times daily. Scapular stabilization exercises are also performed to bring the shoulder blades back. Also pay attention to stress management. Emotional tension causes excessive tension in the muscles around the cervical spine, making headaches worse. Abdominal breathing and progressive muscle relaxation are helpful. ## Frequently asked questions ### Q01What are the symptoms of cervicogenic headache? Cervicogenic headaches are headaches that originate from problems in the neck (cervical spine). It usually starts at the back of the head on one side and spreads to the forehead or around the eyes, and the pain gets worse when you turn or tilt your neck. It may also be accompanied by pain in the shoulder or arm on the same side. It is often confused with migraine, so an accurate diagnosis is important. If your headaches always occur on the same side and are related to neck movements, see a neurologist. ### Q02How to distinguish between cervicogenic headache and migraine? Although the two headaches may seem similar, there are some differences. Cervicogenic headaches always occur on the same side and are triggered or worsened by neck movement or posture. Migraines can shift from side to side and are marked by hypersensitivity to light or sound and nausea. However, since there are cases where the two diseases coexist, it is advisable to accurately differentiate them through detailed examination. At Osang Neurosurgery, we perform a cervical spine examination and autonomic nerve function evaluation to comprehensively identify the cause of headaches. ### Q03Can a sore throat cause a headache? Yes, it is entirely possible. When the nerves in the upper cervical spine (C1-C3) are irritated, the signals are combined with facial and head pain signals in a place called the trigeminocervical nucleus in the brain, causing headaches. This is especially common in people who put strain on their necks from working on a computer or using a smartphone for long periods of time. If you have recurring headaches along with neck pain, you should suspect cervicogenic headaches. ### Q04How is cervicogenic headache treated? Treatment proceeds in stages depending on the cause and symptoms. First, physical therapy and manual therapy restore the mobility of the cervical joints and correct the balance of surrounding muscles. If the pain is severe, nerve block procedures such as occipital nerve block or cervical facet joint block are performed. If the pain becomes chronic, the pain nerve can be selectively treated with radiofrequency thermocoagulation. Strengthening the deep cervical flexors through exercise therapy can greatly help prevent recurrence. Get a consultation at Osang Neurosurgery. ### Q05Can cervicogenic headaches get better on their own? Headaches caused by temporary cervical muscle tension can be improved with rest and posture correction. However, if there is a structural problem in the cervical joint or intervertebral disc, it often becomes chronic without treatment. If you have recurring headaches for more than 3 months, it is important to receive early diagnosis and treatment to prevent chronic headaches. The longer you neglect it, the more persistent the pain will be and the less likely it is to respond to treatment, so we recommend that you seek professional consultation early. ### Q06Does poor posture cause cervicogenic headaches? Yes, poor posture is a major trigger for cervicogenic headaches. In particular, turtle neck (forward head posture) places excessive load on the upper cervical spine, putting stress on joints and muscles. The habit of leaning your head down for a long time, using a high pillow, or talking while holding the phone on only one side can cause headaches. Adjusting the height of the monitor to eye level and stretching your neck every 30 to 40 minutes will help prevent it. ### Q07Can exercise help with cervicogenic headaches? Appropriate exercise is very effective in treating and preventing cervicogenic headaches. According to the study, the frequency of headaches was significantly reduced in 72% of patients who combined deep cervical flexor strengthening exercises and manual therapy. We recommend that you consistently perform chin pulling exercises, neck stabilization exercises, and shoulder blade stabilization exercises under the guidance of an expert. However, it is safe to refrain from excessive exercise during the acute pain period and to proceed in stages after the pain is controlled. ## Related articles - giant cell arteritis - Hemicrania continua - Hypnic Headache - Idiopathic intracranial hypertension This article provides general medical information and does not replace an individual diagnosis or treatment plan. 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