disorder that is refractory to treat- ment if it is not recognized. The condi- tion’s pathophysiology and source of pain have been debated,3-5 but the pain is likely referred from one or more mus- Cervicogenic : cular, neurogenic, osseous, articular, or A Review of Diagnostic and vascular structures in the neck.6 Treatment Strategies The trigeminocervical nucleus is a region of the upper cervical spinal cord David M. Biondi, DO 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 con- vergence of upper cervical and trigeminal sensory pathways allows the bidirec- tional referral of painful sensations between the neck and trigeminal sen- sory receptive fields of the face and head.6 Cervicogenic headache is a syndrome characterized by chronic hemicranial pain that is referred to the head from either bony structures or soft tissues of as a Manifestation the neck. The trigeminocervical nucleus is a region of the upper cervical spinal of Migraine cord where sensory nerve fibers in the descending tract of the trigeminal nerve Neck pain and muscle tension are (trigeminal nucleus caudalis) are believed to interact with sensory fibers from common symptoms of a migraine the upper cervical roots. This functional convergence of upper cervical and attack.1,7-9 In a study of 50 patients with trigeminal sensory pathways allows the bidirectional referral of painful sen- migraine, 64% reported neck pain or stiff- sations between the neck and trigeminal sensory receptive fields of the face and ness associated with their migraine head. A functional convergence of sensorimotor fibers in the spinal accessory attack, with 31% experiencing neck nerve (CN XI) and upper cervical nerve roots ultimately converge with the symptoms during the prodrome; 93%, descending tract of the trigeminal nerve and might also be responsible for the during the headache phase; and 31%, referral of cervical pain to the head. during the recovery phase.1 In the study Diagnostic criteria have been established for cervicogenic headache, but its by Blau and MacGregor,1 7 patients presenting characteristics occasionally may be difficult to distinguish from reported that pain was referred into the primary headache disorders such as migraine, tension-type headache, or hem- ipsilateral shoulder and 1 patient icrania continua. reported that pain extended from the This article reviews the clinical presentation of cervicogenic headache, neck into the low back region. proposed diagnostic criteria, pathophysiologic mechanisms, and methods of In another study of 144 migraine diagnostic evaluation. Guidelines for developing a successful multidisciplinary patients from a university-based program using medication, physical therapy, osteopathic headache clinic, 75% of patients reported manipulative treatment, other nonpharmacologic modes of treatment, and neck pain associated with migraine anesthetic interventions are presented. 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 Dr Biondi is the director of Headache Manage- eck pain and cervical muscle ten- respondents, 98% of whom reported that ment Programs at Spaulding Rehabilitation Hos- it occurred ipsilateral to the side of pital, a consultant to the Department of Neu- Nderness are common and promi- rology, Massachusetts General Hospital, and nent symptoms of primary headache headache. The neck pain occurred during instructor in Neurology, Harvard Medical School, 1 the prodrome in 61%; the acute headache Boston, Mass. disorders. Less commonly, head pain Dr Biondi has a financial interest arrangement may actually arise from bony structures phase, in 92%; and the recovery phase, in or affiliation with the following: Allergan Inc; or soft tissues of the neck, a condition 41%. AstraZeneca; Elan Pharmaceuticals, Inc; Glaxo- 2 Recurrent, unilateral neck pain SmithKline; Merck & Co, Inc; Pfizer Inc; MedPointe known as cervicogenic headache. Cer- Pharmaceuticals; OrthoMcNeil Pharmaceutical, vicogenic headache can be a perplexing without headache is reported as a variant Inc; and Endo Pharmaceuticals. Address correspondence to David M. Biondi, DO, Spaulding Rehabilitation Hospital, 125 Nashua St, Boston, MA 02114-1101. This continuing medical education publication supported by E-mail: [email protected] an unrestricted educational grant from Merck & Co, Inc

S16 • JAOA • Supplement 2 • Vol 105 • No 4 • April 2005 Biondi • Cervicogenic Headache of migraine.10 Careful history gathering in cases of recurrent neck pain discov- Checklist ered that previously overlooked symp- toms were either similar or identical to those associated with migraine. MAJOR CRITERIA Differences in neck posture, pro- Point I—Symptoms and Signs of Neck Involvement nounced levels of muscle tenderness, and (listed in a surmised sequence of importance; obligatory that the presence of myofascial trigger points one or more of phenomena are present) Precipitation of head pain, similar to the usually occurring were observed in subjects with migraine, (suffices as the sole criterion for positivity)*: tension-type headache, or a combination — by neck movement and/or sustained awkward head positioning of both, but not in a nonheadache control (suffices as the sole criterion for positivity within group, and/or: 1,11,12 — by external pressure over the upper cervical or occipital region on group. A comparison of the the symptomatic side headache groups demonstrated no sig- (Provisionally, the combination of the following two points has been nificant differences in myofascial symp- set forth as a satisfactory combination within Point 1) toms or signs, dispelling the common Restriction of the range of motion (ROM) in the neck* belief that tension-type headache is asso- Ipsilateral neck, shoulder, or arm pain of a rather vague ciated with a greater degree of muscu- nonradicular nature or, occasionally, arm pain of a radicular nature* loskeletal involvement than migraine.12

Point II—Confirmatory Evidence Headache as a Manifestation by Diagnostic Anesthetic Blockades of Neck Disorders (This is an obligatory point in scientific works.) Head pain that is referred from the bony Point III—Unilaterality of the Head Pain, Without Sideshift structures or soft tissues of the neck is commonly called “cervicogenic (For scientific work, Point III should preferably be adhered to.) headache.” It is often a sequela of head or HEAD PAIN CHARACTERISTICS neck injury but may also occur in the Point IV absence of trauma. The clinical features (None of the following points is obligatory) of cervicogenic headache may mimic Moderate to severe, nonthrobbing, and nonlancinating pain, those commonly associated with primary usually starting in the neck headache disorders such as tension-type Episodes of varying duration, or headache, migraine, or hemicrania con- Fluctuating, continuous pain tinua, and as a result, distinguishing among these headache types can be dif- OTHER CHARACTERISTICS OF SOME IMPORTANCE Point V ficult. The prevalence of cervicogenic (None of the following points is obligatory) headache in the general population is Only marginal effect or lack of effect of indomethacin estimated to be between 0.4% and 2.5%, Only marginal effect or lack of effect of ergotamine and sumatriptan succinate but in pain management clinics, the (c) female sex prevalence is as high as 20% of patients (d) not infrequent occurrence of head or indirect neck trauma with chronic headache.13 The mean age by history, usually of more than only medium severity of patients with this condition is 42.9 OTHER FEATURES OF LESSER IMPORTANCE years, and cervicogenic headache is four Point VI times more prevalent in women. Patients Various attack-related phenomena, only occasionally present: with cervicogenic headache have demon- — nausea strated substantial declines in quality of — phonophobia and photophobia — dizziness life measurements that are similar to — ipsilateral “blurred vision” those in patients with migraine and ten- — difficulties on swallowing sion-type headache when compared with — ipsilateral edema, mostly in the periocular area control subjects, but they demonstrate *The presence of all three points indicated with asterisk fortifies the diagnosis the greatest loss in domains of physical (but still Point II is an additional obligatory point for scientific work). functioning when compared with the groups with other headache disorders.14 The Cervicogenic Headache Inter- Figure 1. The Cervicogenic Headache International Study Group Diagnostic Criteria. (Modi- national Study Group developed diag- fied from Biondi DM: Cervicogenic headache: mechanisms, evaluation, and treatment strate- nostic criteria that have provided a gies. J Am Osteopath Assoc. 2000;100(9 Suppl):S7-14. Source: Sjaastad 0, Fredriksen TA, Pfaf- detailed, clinically useful description of fenrath V. Cervicogenic headache: diagnostic criteria. Headache. 1998;38:442-445.) the condition (Figure 1).15 The diagnosis

Biondi • Cervicogenic Headache JAOA • Supplement 2 • Vol 105 • No 4 • April 2005 • S17 Figure 2. Clinical characteristics of cervico- Zygapophyseal joint, cervical nerve, genic headache. (Modified from Biondi DM: or medial branch blockade is used to con- Cervicogenic headache: mechanisms, evalu- Checklist firm the diagnosis of cervicogenic ation, and treatment strategies. J Am headache and predict the treatment Osteopath Assoc. 2000;100(9 Suppl):S7-14.) modalities that will most likely provide Unilateral head or face pain without sideshift; the pain may the greatest efficacy. The first three cer- occasionally be bilateral vical spinal nerves and their rami are the Pain localized to the occipital, primary peripheral nerve structures that of cervicogenic headache can often be frontal, temporal or orbital can refer pain to the head. made without resorting to diagnostic regions The suboccipital nerve (dorsal neural blockade by completion of a Moderate to severe pain ramus of C1) innervates the atlanto-occip- careful history and physical examination intensity ital joint; therefore, a pathologic condition (Figure 2). Intermittent attacks of pain or injury affecting this joint is a poten- lasting hours to days, constant tial source for head pain that is or constant pain with Diagnostic Testing for superimposed attacks of pain to the occipital region. Suspected Cervicogenic Headache The C2 spinal nerve and its dorsal Pain is generally deep and Patients with cervicogenic headache will nonthrobbing; throbbing may root ganglion have a close proximity to often have altered neck posture or occur when migraine attacks are the lateral capsule of the atlantoaxial restricted cervical range of motion.16 The superimposed (C1–2) zygapophyseal joint and inner- head pain can be triggered or reproduced Head pain is triggered by neck vate the atlantoaxial and C2–3 by active neck movement, passive neck movement, sustained or zygapophyseal joints; therefore, trauma awkward neck postures; digital positioning especially in extension or pressure to the suboccipital, C2, to or pathologic changes around these extension with rotation toward the side C3, or C4 regions or over the joints can be a source of referred head of pain, or on applying digital pressure to greater occipital nerve; valsalva, pain. of C2 is typically the involved facet regions or over the cough or sneeze might also described as a deep or dull pain that usu- trigger pain ipsilateral greater occipital nerve. Mus- ally radiates from the occipital to pari- Restricted active and passive neck cular trigger points are usually found in range of motion; neck stiffness etal, temporal, frontal, and periorbital the suboccipital, cervical, and shoulder regions. A paroxysmal sharp or shocklike Associated signs and symptoms musculature, and these trigger points can be similar to typical migraine pain is often superimposed over the con- can also refer pain to the head when accompaniments including: stant pain. Ipsilateral eye lacrimation and manually or physically stimulated. There — nausea; conjunctival injection are common asso- are no neurologic findings of cervical — vomiting; ciated signs. Arterial or venous com- radiculopathy, though the patient might — photophobia, phonophobia, pression of the C2 spinal nerve or its and dizziness; report scalp paresthesia or dysesthesia. — others include ipsilateral blurred dorsal root ganglion has been suggested Diagnostic imaging such as radio- vision, lacrimation and as a cause for C2 neuralgia in some graphy, magnetic resonance imaging conjunctival injection or cases.11,20-23 The third occipital nerve (MRI), and computed tomography (CT) ipsilateral neck, shoulder (dorsal ramus C3) has a close anatomic or arm pain myelography cannot confirm the diag- proximity to and innervates the C2–3 nosis of cervicogenic headache but can zygapophyseal joint. This joint and the lend support to its diagnosis.17 One study third occipital nerve appear most vul- reported no demonstrable differences in ment.20 The differential diagnosis in cases nerable to trauma from acceleration- the appearance of cervical spine struc- of suspected cervicogenic headache could deceleration (“whiplash”) injuries of the tures on MRI scans when 24 patients include posterior fossa tumor, Arnold- neck.24 Pain from the C2–3 zygapophy- with clinical features of cervicogenic Chiari malformation, cervical spondy- seal joint is referred to the occipital region headache were compared with 20 control losis or arthropathy, herniated interver- but is also referred to the frontotemporal subjects.18 Cervical disc bulging was tebral disc, spinal nerve compression or and periorbital regions. Injury to this reported equally in both groups (45.5% tumor, arteriovenous malformation, ver- region is a common cause of cervicogenic vs 45.0%, respectively). tebral artery dissection, and headache. The majority of cervicogenic A comprehensive history, review of intramedullary or extramedullary spinal occurring after whiplash systems, and physical examination tumors. resolve within a year of the trauma.25 including a complete neurologic assess- A laboratory evaluation may be nec- Of interest are reports that patients ment will often identify the potential for essary to search for systemic diseases with chronic headache had experienced an underlying structural disorder or sys- that may adversely affect muscles, bones, substantial pain relief after diskectomy at temic disease.19 Imaging is then primarily or joints (ie, rheumatoid arthritis, sys- spinal levels as low as C5–6.26,27 used to search for suspected secondary temic lupus erythematosus, thyroid or Diagnostic anesthetic blockade for causes of pain that may require surgery parathyroid disorders, primary muscle the evaluation of cervicogenic headache or other more aggressive forms of treat- disease, etc). can be directed to several anatomic struc-

S18 • JAOA • Supplement 2 • Vol 105 • No 4 • April 2005 Biondi • Cervicogenic Headache tures such as the greater occipital nerve the trigeminocervical nucleus and ulti- (dorsal ramus C2), lesser occipital nerve, mately resulting in the referral of pain atlanto-occipital joint, atlantoaxial joint, Checklist to trigeminal sensory fields of the head C2 or C3 spinal nerve, third occipital and face. nerve (dorsal ramus C3), zygapophyseal Muscular trigger points, a hallmark joint(s) or intervertebral discs based on Pharmacologic of MPS, are discreet hyperirritable the clinical characteristics of the pain and (None of the listed medications are regions of contracted muscle that have a 28 given an indication for this findings of the physical examination. condition by the US Food and Drug lowered pain threshold and refer pain Fluoroscopic or interventional MRI- Administration [FDA]) to distant sites in predictable and repro- 35,36 guided blockade may be necessary to Tricyclic ducible patterns. Anesthetic injections assure accurate and specific localization (amitriptyline hydrochloride, into trigger point regions can assist in of the pain source.29-31 nortriptyline hydrochloride, the diagnostic evaluation and therapeutic doxepin hydrochloride, Occipital neuralgia is a specific pain desipramine hydrochloride, and management of referred head or face 35 disorder characterized by pain that is iso- others) pain from cervical muscular sources. lated to sensory fields of the greater or Antiepileptic drugs (gabapentin, lesser occipital nerves.32 The classic carbamazepine, topiramate, Treatment of Cervicogenic divalproex sodium, and others) description of occipital neuralgia includes Muscle relaxants (tizanidine Headache the presence of constant deep or burning hydrochloride, baclofen, The successful treatment of cervicogenic pain with superimposed paroxysms of cyclobenzaprine hydrochloride, headache usually requires a multifaceted shooting or shocklike pain. Paresthesia metaxalone, and others) approach using pharmacologic, non- Nonsteroidal, anti-inflammatory and numbness over the occipital scalp drugs pharmacologic, manipulative, anesthetic, are usually present. It is often difficult to — nonselective cyclooxygenase and occasionally surgical interventions37 determine the true source of pain in this (COX) inhibitors (indomethacin, (Figure 3). Medications alone are often condition. In its classic description, the ibuprofen, naproxen, and others) ineffective or provide only modest ben- — COX-2 selective inhibitor pain of occipital neuralgia is believed to (celecoxib) efit for this condition. arise from trauma to or entrapment of Anesthetic injections can temporarily the occipital nerve within the neck or Nonpharmacologic reduce pain intensity but have their scalp, but the pain may also arise from Osteopathic manipulative greatest benefit by allowing greater par- treatment or manual modes of the C2 spinal root, C1–2, or C2–3 therapy ticipation in physical treatment modali- zygapophyseal joints or pathologic Physical therapy ties. The success of diagnostic cervical change within the posterior cranial fossa. Transcutaneous electrical nerve spinal nerve, medial branch, or stimulation (TENS) Occipital nerve blockade, as it is typ- Biofeedback/relaxation therapy zygapophyseal joint blockade can pre- ically done in the clinic setting, often Individual psychotherapy dict response to radiofrequency thermal results in a nonspecific regional blockade neurolysis.38 Developing an individual- rather than a specific nerve blockade and Interventional ized treatment plan enhances successful Anesthetic blockade might result in a misidentification of the — spinal roots, nerves, rami, or outcomes. occipital nerve as the source of pain. This branches “false localization” might lead to unnec- — muscular trigger points Pharmacologic Treatment essary interventions aimed at the occip- Neurolytic procedure Pharmacologic treatment modalities for — radiofrequency thermal ital nerve, such as surgical transection or neurolysis cervicogenic headache include many other neurolytic procedures.5 Botulinum toxin injections (not medications that are used for the pre- A regional myofascial pain syn- given an indication for this ventive or palliative management of ten- drome (MPS) affecting cervical, pericra- condition by the FDA) sion-type headache, migraine, and “neu- Occipital nerve stimulator nial, or masticatory muscles can be asso- ropathic” pain syndromes. The listed ciated with referred head pain. Sensory Surgical medications have neither been approved afferent nerve fibers from upper cervical Neurectomy by the US Food and Drug Administra- regions have been observed to enter the Dorsal rhizotomy tion (FDA) nor rigorously studied in con- Microvascular decompression spinal column by way of the spinal acces- Nerve exploration and “release” trolled clinical trials for the treatment of sory nerve before entering the dorsal Joint fusion cervicogenic headache and are only sug- spinal cord.33,34 The close association of gested as potential treatments based on sensorimotor fibers of the spinal acces- the anecdotal experiences of clinicians sory nerve with the spinal sensory nerves who treat this condition or similar pain is believed to allow for a functional Figure 3. Potential treatment interventions for disorders. The side effects and labora- exchange of somatosensory, proprio- cervicogenic headache. (Modified from Biondi tory monitoring guidelines provided are ceptive, and nociceptive information DM: Cervicogenic headache: mechanisms, eval- not intended to be comprehensive, and from the trapezius, sternocleidomastoid, uation, and treatment strategies. J Am consultation of standard references or and other cervical muscles to converge in Osteopath Assoc. 2000;100(9 Suppl):S7-14.) product package inserts are recom-

Biondi • Cervicogenic Headache JAOA • Supplement 2 • Vol 105 • No 4 • April 2005 • S19 mended before prescribing any of these migraine headache and may be effective tion and warnings found in the product medications. for cluster headaches as well as other package inserts. Many patients with cervicogenic neurogenic pain syndromes. Serum drug Narcotic are not gener- headache overuse or become dependent levels can be used as a therapeutic dosing ally recommended for the long-term on analgesics. Medication when used as guide. Monthly monitoring of liver management of cervicogenic headache39 the only mode of treatment for cervico- transaminase levels and of complete but may be cautiously prescribed for tem- genic headache does not generally pro- blood cell (CBC) counts for evidence of porary pain relief to expedite the vide substantial pain relief in most cases. toxicity is recommended, especially advancement of manual modes of Despite this observation, the judicious during the first 3 to 4 months of treat- therapy or improve tolerance for anes- use of medications can provide enough ment or whenever dosages are escalated. thetic interventions. pain relief to allow greater patient par- Gabapentin is indicated for the man- Migraine-specific abortive medica- ticipation in a physical therapy and reha- agement of postherpetic neuralgia and tions such as ergot derivatives or trip- bilitation program. To improve compli- has been used for management of other tans are not effective for the chronic head ance, medications are initially prescribed neuropathic pain syndromes and pain of cervicogenic headache but may at a low dose and increased over 4 to 8 migraine. No specific laboratory moni- relieve the pain of episodic migraine weeks as necessary and tolerated. toring is usually necessary. attacks that can occur in some patients The cautious combining of medica- Topiramate is indicated for migraine with cervicogenic headache. tions from different drug classes or with prophylaxis and has been anecdotally Other Medications—Muscle relax- complementary pharmacologic mecha- reported effective in the management of ants, especially those with central nisms may provide greater efficacy than painful diabetic neuropathy and cluster activity such as tizanidine hydrochlo- using individual drugs alone (eg, an headache. Intermittent monitoring of ride and baclofen, may provide some antiepileptic drug combined with a tri- serum electrolyte levels might be needed efficacy. Botulinum toxin, type cyclic [TCA]). Frequent because of this medication’s diuretic A injected into pericranial and cervical follow-up visits for medication dosage effect through carbonic anhydrase inhi- muscles is a promising treatment for adjustments, monitoring of serum drug bition. patients with migraine and cervicogenic levels, and evidence of medication toxi- Carbamazepine is an effective med- headache,37,40,41 but further clinical and city are recommended. ication in the treatment of patients with scientific study is needed. trigeminal neuralgia and central neuro- Antidepressants—The TCAs have pathic pain. Serum drug levels can be Physical and Manual Modes of long been used for management of var- used as a therapeutic dosing guide. Therapy ious neuropathic, musculoskeletal, head, Monthly monitoring of liver transami- Physical and manual modes of therapy and face pain syndromes. Analgesic nase levels and of CBC counts is recom- are important therapeutic modalities for dosages are typically lower than those mended, especially during the first 3 to the acute rehabilitation of cervicogenic required for the treatment of patients 4 months of treatment or whenever headache.42 A controlled trial testing the with depression. The serotonin and nore- dosages are increased. effectiveness of therapeutic exercise and pinephrine reuptake inhibitors (SNRIs) Several of the other newer AEDs manipulative treatment for cases of cer- such as venlafaxine hydrochloride and might be used when other treatments vicogenic headache found that efficacy duloxetine hydrochloride have been are ineffective. was not substantially affected by age, anecdotally observed helpful in the pro- Analgesics—Simple analgesics such gender, or headache chronicity in patients phylactic management of migraine. Sim- as acetaminophen or nonsteroidal anti- with moderate to severe pain intensity.43 ilar observations have been reported for inflammatory drugs (NSAIDs) may be This finding suggests that all patients venlafaxine in the treatment of painful used as regularly scheduled medications with cervicogenic headache could benefit diabetic neuropathy, fibromyalgia, and for round-the-clock management of from manual modes of therapy and regional myofascial pain syndromes, or as needed for the man- physical conditioning. while duloxetine is indicated for the man- agement of acute pain. Another study comparing an exer- agement of painful diabetic neuropathy. The selective cyclooxyenase-2 (COX- cise program with manipulative therapy The selective serotonin reuptake 2) antagonist celecoxib might have less for cervicogenic headache reported sub- inhibitors (SSRIs) are generally ineffective gastrointestinal toxicity than nonselec- stantial and sustained reductions of for pain control. tive NSAIDs, but renal toxicity after long- headache frequency and intensity that Antiepileptic Drugs—The anti- term use remains as a concern. Recent were similar in both treatment groups epileptic drugs (AEDs) are believed to reports have linked the long-term use of but with a trend toward greater efficacy be modulators or stabilizers of periph- selective COX-2 antagonists with an when the treatment modalities are com- eral and central pain transmission and increased risk of cardiovascular and cere- bined.44 are commonly used for the management brovascular events; therefore, the risk- A review of the medical literature of neuropathic, head, and face pain syn- benefit ratio of their use requires strong suggested that the efficacy of physical dromes. Divalproex sodium is indicated consideration. It is recommended that treatment modalities for the long-term for the preventive management of prescribers review the safety informa- prevention and control of headaches

S20 • JAOA • Supplement 2 • Vol 105 • No 4 • April 2005 Biondi • Cervicogenic Headache appears greatest in patients who are anesthetic may also provide temporary Its presenting symptom complex can be involved in ongoing exercise and phys- pain relief and relaxation of local muscle similar to that of the more commonly ical conditioning programs.45 spasm. If diagnostic blockade of cervical encountered primary headache disor- Osteopathic manipulative tech- nerve, medial branch, or zygapophyseal ders such as migraine or tension-type niques such as craniosacral, strain- joint blockade is successful in providing headache. Early diagnosis and manage- counter strain, and muscle energy tech- substantial, but temporary, pain relief, ment by way of a comprehensive, mul- niques are particularly well suited for the treatment algorithm can then pro- tidisciplinary pain treatment program the management of cervicogenic ceed to consideration for a longer-acting can significantly decrease the protracted headache. High velocity, low amplitude neurolytic procedure such as radiofre- course of costly treatment and disability manipulation can be carefully used in quency thermal neurolysis.38,50,51 that is often associated with this chal- some patients, though it is not unusual to A course of physical therapy and lenging pain disorder. observe an increase in headache inten- rehabilitation is recommended after sity after manual modes of therapy of anesthetic blockade and neurolytic pro- References this type, especially if it is delivered too cedures to enhance functional restora- 1. Blau JN, MacGregor EA. Migraine and the neck. vigorously. Physical treatment modali- tion and effect a longer-lasting analgesic Headache. 1994;34:88-90. ties are generally better tolerated when benefit. 2. Sjaastad 0, Saunte C, Hovdahl H, Breivik H, Gron- initiated with gentle muscle stretching back E. “Cervicogenic” headache. A hypothesis. and manual cervical traction. Therapy Surgical Treatment Cephalalgia. 1983;3:249-256. can be slowly advanced as tolerated to A variety of surgical interventions have 3. Edmeads J. The cervical spine and headache. include strengthening and aerobic con- been done for presumed cases of cer- Neurology. 1988;38:1874-1878. ditioning. Using anesthetic blockade and vicogenic headache.3 Surgical liberation neurolytic procedures for temporary pain of the occipital nerve from “entrapment” 4. Pollmann W, Keidel M, Pfaffenrath V. Headache and the cervical spine: a critical review. Cepha- relief can enhance the efficacy and in the trapezius muscle or surrounding lalgia. 1997;17:501-516. advancement of physical modes of connective tissues can provide substan- therapy. tial, but temporary, pain relief in some 5. Leone M, D’Amico D, Grazzi L, et al. Cervico- 52 genic headache: a critical review of the current patients. Similarly, only temporary pain diagnostic criteria. Pain. 1998;78:1-5. Psychological and Behavioral relief is observed after surgical transection Treatment of the greater occipital nerve.52 Intensifi- 6. Bogduk N. The anatomical basis for cervicogenic headache. J Manipulative Physiol Ther. 1992;15:67- Psychological and nonpharmacologic cation of pain or dolorosa is a 70 interventions such as biofeedback, relax- potential adverse outcome that must be ation, and cognitive-behavioral therapy seriously considered when contem- 7. Tfeld-Hansen P, Lous I, Olesen J. Prevalence and significance of muscle tenderness during common are important adjunctive treatments in plating the use of surgical interventions. migraine attacks. Headache. 1981;21:49-54. the comprehensive management of There have been preliminary reports pain.46 Ongoing intensive, individual of efficacy in reducing headache fre- 8. Kaniecki RG. Migraine and tension-type headache: an assessment of challenges in diag- psychotherapy is often required if the quency, intensity, and associated dis- nosis. Neurology. 2002;58 (9 Suppl 16):S15-S20. patient with chronic pain has a promi- ability in cases of chronic migraine after nent affective or behavioral component surgical implantation of occipital or 9. Waelkens J. Warning symptoms in migraine: 53 characteristic and therapeutic implications. Cepha- and the pain persists despite aggressive spinal nerve stimulators. Based on lalgia. 1985;5:223-228. treatment. pathogenic models of cervicogenic headache, neurostimulation would 10. DeMarinis M, Accornero N. Recurrent neck Anesthetic Blockade and Neurolysis pain as a variant of migraine: description of four appear to be a reasonable option for the cases. J Neurol Neurosurg . 1997;62:669- Cervical epidural steroid injections may management of cervicogenic headache, 670. be indicated in patients with multilevel but its safety and efficacy have not yet 47 11. Lebbink J, Speirings EL, Messinger HB. A ques- disc or spine degeneration. Greater and been determined. Overall, surgical pro- tionnaire survey of muscular symptoms in chronic lesser occipital nerve blockade may pro- cedures such as neurectomy, dorsal rhi- headache: an age- and sex-controlled study. Clin vide temporary, but substantial, pain zotomy, and microvascular decompres- J Pain. 1991;7:95-101. 48 relief in some cases. A published report sion of nerve roots or peripheral nerves 12. Marcus D, Scharff L, Mercer MA, Turk DC. 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Biondi • Cervicogenic Headache JAOA • Supplement 2 • Vol 105 • No 4 • April 2005 • S21 15. Sjaastad 0, Fredriksen TA, Pfaffenrath V. Cer- 28. van Suijlekom JA, Weber WEJ, van Kleef M. Cer- 42. Nilsson N, Christensen HW, Hartvigsen J. The vicogenic headache: diagnostic criteria. Headache. vicogenic headache: Techniques of diagnostic nerve effect of spinal manipulation in the treatment of 1998;38:442-445. blocks. Clin Exp Rheumatol. 2000;18(Suppl 19):S39- cervicogenic headache. J Manipulative Physiol Ther. S44. 1997;20:326- 330. 16. Hall T, Robinson K. The flexion-rotation test and active cervical mobility—a comparative measure- 29. Stolker R, Vervest A, Groen G. The management 43. Jull GA, Stanton WR. Predictors of responsive- ment study in cervicogenic headache. Man Ther. of chronic spinal pain by blockades: a review. Pain. ness to physiotherapy management of cervico- 2004;9:197-202. 1994;58:1-20. genic headache. Cephalalgia. 2005:25:101-108.

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27. Fredriksen TA, Salvesen R, Stolt-Nielsen A, Sjaastad O. Cervicogenic headache:long-term post- operative follow-up. Cephalalgia. 1999;19:897-900.

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