Cervicogenic headaches (CGHs) pose a challenge for many sports Chiropractors because the head pain results from somewhere other than the head: the cervical spine. Interestingly, CGHs are one of the most common types of headache in weight-lifting athletes. Patients who have sustained whiplash or concussion injuries with resulting neck pain sometimes develop CGH. In fact, headaches developing 3 months or more after concussion are generally not caused by brain or head injury, suggesting a possible cervical spine etiology.
The International Headache Society published their International Classification of Headache Disorders 2nd edition, identifying 14 different types and sub classifications of headaches. There are 2 basic categories of headaches, primary and secondary. Primary headaches include those of vascular origin (cluster and migraine headaches) as well as those of muscular origin (tension-type headaches). Secondary headaches result from another source including inflammation or head and neck injuries. Norwegian physician Dr. Ottar Sjaastad coined the term, “cervicogenic headache” in 1983 by recognizing a sub-group of headache patients with concomitant head and neck pain; therefore, CGHs are considered “secondary headaches.”
The diagnostic criteria for CGH include headache associated with neck pain and stiffness. Cervicogenic headaches are unilateral, starting from one side of the posterior head and neck, migrating to the front, and sometimes are associated with ipsilateral arm discomfort. Sjaastad et al identified another type of CGH with bilateral head and neck pain, aggravated by neck positions and specific occupations such as hair-dressing, carpentry, and truck/tractor driving. The neck pain precedes or co-exists with the headache, and is aggravated by specific neck movements or sustained postures. Vincent described several factors to differentiate CGHs, including:
Because the diagnosis of CGH is relatively new, its particular etiology remains unclear. Sjasstad and his colleagues suggested that CGH is a “final common pathway” for pain generating disorders of the neck. Bogduk has proposed that the pathophysiology of CGH results from a convergence of sensory input from the upper cervical spine into the trigeminal spinal nucleus, including input from:
The trigeminal pathway theory is somewhat supported by the fact that injection of the greater and lesser occipital nerves with steroids decrease headaches by blocking the trigeminal relay.Furthermore, Chua and colleagues recently reported impairments of sensory testing of the head in CGH patients compared to patients with neck dysfunction without headache. They concluded that the pathophysiology of CGH includes central sensitization of pain, likely from the trigeminal spinal nucleus.
Approximately 47% of the global population suffers from a headache, and 15-20 percent of those headaches are cervicogenic. Recently, CGHs were estimated to affect 2.2% of the population. Epidemiological researchers suggest a higher prevalence of headache in adults with neck pain. Females seem more predisposed to CGHs affecting 4 times as many women as men. Since CGHs commonly affect women, it is important to consider menstruation and hormonal shifts as a contributor to headaches. Menstrual-type headaches often occur 2 days before menstruation and last until the last day of the cycle. These headaches are usually migraine-type, but may be cervicogenic as well.
Migraine or tension-type headaches can also present with neck pain, further complicating differential diagnosis; in fact, some migraine patients experience more neck pain than nausea. Up to 44% of CGH patients may have temporomandibular joint (TMJ) issues as well. Sports physical therapists should perform a comprehensive assessment of the neuromusculoskeletal system in patients with chronic headaches.
As with any differential diagnosis, it is important to first identify any “red flags” associated with headaches that may be a symptom of a serious condition. Patients with vertebral artery dissection present with concomitant headache and neck pain, so it is critical to rule out that condition in patients with headache and neck pain first. Red flag symptoms requiring further medical evaluation include: