cervicogenic headache diagnosis and treatment bogduk

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Cervicogenic headache: an assessment of the evidence o n

clinical diagnosis invasive tests and

treatment

ikolai Bogduk, jayantilal Govind*

Cervicogenic headache is characterised by pain referred to th e head from th e cervical spine. Although th e International Headache Society recognises this type of headache as a distinct disorder some clinicians remain sceptical. Laboratory an d clinical studies have shown that pain from upper cervical joints an d muscles can be referred to th e head. Clinical diagnostic criteria have no t proved valid but a cervical source of pain ca n be established by use of fluoroscopically guided ontrolled diagnostic nerve blocks. n this Review we outline th e basic science an d clinical evidence for cervicogenic headache an d indicate how opposing approaches to its definition and diagnosis affect th e evidence fo r its clinical management W e rovide ecommendations ha t nable ragmatic pproach o he iagnosis nd management of probable cervicogenic headache as well as a rigorous approach to th e diagnosis an d management of definite cervical headache.

Introduction

Cervicogenic headache is pain referred to the head from a ource n he ervical pine. Unlike ther ypes f headache, ervicogenic headache has ttracted interest from isciplines ther han eurology, n articular manual herapists nd nterventional pain pecialists, who believe that they can find the source of pain among the oints of the ervical pine. Neurologists iffer n their cceptance f his isorder. he nternational Headache ociety recognises ervicogenic headache s a istinct isorder 1 nd ne hapter n eading headache textbook acknowledges that injuries to upper cervical oints an ause eadache fter whiplash, 2 although another chapter indicates that this concept is

not fully accepted.3

In terms of basic ciences, ervicogenic headache s the est understood f the ommon headaches. he mechanisms re nown, nd his headache has een induced experimentally in healthy volunteers. n some patients, ervicogenic eadache an e elieved temporarily y diagnostic locks f cervical oints r nerves. However, matter that remains ontentious s how cervicogenic headache should be diagnosed. Some neurologists aintain hat his eadache an e diagnosed on clinical features; others are not convinced of the validity of such diagnosis. Manual therapists use manual xamination f ertebral motion egments, whereas nterventional ain pecialists se luoroscopically guided diagnostic blocks.

In this Review, we provide a synopsis of the available evidence on cervicogenic headache. W e summarise the basic mechanisms, nalyse he vidence n diagnosis and reatment, nd rovide ecommendations n management.

Mechanism of pain referral Cervicogenic headache is referred pain from the cervical spine. Physiologically, this pain is analogous to pain felt in he houlders, hest wall, uttocks, r ower limbs that is referred from spinal sources; hence its familiarity to pain specialists.

The

echanism

nderlying

he

ain

nvolves convergence between cervical and trigeminal afférents in he rigeminocervical ucleus figure ).45 n his nucleus, nociceptive afférents from the Cl, C2, and C3 spinal nerves converge onto second-order neurons that also receive afférents from adjacent cervical nerves and from the irst division of the rigeminal nerve V ), ia the trigeminal nerve spinal tract. This convergence has been hown natomically nd hysiologically n laboratory nimals. 5-9 onvergence etween ervical afférents allows for upper cervical pain to be referred to regions f he ead nnervated y ervical erves (occipital nd uricular egions). onvergence with trigeminal afférents allows for referral into the parietal,

frontal, and orbital regions. Such patterns of referral have been elicited in healthy

volunteers y xperimental, oxious timulation f cervical

tructures.

arly tudies argeted he

suboccipital nd osterior ervical muscles, 1011 nd investigators ave hown hat oxious timulation f more ostral tructures n he ervical pine licited referred pain n the ccipital egion nd more distant regions, such as the frontal region and orbit. B y contrast, stimulation of more audal tructures licited pain n the eck, which ould e eferred o he ccipital regions, lthough ot o distant egions f the ead (figure ). Results rom later tudies have hown hat noxious timulation of the tlanto-occipital nd lateral

atlanto-axial joints,1 2

the C2-3 zygapophysial joint,1 3

and the C2-3 intervertebral disc 1415 can produce pain in the occipital region (figure 3) .

Complementary studies have mapped the distribution of pain that could be relieved in patients by controlled diagnostic blocks of the lateral atlanto-axial joint or the C2-3 or C3-4 zygapophysial joints. 16 Patients with pain from particular oint o ot ave xactly he ame distribution f pain, ut here re imilarities n he distribution. ain rom he ateral tlanto-axial oint (Cl-2) ends o e ocused n he ccipital nd suboccipital egions, nd ends o e eferred o he vertex, rbit, nd ar figure ). ain rom he C2-3

Lancet Ncuro/ 2009; 8:959 68

See Reflection and Reaction

page 875

Newcastle Bone and Joint

Institute Royal Newcastle

Centre Newcastle

New South Wales Australia

(N Bogduk MD); Faculty of

Health Sciences University of

Newcastle Callaghan

New South Wales Australia

(N Bogduk); Pain Management

Unit Canberra Hospital

Woden Australian Capital

Territory Australia

J Govind MBChB); and School

of Medicine Australian

National University Canberra

Australian Capital Territory

Australia J Govind) *Dr Govind died on June 16,

2009

Correspondence to:

Nikolai Bogduk, Newcastle Bone

and Joint Institute, Royal

Newcastle Centre, PO Box 564J,

Newcastle, New South

Wales 2300, Australia

[email protected]

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Midbrain

Trigeminothalamic tract

Trigeminocervical nucleus

Trigeminal nerve (V )

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The evised riteria f the nternational Headache Society1 eflect he ontroversy etween linical diagnosis nd bjective esting or ervicogenic headache (panel 2) . Evidence of a cervical source of pain is equired, ut he xplanatory otes eclare hat clinical features that have little reliability or validity are not cceptable. With ut ther vidence, ontrolled diagnostic blocks become the only means of establishing the diagnosis.

An idiosyncrasy of the International Headache Society criteria s riterion , which escribes esolution f pain months fter treatment. This riterion was not designed for diagnosis before treatment, but to promote rigour. The riterion requires that, if a cause is found, relief of pain should ensue if that cause is successfully treated. orollary f this riterion s hat partial r

short-lasting relief after treatment does not qualify as

a diagnostic criterion.

Interventional diagnosis Practitioners f nterventional ain edicine se fluoroscopically guided, controlled diagnostic blocks to test whether particular structures are the source of pain in atients ith uspected ervicogenic eadache. Studies ave ocused n hree tructures: he ateral atlanto-axial oint an e naesthetised y se f intr a-articular

locks

figure

);35 37

he

2-3 zygapophysial oint an e locked y naesthetising the third occipital nerve where it crosses the joint and supplies t with rticular ranches; 19,38 nd he 3-4 zygapophysial

oint

an

e

naesthetised

y

locking the medial ranches f the 3 nd 4 dorsal ami. 38

Complete elief of headache fter uch locks, under controlled conditions, provides bjective vidence of a cervical source of pain.

The est vailable tudies ndicate hat he 2-3 zygapophysial oints re he most ommon ource f cervicogenic headache, 1619 3 9 , 4 0 accounting for about 7 0of ases. 1 3 Although ata re ot vailable or he prevalence f lateral tlanto-axial oint s ource f cervicogenic eadache, his oint eems o e uite commonly nvolved. 13,35 The C3-4 ygapophysial oint has nly ccasionally been mplicated n ervicogenic headache. 16 The C2-3 ntervertebral disc an lso be

source of this headache, but its prevalence as a causative factor is not known. 41

In patients whose headaches ave een elieved y controlled iagnostic locks f upper ervical oints, there re o istinctive linical eatures. The pain s typically ull nd ching n uality. he ange f movement of the head might be estricted, but not in any haracteristic manner r o ny haracteristic degree. enderness ver he 2-3 oint s ot diagnostic feature as this ign has a positive likelihood ratio of only 2 • 1 to I.19

A ll studies that have implicated the C2-3 zygapophysial joint s ource of cervicogenic headache have een

Interspinous C3-4 Interspinous C4-5 Interspinous C5-6

Figure 2: Referred pain patterns after noxious stimulation of basal occipi tal periosteum an d interspinous muscles at Cl-2 C2-3 C3-4 C4-5 an d C5-6

Th e morecephaladthesiteof stimulation, the more likely that pain s referred to distant regions of the head. The

numbers indicate the percentage of individuals who reported pain in the area shown after stimulation at each

segmental level. The arrows indicate the approximate site of stimulation. Adapted from Campbell and Parsons, with

permission from Lippincott Williams Wilkins.10

C2-3 zygapophysial jo nt

Atlanto-occipital jo nt

O-Cl

Lateral atlanto-axial jo nt

C2-3 intervertebral disc Cl-2

Figure 3: Referred pain patterns after noxious stimulation of upper cervical

joints an d the C2-3 ntervertebral disc

Based o n data from Dreyfuss a nd colleagues, 12 Dwyer and colleagues,13 Schellhas

and colleagues,14 and Grubb an d Kelly.15

conducted in patients with a history of trauma. 1 6 , 1 9 , 3 9 , 4 0 No patients with spontaneous onset of headache have had a ervical ource f pain. This bservation einforces one eature n he linical pproach o iagnosis, n which history of neck trauma is an important criterion.

A omplement to this bservation is hat no tudies that have used controlled diagnostic blocks have shown complete elief of pain n atients with migrainous

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95-100 70-94 45-69 20-44%

C2-3 C3-4

Figure 4: Areas of pain relief in patients who underwent controlled blocks of the synovial joints at Cl-2 C2-3 and C3-4

The density of shading is proportional to the number of patients who perceived pain in the particular area indicated. Adapted from Cooper a nd colleagues, with

permission from Blackwell Science.16

Panel : Clinical criteria for the diagnosis of cervicogenic

headache

1 nilateral headache without side-shift 2 ymptoms and signs of neck involvement: pain triggered

by neck movement or sustained awkward posture and/or

external pressure of the posterior neck or occipital region;

ipsilateral neck, shoulder, and arm pain; reduced range of

motion

3 ain episodes of varying duration or fluctuating continuous pain

4 oderate, non-excruciating pain, usually of a non-throbbing nature

5 ain starting in the neck, spreading to oculo-fronto-temporal areas

6 naesthetic blockades abolish the pain transiently provided complete anaesthesia is obtained, or occurrence

of sustained neck trauma shortly before onset

7 arious attack-related events: autonomie symptoms and signs, nausea, vomiting, ipsilateral oedema and flushing

in the peri-ocular area, dizziness, photophobia,

phonophobia, or blurred vision in the ipsilateral eye

Satisfying criteria 1 and 5 qualifies for a diagnosis of possible cervicogenic headache.

Satisfying any additional three criteria advances the diagnosis to probable cervicogenic

headache. Adapted from Antonaci and colleagues, 34 with permission from

Wiley-Blackwell.

features, uch s hotophobia nd omiting. n ur experience, uch patients do not respond to diagnostic blocks of cervical joints.

Manual diagnosis

Manual herapists ontend hat hey an iagnose cervical sources of headache by manual examination of upper ervical oints. owever, his ractice as ot been validated. An early study compared the diagnosis made y manual herapist with hat made with diagnostic blocks, 42 but the ample ize was mall and

the blocks were not controlled. n later tudy, which used arge ample nd ad ontrolled iagnostic blocks, manual examination had a high ensitivity but no specificity and, therefore, had no diagnostic validity.43

Further evidence is required before a scientific basis for manual diagnosis can be confirmed.

Diagnosis through greater occipital nerve blocks

Some investigators use greater occipital nerve blocks as a diagnostic test either for greater occipital neuralgia or for cervicogenic headache. 44 However, there is no clear rationale or his ractice. Diagnostic locks elieve pain from a source innervated by a nerve distal to where it is blocked. Greater occipital nerve blocks are executed near o where he erve rosses he uperior uchal line. Distal o his point, he erve upplies nly he skin f he ccipital egion. here re o nown disorders of the scalp that might cause persistent pain. Therefore, greater occipital nerve blocks cannot be used to diagnose ervicogenic headache s hese locks onot establish a cervical source of pain. Furthermore, no studies have shown that controlled blocks of the greater occipital nerve onsistently produce omplete elief of headache. At best, greater occipital nerve blocks have a type f partial, euromodulatory ffect n eadache mechanisms, whether he eadaches ave ervical source r ot. Greater ccipital erve locks elieve pain, temporarily, in substantial proportions of patients with igraine, luster eadache, nd emicrania continua. 4 54 A ositive, reater ccipital erve lock, therefore, annot e pecific est or ervicogenic headache. 47

Differential diagnosis

Several disorders share certain features of cervicogenic headache, uch s pain n he eck nd head. These disorders an e ifficult o istinguish, nless or until) additional features emerge. Other disorders form the differential diagnosis of cervicogenic headache only

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notionally ecause hey ffect ervical tructures nd might ause eadache, ut hese isorders ave distinctive features.

The most crucial differential diagnosis of cervicogenic headache s issecting neurysms f the ertebral r internal arotid rteries, which an present with neck pain nd headache. 48-50 These neurysms re ndicated by the onset of cerebrovascular features, which typically emerge within 1 -3 weeks. f this differential diagnosis is ot onsidered, here s isk f patients eing treated ith ervical anipulation, ith atal consequences due to aggravation of the aneurysm.

The econd most mportant differential diagnosis s lesions of the posterior cranial fossa, as the dura mater and essels f the osterior ossa re nnervated y upper cervical nerves. These lesions re distinguished

by the onset of neurological features or systemic illness. Meningitis f he pper ervical pine an e distinguished rom ervicogenic eadache y he presence f ystemic llness nd eck igidity. Additionally, erpes oster an roduce ain n he occipital egion during ts prodromal phase; owever, the eruption of vesicles distinguishes this disease from cervicogenic headache.

Because the C2 pinal nerve uns behind the ateral atlanto-axial joint and is accompanied by its durai sleeve and ubstantial lexus f eins, wo istinctive disorders can be confused with cervicogenic headache. 51

First, eck-tongue yndrome ccurs hen apid turning of the head ubluxates he lateral atlanto-axial

joint

osteriorly.

Tension n

he oint apsule

auses ipsilateral ccipital ain, while ompression f he C2 pinal nerve produces numbness of the ongue. 5253

This yndrome s istinguished y ts recipitating factor and accompanying features. Second, C2 neuralgia can e aused y arious isorders. nflammatory disorders or injuries of the lateral atlanto-axial joint can result in the djacent nerve becoming incorporated in the ibrotic hanges f chronic nflammation. 54,55 The C2 spinal nerve can be compromised by a meningioma, 56

neurinoma, 57 anomalous vertebral arteries, 58 and several other ascular nomalies. 54 58,59 erves ffected y vascular abnormalities have everal features ndicative of europathy, uch s myelin reakdown, hronic haemorrhage, axon degeneration and regeneration, and increased ndoneurial nd ericapsular onnective tissue. 58 Unlike he ull, ching pain f cervicogenic headache, the features of C2 neuralgia are intermittent, lancinating pain in the occipital region associated with lacrimation and ciliary injection. 54,5859

Greater occipital neuralgia s n outdated diagnosis, used efore he oncept of somatic eferred pain was widely understood, when physicians elieved that ny pain in a particular region was due to some affliction of the erve hat an hrough hat egion. ccordingly, pain n he ccipital egion was ttributed o reater occipital neuralgia. However, no pathology of he

Panel 2: Diagnostic criteria fo r cervicogenic headache a s proposed by th e International Headache Society

Diagnostic criteria A Pain referred from a source in the neck and felt in one or more regions of the head

and/or face, fulfilling criteria C and D B Clinical, laboratory, and/or imaging evidence of a disorder or lesion within the cervical

spine or soft tissues of the neck known to be, or generally accepted a s , a valid cause of headache 1

C Evidence that the pain can be attributed to the neck disorder or lesion based on at least on e of the following: 1) evidence of clinical signsthat implicatea source of pain

in the neck;2 or 2) abolitionof headache after diagnostic blockade of a cervical

structure or its nerve supply with placebo or other adequate controls3

D Pain resolves within 3 months after successful treatment of the causative disorder or lesion

Notes 1 umours, fractures, infections, and rheumatoid arthritis of the upper cervical spine

have not been validated formally a s causes of headache, but are nevertheless

accepted a s valid causes when proven to be so in individual cases. Cervical spondylosis and osteochondritis are not accepted a s valid causes fulfilling criterion B .

When there are myofascial tender spots, the headache should be coded under 2

(tension-type headache) 2 linical signs acceptable for criterion Cl must have shown reliability and validity. The

future task s the identification of such reliable and valid operational tests. Clinical

features such a s neck pain, focal neck tenderness, history of neck trauma, mechanical exacerbation of pain, unilaterality, coexisting shoulder pain, reduced range of motion

in the neck, nuchal onset, nausea, vomiting, and photophobia are not unique to cervicogenic headache. These can be features of cervicogenic headache, bu t they do no t define an association between the disorder and the source of the headache

3 bolition of headache means complete relief of headache, indicated by a score of zero on a visual analogue scale. Nevertheless, a >90% decrease in pain to a level of


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A O J

LAAJ

C2-3 Z J

C3-4ZJ'

Lateral view

Figure 5: Posterior an d lateral views of the upper cervical spine showing the leading art icular sources of

cervicogenic headache the related nerves an d where needles ar e placed for diagnostic blocks of these

structures Red labels and needles point to target sites for diagnostic blocks. AOJ=atlanto-occipital joint. C3 DMB=C3 deep

medial branch block. C4mb=medial branch of the C4 dorsal ramus. dmb=deep medial branch of the C3 dorsal

ramus. LA A IAB=intra-articular block of the lateral atlanto-axial joint. LAAJ=lateral atlanto-axial joint. ton=third

occipital nerve.TONB=third occipital nerve block. ZJ=zygapophysial joint.

nerve 66 nd ven nert o ntra-arterial nfusions f vasoactive rugs. 67 hese roperties ule ut he purported mechanism of migraine cervicale. 5

Lower cervical disorders Some nvestigators ave tudied he proposition hat lower ervical isorders an ause eadache. hese researchers refer to ircumstantial evidence that some

patients

with

ower

ervical

adiculopathy

lso

ave headache, of whom various proportions are relieved of headache when the radiculopathy is treated surgically. 68,69

Although these data imply an association, hey do not indicate irect ssociation etween eadache nd lower cervical disorders. Neuroanatomically, there is no direct ink etween ower ervical fférents nd he trigeminocervical ucleus. ntermediate mechanisms, such s uscle ension nd econdary inematic abnormalities hat ffect upper ervical oints 70 might be involved.

Treatment Although there have been many treatments uggested

for ervicogenic headache, ew have een ested nd even ewer have een proven uccessful. Among he determinants of effectiveness are whether the headache was diagnosed linically r whether ervical ource was proven.

Clinical diagnosis No rugs re ffective or ervicogenic eadache. Transcutaneous lectrical erve timulation has een investigated, but not in controlled tudy. About 80of patients btained t east 0 ecrease n heir headache ndex ith his echnique, ut nly t 1 month after treatment. 71

Fo r manual herapy, ost ublications re as e reports or case series. 72 The few randomised, controlled studies provided follow-up of only 1 or 3 weeks, 73-75 and gave onflicting esults. 72 The argest nd most ecent study howed hat reatment with manual herapy, specific exercises, or manual therapy plus exercises was significantly ore ffective t educing eadache frequency and intensity than was no pecific care by a general practitioner. 76 Manual herapy lone, owever, was ot more ffective han xercises lone, nd combining the two interventions did not achieve better outcomes than either intervention alone. About 7 6 of patients achieved a more than 50 decrease in headache frequency nd 5 chieved omplete elief t he 7-week follow-up. At 2 months, 7 2 had a more than 50 decrease in headache frequency, but the proportion

that had complete relief was not

reported. Corresponding figures or ecrease n ain ntensity ere ot reported.

In patients with linical diagnosis of cervicogenic headache, ome investigators have targeted the greater occipital erve or reatment. n ne eries, 6 9 f 180 patients 94 ) btained relief after an injection of 16 0 mg f depot methylprednisolone nd — 4 mL of 1 lidocaine, but only for a mean duration of 23 • 5 days (range 10-77 days).77 In an unrelated study of 50 patients, surgical liberation f he erve nitially elieved headache n bout 0 f ases, ut or median duration of only bout -6 months. 63 Excision of the greater occipital nerve provided relief in about 7 0 of

patients, but for a median duration of only 24 4 days.78

Specific diagnosis In one tudy, patients were selected for surgery if they fulfilled the linical riteria or ervicogenic headache and btained elief f eadache rom iagnostic blockade of the 2 pinal erve. 79 Patients underwent decompression nd microsurgical eurolysis f he C2 spinal nerve, with excision of scar, and ligamentous and vascular elements that compressed the nerve. 14 of 31 patients were rendered pain-free at a mean follow-up of 6 months. Details n he emaining patients re incomplete, but 51 gained what was called adequaterelief, and 11 suffered a recurrence.

Fo r atients with ain temming rom he ateral atlanto-axial oints, wo ptions re vailable. n n observational tudy, 6 f 2 atients btained immediate elief fter ntra-articular njection f steroids. 80 About ne n ive patients btained reater than 50 relief from their headache for 3 months, and one in eight obtained complete relief lasting 9 months. However, such outcomes have not been confirmed in a controlled trial and, therefore, annot ye t be attributed to the injection of steroids. t is possible that a placebo effect might have influenced results. The other option is arthrodesis of the joint. The surgical reports attest to success with this procedure, albeit in small numbers of

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patients, ith omplete elief f ain asting ver 2 years. 81 83

Fo r atients with ain temming rom he 2-3 zygapophysial oint, nvestigators rom ne tudy reported hat ome patients ould btain elief from intra-articular injection of steroids. 84 At 19 months after such njections, wo f 18 patients 11 ) were ree of pain. urther 0 ad educed requency f headaches. This study, however, was not controlled and placebo effects were not excluded. Nevertheless, without other lternatives, ntra-articular njection f steroids would seem to be a safe and expedient intervention that could benefit some patients.

Radiofrequency neurotomy The most extensively studied treatment for cervicogenic

headache

s

percutaneous

adiofrequency

eurotomy. The rationale for this procedure is that if headache can be relieved temporarily by controlled diagnostic blocks of he erve or erves) hat nnervate articular cervical oint, hen nterrupting he pain ignal long that nerve, by coagulating it, should provide long-lasting relief. his eurosurgical rocedure s articularly applicable or he reatment f headache temming from he C2-3 ygapophysial oint, n which as e he target nerve is the third occipital nerve, which innervates that joint.

Three tudies ave eported hat adiofrequency neurotomy is not effective.85-87 In these studies, patients were elected n he asis f linical riteria, nd neurotomy

was

one

t

ll

evels

rom

3

o

6 . Diagnostic locks were one n ne tudy,86 ut he results were not used as an indication for treatment. n the first study, only one of 15 patients achieved complete relief of pain; 85 n he econd tudy n=12), utcomes were no different in patients who received active lesions from hose who eceived ham esions; 86 nd n he third study (n=30), outcomes from neurotomy were no different from those of an injection of local anaesthetic into the greater occipital nerve. 87

However, here re hree otential ifficulties with these studies of radiofrequency neurotomy. First, at no stage was he ource of pain stablished. econd, he technique used for neurotomy has never been validated.

Third, neurotomy was done at segmental levels C3-6) that have rarely, if ever, been implicated as source of headache. Nerves ot proven o mediate he patient's pain were disrupted by use of techniques not proven to denervate them.

Opposite esults were eported n wo tudies n which he iagnosis was arefully stablished with controlled iagnostic locks nd meticulous urgical techniques were used. 88,89 or patients in whom effects of diagnostic blocks indicate that the C2-3 zygapophysial joint is the source of pain, that joint can be denervated percutaneously y adiofrequency eurotomy f he third occipital nerve. The procedure involves placing an

electrode parallel and close to the nerve where it crosses the joint, and using the electrode to disrupt the nerve. 90

Under hese onditions, omplete elief of pain was achieved in 88 of patients, 88,91 with a median duration of relief of 29 7 days.88 Fo r patients in whom headaches recur, elief an e einstated y epeating he neurotomy. y ndertaking epetition s equired, some patients have been able to maintain relief of their headache or onger han ears. 88 The esults f randomised, lacebo-controlled rial ndicate hat responses to radiofrequency neurotomy are not due to placebo ffects p=0-03). 91 The uccessful treatment of third occipital headache in this study cannot, therefore, be dismissed as a placebo effect.

A pragmatic clinical approach

The

egree

o

hich

ractitioners

ight

anage cervicogenic headache depends on the facilities available to hem. f linicans an ndertake iuoroscopically guided diagnostic blocks, hey can stablish ervical source of pain and thereby fulfil the diagnostic criteria for ervicogenic headache s et y he nternational Headache Society.1 If physicians are restricted to clinical diagnosis nly, hey annot ulfil hose riteria. Nevertheless, orking iagnosis f ossible r probable ervicogenic eadache an e stablished based on the criteria listed in panel I.34

Fo r probable cervicogenic headache, exercises with or without manual herapy eems o e he est ption among onservative herapies. 76 ll ther reatment strategies are entirely speculative. If diagnostic blocks r discography can be pplied, source f pain might e stablished n he ateral atlanto-axial oint, he C2-3 ntervertebral disc, r the C2-3 zygapophysial joint. or pain stemming from the lateral tlanto-axial oint, rthrodesis s he nly treatment or hich here s ny vidence f effectiveness. 81 83 ntra-articular njections f teroids are more conservative but their efficacy has not ye t been shown. Fo r pain stemming from the C2-3 intervertebral disc, nterior ervical usion an e ffective.4 1 o alternative s nown or iscogenic ain. or ain stemming rom he 2-3 ygapophysial oint, intra-articular njection f teroids s ow-risk treatment rom which ome atients an enefit.

84

However, placebo ffect has not been xcluded. The only definitive treatment for headache stemming from the 2-3 ygapophysial oint s adiofrequency neurotomy. 8889 However, this procedure has to be done with meticulous ccuracy nd s ndicated nly f patients btain omplete elief f eadache fter controlled blocks of the third occipital nerve. 8889

Conclusions Neurologists re ccustomed o iagnosing headache on the basis of clinical features, supplemented in some cases y medical maging r other tests. Cervicogenic

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Search strategy and selection criteria

References for this Review were identified from the personal

libraries of the authors, supplemented by the reference lists of recent reviews and book chapters and by a search of PubMed with the search terms cervicogenic headache , cervical

headache , headache , cervical vertebrae , and neck pain , between 1 9 5 0 and July, 2 0 0 9 - Papers published in English, French, German, Italian, Spanish, and Slavic languages were

reviewed. Seminal articles that introduced new concepts or

provided original data were included. Articles that only

reiterated established concepts or data were excluded. Review

articles have been cited to cover older and extensive literature on neuroanatomy and neurophysiologyorwhen reviews

cover several articles on particular interventions.

headache oes ot end tself to his pproach. A s result, ensions nd ontroversies ave risen within the field. On the one hand, ome experts have insisted that ervicogenic headache an e defined y linical criteria, butthe evidence shows otherwise. Consequently, owing o he bsence f valid linical riteria, ome neurologists have doubted the diagnosis or consider it to e oo ften arelessly pplied. On he other hand, pain pecialists ave eveloped nvasive echniques whereby he diagnosis an e stablished bjectively. B ut luoroscopically uided, ontrolled iagnostic blocks are not among the conventional armamentarium of neurologists, nor are they widely available.

One of two developments is required for cervicogenic headache o ecome more ommonly ccepted. ain specialists, r nterventional adiologists, ould collaborate with neurologists o dd further tudies o the published works howing the ffects of diagnostic blocks in patients with suspected cervicogenic headache and he ffects f arget-specific nterventions. uch collaboration would e n ine with he al l o educe iatrogenic discomfort resulting from incorrect diagnosis and inappropriate treatment of headaches in general. 92

Alternatively, hysicians ntent n linical iagnosis need o evelop riteria hat re not nly eliable but also valid for a cervical source of pain. Doing so would allow elimination of the footnotes in the criteria of the

International eadache ociety, hich urrently prohibit clinical diagnosis. 1 Contributors

NB drafted the Review. JG reviewed, improved, and finalised the paper, and designed the figures.

Conflicts of interest

W e have no conflicts of interest.

References 1

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2

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