pain 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 Headache: 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 Neck Pain 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 pain management 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- Ⅵ 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) Ⅺ 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 Ⅺ Restriction of the range of motion (ROM) in the neck* belief that tension-type headache is asso- Ⅺ 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 Ⅵ 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 Ⅵ 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 Ⅵ Point IV absence of trauma. The clinical features (None of the following points is obligatory) of cervicogenic headache may mimic Ⅺ Moderate to severe, nonthrobbing, and nonlancinating pain, those commonly associated with primary usually starting in the neck headache disorders such as tension-type Ⅺ Episodes of varying duration, or headache, migraine, or hemicrania con- Ⅺ Fluctuating, continuous pain tinua, and as a result, distinguishing among these headache types can be dif- OTHER CHARACTERISTICS OF SOME IMPORTANCE Ⅵ Point V ficult. The prevalence of cervicogenic (None of the following points is obligatory) headache in the general population is Ⅺ Only marginal effect or lack of effect of indomethacin estimated to be between 0.4% and 2.5%, Ⅺ 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 Ⅵ Point VI times more prevalent in women. Patients Ⅺ 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