Cervicogenic Headache
Whether from chronic tension or acute whiplash injury,
intervertebral disc disease or progressive facet joint
arthritis, the neck can be a hidden and severely debilitating
source of headaches. Such headaches are grouped under
the term “cervicogenic headache”, indicating
that the primary contributing structural source of the
headache is the cervical spine. There are well mapped
out patterns of headache relating to a multiplicity
of muscular trigger points in the neck and shoulder-blade
(or peri-scapular) region, as well as to disc and joint
levels in the upper cervical spine. Even headaches located
predominantly in the forehead, or behind, in and around
the eyes are very often “referred” pain zones
for pathology located in the back of the neck and at
the base of the skull. This base of the skull area is
called the suboccipital region, because it is below
the occipital part of the head. The joints connecting
the top two or three levels of the cervical spine to
the base of the skull handle almost 50% of the total
motion of the entire neck and head region, thus absorbing
a continuous amount of repetitive stress and strain,
in addition to bearing the primary load of the weight
of the head. Fatigue, postural malalignment, injuries,
disc problems, joint degeneration, muscular stress and
even prior neck surgeries all can compound the wear
and tear on this critical region of the human skeletal
anatomy. One may also develop a narrowing of the spinal
canal itself, through which runs the spinal cord and
all of its exiting nerve roots, leading to a condition
termed spinal stenosis, also a possible source of headaches,
among other symptoms.
Treatment requires a thorough evaluation of the possible
contributing factors, several of which often exist together.
Physical therapy, provided by an expert spine therapist,
is critical to the success of most other treatment modalities,
whether those include pain injections or surgery or
relaxation and posture techniques. Injections can take
the form of muscle (or myofascial) trigger point blocks,
nerve blocks or epidural spinal injections. The most
effective injections for cervicogenic headaches usually
end up being x-ray guided facet joint blocks, especially
of the upper facet levels. These should only be performed
by a physician trained, skilled and experienced in such
procedures, as the area in the neck where they are given
is quite complex. If investigation leads to discovery
of significant enough disc or joint disease in the cervical
spine, leading to altered load bearing in that area
and pain, surgery is sometimes the best answer. Any
particular treatment, however, is provided in the context
of a comprehensive program addressing all of the issues
and possible contributing factors noted above.
Chiropractic adjustments, acupuncture and massage are
all excellent therapeutic options to assist in managing
chronic pain problems or in arresting acute flare-ups
of headache pain emanating from the neck area. A word
of caution about such modalities, though, is that they
are passive. A critical component of any long-term effective
pain-management regimen is a committed, active participation
of the patient. Triggering activities need to be recognized.
Early pain-building warning signs must be learned and
counter-acted. Posture and exercise need to be attended
to, while stress must be diffused out of the body. Medications
are very effective for cervicogenic headaches, to the
degree that they can be tolerated while an individual
goes on living a functional life. Certainly in severe
pain crises, the paramount goal is to maximally relieve
pain as quickly as possible. The balance is to work
toward minimizing the number of crises one has to experience,
whether through corrective treatment or proactive effective
management.
Severe headaches are almost universally described as
“oh this was a migraine”, but true migraine
variant headaches are thought to comprise only 8% of
all headache episodes. The much more common, but just
as severe, pounding, throbbing, stabbing and nauseating
headaches originate from tension, absorbed most frequently
in the body in the neck and shoulder region. The majority
of these can fall into the category of cervicogenic
headache. TMJ and sinus sources are in actuality small
fractions of the primary etiologies of headaches. They
certainly can be secondary contributors, which set off
a smoldering major complex headache. But beware of sinus
or major dental surgical procedures without at least
a thorough evaluation of all diagnostic possibilities.
Remember, pain is invisible. Very few headaches “show
up” on brain MRI scans. There is much to be seen
and found in the high stress zone of the neck, however,
and this area should be evaluated in detail and treated
aggressively in anyone with chronic or recurrent headaches.
Even patients with true migraines or cluster headaches
will eventually also often end up with compounding cervicogenic
headaches, because of the severe stress of the original
headache in the first place. One headache is bad enough.
No one needs two types to suffer under.
I happen to be a Physiatrist, or Physical Medicine
and Rehabilitation spine and pain specialist. Whoever
you see for your headaches, at least make sure they
have addressed the possibility of a contributing source
of pain and dysfunction in your neck. Your head is heavy
(the weight of a small bowling ball) without pain; you
don’t need to carry around a tonnage of pain besides.
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