The Headache Diagnosis and Management Series for the Chiropractor, Part VI

Did you know that 35%-40% of patients who seek treatment for headaches suffer from daily or near daily headaches? Chronic daily headache (CDH), as we learned, consists of only five headache subtypes. (If you missed this article, you can find it at on line at http://www.ChiroWeb.com/archives/17/09/05.html ). Today, we will discuss cervicogenic headache with more detail.]

Please note that cervicogenic headache is not restricted to the CDH classification, as this headache may be short lived or episodic. However, when this headache persists in its chronic fluctuating form, it may fulfill the criteria for CDH.

In this article, the overall criteria for cervicogenic headache is presented. Keep in mind that there are additional criteria needed to fulfill the definition of CDH.

Quick Reference to Key Features¹

Cervicogenic Headache (CGH)

• Cervicogenic headache is typically unilateral, but it may be bilateral. The duration varies from a few hours to weeks. Initially, the headache tends to be episodic; later it may have a chronic fluctuating character.

• Subjective and objective findings referable to the neck are essential. These may include reduced range of motion in the neck or mechanical precipitation of attacks.

• This headache is not hallmarked by nausea, phonophobia and photophobia but when present, the symptoms are somewhat mild.

• A positive response to appropriate anesthetic blockade of the neck is preferred.

• No specific radiological abnormalities of the cervical spine define this type of headache.

The Major Criteria of Cervicogenic Headache

It is obligatory that one or more of the findings in this group are present. Point A suffices as the sole criterion for positivity within this group; points B or C, however, do not. The presence of all three points (A, B and C) fortifies the diagnosis.

I. Symptoms and signs of neck involvement are (in order of importance):

A. precipitation of head pain, similar to the usually occurring one:

1. by neck movement and/or sustained awkward head positioning; and/or 2. by external pressure over the upper cervical or occipital region on the symptomatic side (see comment 1 below).

B. restriction of the range of motion (ROM) in the neck;

C. ipsilateral neck, shoulder or arm pain of a rather vague non-radicular nature; arm pain of a radicular nature may be present on occasion.

II. Confirmatory evidence of cervicogenic headache with the administration of diagnostic anesthetic blockades (injections) is preferred for routine diagnostic workup.

III. Unilateral head pain without side shift is preferred in the diagnostic workup. In other words, the headache has a preferred side of occurrence and does not readily appear on one side and then the other.

Subjective Characteristics (None of the single points under part IV are obligatory)

IV. Symptoms that hallmark cervi-cogenic headache:

A. moderate to severe, nonthrobbing and nonlancing pain, usually starting in the neck;

B. episodes of varying duration; or

C. fluctuating, continuous pain.

Cervicogenic headache has other characteristics, but these are only of some importance. (None of the single points under part V are obligatory.)

V. Response to medications:

A. only marginal effect or lack of effect of indomethacin;

B. only marginal effect or lack of effect of ergotamine and sumatriptan;

C. there may be a history of head trauma or indirect neck trauma, usually of more than only medium severity.

Cervicogenic headache has other characteristics, but these are only of lesser importance.

VI. Various attack-related phenomena may occasionally be present, and/or moderately expressed.

A. nausea;

B. phonophobia and photophobia;

C. dizziness;

D. ipsilateral "blurred vision";

E. difficulties on swallowing;

F. ipsilateral edema, mostly in the periocular area.

What Is the Strongest Combination of Findings to Support the Diagnosis of Cervicogenic Headache?

The combination of the Group I-A (I-A1 and/or I-A2) and Group II strongly supports the diagnosis. When added to by the points IB and I-C, the diagnosis is utterly fortified.

The next article in this series will discuss the fascinating role of sex hormones in headache.

Enjoy!

Reference

1. These criteria are from: Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. Headache 1998;38:442-445. This article may be ordered from your local chiropractic library or biomedical library.