NIH Classification of Headaches - Cervicogenic

Cervicogenic

Cervicogenic headache is a syndrome characterized by chronic hemicranial pain that is referred to the head from either bony structures or soft tissues of the neck. The trigeminocervical nucleus is a region of the upper cervical spinal cord where sensory nerve fibers in the descending tract of the trigeminal nerve (trigeminal nucleus caudalis) are believed to interact with sensory fibers from the upper cervical roots. This functional convergence of upper cervical and trigeminal sensory pathways allows the bidirectional referral of painful sensations between the neck and trigeminal sensory receptive fields of the face and head. A functional convergence of sensorimotor fibers in the spinal accessory nerve (CN XI) and upper cervical nerve roots ultimately converge with the descending tract of the trigeminal nerve and might also be responsible for the referral of cervical pain to the head.

Diagnostic criteria have been established for cervicogenic headache, but its presenting characteristics occasionally may be difficult to distinguish from primary headache disorders such as migraine, tension-type headache, or hemicrania continua.

This article reviews the clinical presentation of cervicogenic headache, proposed diagnostic criteria, pathophysiologic mechanisms, and methods of diagnostic evaluation. Guidelines for developing a successful multidisciplinary pain management program using medication, physical therapy, osteopathic manipulative treatment, other nonpharmacologic modes of treatment, and anesthetic interventions are presented.

Previous Section Next Section Neck pain and cervical muscle tenderness are common and prominent symptoms of primary headache disorders.1 Less commonly, head pain may actually arise from bony structures or soft tissues of the neck, a condition known as cervicogenic headache.2 Cervicogenic headache can be a perplexing pain disorder that is refractory to treatment if it is not recognized. The condition's pathophysiology and source of pain have been debated,3-5 but the pain is likely referred from one or more muscular, neurogenic, osseous, articular, or vascular structures in the neck.6

The trigeminocervical nucleus is a region of the upper cervical spinal cord where sensory nerve fibers in the descending tract of the trigeminal nerve (trigeminal nucleus caudalis) are believed to interact with sensory fibers from the upper cervical roots. This functional convergence of upper cervical and trigeminal sensory pathways allows the bidirectional referral of painful sensations between the neck and trigeminal sensory receptive fields of the face and head.6

Previous Section Next Section Neck Pain as a Manifestation of Migraine

Neck pain and muscle tension are common symptoms of a migraine attack.1,7-9 In a study of 50 patients with migraine, 64% reported neck pain or stiffness associated with their migraine attack, with 31% experiencing neck symptoms during the prodrome; 93%, during the headache phase; and 31%, during the recovery phase.1 In the study by Blau and MacGregor,1 7 patients reported that pain was referred into the ipsilateral shoulder and 1 patient reported that pain extended from the neck into the low back region.

In another study of 144 migraine patients from a university-based headache clinic, 75% of patients reported neck pain associated with migraine attacks.8 Of these patients, 69% described their pain as “tightness”, 17% reported “stiffness” and 5% reported “throbbing.” The neck pain was unilateral in 57% of respondents, 98% of whom reported that it occurred ipsilateral to the side of headache. The neck pain occurred during the prodrome in 61%; the acute headache phase, in 92%; and the recovery phase, in 41%.

Recurrent, unilateral neck pain without headache is reported as a variant of migraine.10 Careful history gathering in cases of recurrent neck pain discovered that previously overlooked symptoms were either similar or identical to those associated with migraine.