Cervical Spine Considerations in Headache Management

Headache is one of the most common reasons people seek neurology consultations, and the American Academy of Neurology has identified headache medicine as the most common neurologic subspecialty.¹ Headache is a major public health concern with a reported prevalence of active headache disorders affecting 52% of the general population.² Headaches theorized to emanate from the cervical spine were first described by John Hilton in the 1860s and reported by Sjaastad et al^3,4 in 1983. Cervicogenic headaches were formally recognized in the second edition of the International Classification of Headache Disorders (ICHD-2) in 2004.⁵ With a prevalence of 0.17% within the general population, cervicogenic headache in its pure form has been reported to account for 15% to 20% of all headaches.^6,7 Despite the presence of classification systems for cervicogenic headache and increased attention to this entity within the literature, the diagnosis and management of cervicogenic headache present a challenge within neurology practice. This article provides an overview of cervicogenic headache along with apporaches that may improve the identification and treatment of individuals with this condition.

Definition, Diagnostic Criteria, and Challenges

ICHD-3 defines cervicogenic headache as a type of secondary headache “caused by a disorder of the cervical spine and its component bony, disc and/or soft tissue elements, usually but not invariably accompanied by neck pain.”⁸ Criteria for diagnosis include “clinical or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck known to be able to cause headache” (criterion B) and causation established by at least 2 of the following: temporal relationship with the onset of cervical disorder/lesion, significant improvement with resolution of cervical disorder/lesion, reduced range of motion (ROM), and/or abolition of headache following diagnostic blockade of a cervical structure or nerve supply (criteria C-1 to C-4).⁸ Concern has been raised regarding some criteria, including subjecting individuals to invasive and skill-intensive nerve blocks (criterion C-4) as well the amount of time required before a diagnosis can be established while a clinician assesses whether headaches respond to interventions delivered to the cervical spine (criterion C-2).⁹ Fredriksen et al¹⁰ assert that criterion C-1 is of limited practical utility because providers rarely are able to observe the development of a pathologic process or lesion within the spine leading to headache development. Furthermore, fulfilling criterion B may pose a challenge due to limited relationships between cervical imaging findings and reported symptoms of headache.¹¹ Providers may order multiplane cervical spine radiographs to assess for signs of cervical pathology including spondylosis, spondylolisthesis, and segmental dysfunction or misalignment. Additional radiographic studies to rule out ligamentous instability, including flexion-extension and open-mouth films, may also be of diagnostic utility. As part of the headache differential diagnosis, MRI may be used, which often provides the opportunity to observe upper cervical segments. MRI may also aid in ruling out more sinister pathology including Chiari malformation or other intracranial abnormalities. 

Proposed Pathophysiology

Within the brainstem and upper spinal cord segments there is convergence between nociceptive afferent fibers from the upper cervical spine and the trigeminal nerve in the trigeminocervical nucleus (Figure 1). From the trigeminocervical nucleus, sensory signals are then carried to the ventral posteromedial nucleus of the thalamus through the trigeminal thalamic tract (trigeminal lemniscus) and ultimately synapse at the lateral primary sensory cortex. This circuitry enables pain signals from the upper cervical spine to be referred to regions innervated by the trigeminal nerve (eg, orbital, frontal, parietal regions of the head).^12-14 Spinal nerves at C1 innervate the atlanto-occipital joints, C2 fibers innervate the atlanto-axial and facet (zygapophyseal) joints, and C3 fibers also innervate upper cervical facet joints. Referral patterns following stimulation at upper cervical regions to include occipital, periorbital, or frontal pain with C1 stimulation and occipital or cervical pain with C2 to C3 stimulation have been described.¹²

Figure 1. Cervicogenic headache pain referral mechanism
Created in BioRender

Symptoms and Differential Diagnosis

Cervicogenic headache typically presents with unilateral, nonthrobbing pain that begins in the neck and is referred from vertebral segments or soft tissues within the cervical region.⁴ Symptoms are often exacerbated with neck movement and accompanied by limited cervical range of motion. Individuals typically describe their pain as intermittent and variable in duration, although some will report constant discomfort. Pain is often described as mild to moderate in intensity and not typically severe or excruciating.

Diagnosis of cervicogenic headache presents a challenge because symptoms and clinical features overlap substantially with those of other headache subtypes including migraine, tension-type headache, and occipital neuralgia. Figure 2 shows the commonly shared signs and symptoms among individuals with these 4 types of headache as described by Blumenfeld and Siavoshi.¹⁵ Further complicating diagnostic efforts, headache subtypes are not mutually exclusive, and individuals may present with multiple headache diagnoses.

Neck pain is reported by 73% to 90% of individuals with migraine or tension-type headache and by nearly all individuals with occipital neuralgia, which limits the diagnostic utility of the presence of neck pain.¹⁶ In most cases, individuals with cervicogenic headache are less likely to report pulsatile symptoms, photosensitivity, phonosensitivity, or nausea compared with individuals with migraine. The localization of pain in individuals with migraine is more likely to be anterior; individuals with cervicogenic headache more often report pain either posteriorly or radiating posterior to anterior. Individuals with migraine or cervicogenic headache may report increased symptoms with movement; however, people with cervicogenic headache may have more focal or specific movement sensitivities compared with more vague movement- or position change–related sensitivities in an individual with migraine. 

People with tension-type headache are more likely to report bilateral symptoms or sensations of a tight band around the head. Pain tends to be dull in nature and may be accompanied by tension or tenderness at the temples and other pericranial musculature. People with tension-type headache are less likely to describe pain radiating from the cervical region and discomfort is less often elicited with motion of the cervical spine. 

Occipital neuralgia, another type of secondary headache, is characterized by intermittent pain occurring in the distribution of the greater occipital nerve, the lesser occipital nerve, or both. Discomfort is described in periods of “attacks,” usually lasting seconds to minutes. Pain is more often severe (ie, sharp, shooting, stabbing), radiates from the suboccipital region to the top of the head, and may be accompanied by dysesthesia or allodynia. Individuals typically report tenderness to palpation over affected nerve segments with some also describing sensations of tingling. 

Figure 2. The clinical features of cervicogenic headache that overlap with other headache and pain disorders including migraine, occipital neuralgia, and tension-type headache.
Data from Blumenfeld A, Siavoshi S. The challenges of cervicogenic headache. Curr Pain Headache Rep. 2018;22(7):47.15

Physical Examination

The physical examination is a crucial element of the diagnostic process for neurology providers. There are several clinical tests available to assess cervical function and its potential contribution to headache presentations. Jull et al¹⁷ proposed a 3-item examination battery that identified cases of cervicogenic headache with 100% sensitivity and 94% specificity. The 3 domains assessed with this approach were cervical ROM, palpable upper cervical joint dysfunction, and impairment in activation and endurance of deep neck flexor muscles. We propose 3 brief physical examination techniques (ROM assessment, cervical flexion rotation test, and the deep neck flexor endurance test) to assess each of these key clinical domains. A fourth assessment consideration (posture) is offered because observations of postural deviations may inform the need for further tests of cervical function. When combined with elements of the individual history that are suggestive of cervicogenic headache, positive findings with these tests should further raise suspicions of this diagnosis. 

Postural Screening Assessment

Briefly observing an individual’s resting posture can provide important insights into structural misalignments and potential cervical impairments affecting headache symptoms. This can be done by having the individual stand firmly against a wall and making contact with both heels, buttocks, shoulder blades, and head. The individual may also be instructed to close their eyes, turn their head left and right, and then turn back to their perceived center with their eyes remaining closed to observe for deviations in their sense of postural midline. Postural abnormalities observed can include forward head carriage, head unleveling, head rotation or tilt, and listing of the cervical spine. The presence of postural impairments combined with information gained from the individual history may prompt clinicians to screen further for signs of cervical impairment. 

Cervical Range of Motion

While seated, the individual can be asked to demonstrate active cervical movement including flexion, extension, bilateral lateral flexion, and bilateral rotation. Limitations in any plane of movement, complaints of pain before achieving full ROM, or reproduction or exacerbation of headache symptoms should be noted as suggestive of cervical impairment.

Cervical Flexion Rotation Test

Compared with more complicated and cumbersome approaches to manual cervical examination, the cervical flexion rotation test offers strong interrater reliability even among novice clinicians and can be used to conveniently assess for mobility dysfunction at upper cervical spine segments.¹⁸ With the individual supine, the clinician passively flexes the neck to end range, and then passively rotates the head to the right and left side. If firm resistance is noted prior to 45 degrees of rotation, the test is considered positive for upper cervical mobility dysfunction. Performance of this test is depicted in Figure 3. 

Figure 3. Performance of the cervical flexion rotation test. With the patient supine, the clinician firmly grasps the patient’s head (A). The patient’s neck is flexed to end range. Firm support is maintained (B). The neck is passively rotated to the patient’s left and then right sides. The clinician observes for movement that is <45 degrees in either direction or for obvious left/right asymmetry (C and D).

Deep Neck Flexor Endurance Test

Individuals with cervicogenic headache often have limited strength and endurance within the deep neck flexor musculature (ie, longus colli and longus capitis muscles). The deep neck flexor endurance test can be used to quantify the endurance of these muscles. The individual is placed supine and assisted into deep neck flexion (ie, a chin-tucked position). The clinician then lifts the individual’s head 1 inch off the table and cues the individual to hold their head in this tucked and elevated position. A timer is started when the clinician releases the individual’s head. The clinician observes for dropping of the head toward the table or separation in the skin fold along the sternocleidomastoid muscle that is created during the chin tuck motion (Figure 4). Normal hold times for adults age 20 to 80 years have been established as 39 seconds in men and 29 seconds in women.¹⁹

Figure 4. Performance of the deep neck flexor endurance test. The patient is positioned supine and is assisted into a chin-tucked position (A). The clinician lifts the patient’s head 1 inch from the surface (green arrow) while the patient maintains the chin-tucked position (red circle) (B). The clinician cues the patient to maintain this head and neck position while releasing the patient’s head. The clinician starts a timer, which is stopped upon observation of loss of deep neck flexion evidenced by separation of the skin fold near the belly of the sternocleidomastoid muscle (red circle) or movement of the head back toward the surface (green arrow) (C).

Treatment

The overall goal in the management of chronic headache is to steadily reduce the number of headache days and improve function. Once a diagnosis of cervicogenic headache is made, clinicians may prescribe medications to address nociceptive pain and muscle spasm. Individuals with suspected migraine or combined migraine-cervicogenic headache presentations are often prescribed abortive medications. Some individuals will be prescribed a migraine maintenance therapy plan. Additional interventional procedures including occipital nerve blocks and trigger point injections may also be used. Referral for conservative therapy with a properly experienced chiropractor or physical therapist is recommended to occur early in the management process to reduce chronicity and prevent development of central sensitization. Neurologists may also provide education including stretching exercises to improve postural dysfunction and cervical mobility if delays with initiating physical therapy or chiropractic care are anticipated. 

Conservative treatment of cervicogenic headache is appropriate and may include gentle chiropractic care and physical therapy. The goals of chiropractic care and physical therapy are similar, and both chiropractors and physical therapists may be consulted simultaneously on more complicated cervicogenic headache cases. Common therapeutic goals include promoting neutral spinal alignment, pain relief, increased ROM, postural correction, reduction of nerve and musculoskeletal irritability, and improvement of spinal muscle strength and function as well as providing education regarding stress management, symptom exacerbation, and overall well-being. When these goals are accomplished, individuals with cervicogenic headache (and some with primary headaches) experience improvements in headache thresholds. This is especially true when accompanied by lifestyle modifications including improving sleep, diet, exercise, and stress management. These services and their associated outcomes are complementary to the management of the individual offered by neurology clinicians. 

Summary and Practical Takeaways

Diagnosing cervicogenic headache can be a challenge because of its overlapping symptoms. In addition, headache subtypes are not mutually exclusive. Individuals may present with multiple headache diagnoses or may experience the evolution of one subtype into another (eg, chronic cervicogenic headache may evolve into chronic tension-type headache or chronic migraine). 

With a careful history and integration of a few cervical-specific considerations, clinicians may be able to reduce the ambiguity between similarly presenting headaches and increase their diagnostic confidence of cervicogenic headache, leading to more targeted treatment recommendations. For headaches suspected to possess a cervical component, neurology providers should consider early consultation with a chiropractor or physical therapist with experience in cervical and headache management. Complex cases of headache, especially those that are resistant to frontline medical management approaches, can be challenging for neurologists, chiropractors, or physical therapists to manage independently; however, outcomes may be improved with coordinated, comprehensive interdisciplinary management. Communication between disciplines is essential to optimize patient success.