Cervicogenic Headache

80% of all headache and migraine has the neck as a source of pain. It seems an incredible claim, but the independent research is supported by our clinic data.

​80% of migraine (including all subtypes - with aura, menstrual migraine etc), tension-type headache and cluster headache may have a solution that is:

• Targeting the underlying cause and providing a remedy rather than 'masking' symptoms.
• Fostering independent self-management with a clear plan to discharge rather than dependence on ongoing 'adjustments' or increasingly more potent medications. 
• A natural solution to help you get your quality of life back within a few weeks

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The research shows clearly that:

1. Headache originating in the neck looks identical in symptoms to other forms of headache. They cannot be distinguished on symptoms alone. According to the official diagnostic guidelines to diagnose your headache type the neck MUST be excluded as a source.
2. Eliminating referral from the neck using injections abolishes headache in at least 80% of migraine (including with aura), tension headache and cluster headache.
3. The neck is painful or symptomatic in 60-70% of all headache types.
4. That means 10-20% of people whose pain was eliminated by injections did not have neck-based symptoms. Our clinic data supports this finding.
   
5. Applying the ‘headache specific’ techniques used in this clinic, the research (14-15) proves we ‘normalise’ the underlying problem in all types of headache – an overactive brainstem. No other manual or ‘hands on’ techniques have been shown to do this. 

   
There is no coincidence that:

·      80% of headache sufferers regardless of diagnosis have the neck as a source of symptoms
·      The neck is considered irrelevant in migraine, tension-type headache and cluster headache
        (cervicogenic headache was not 'officially' recognised by the IHS until 2004!!) 
·      80% of headache suffers are looking for a better solution.

The reason why you, along with 80% of sufferers are looking for a better solution is because a significant part of the underlying cause is being ignored, or treated with techniques not designed for treating headache.

The evidence your neck is causing your headaches

So what is the evidence that your neck is the underlying source of symptoms in 80% of all headache types?

Firstly, you might think it is easy to determine whether or not you have a migraine, tension-type headache or cluster headache compared to a cervicogenic (originating in the neck) headache because they all look different, right? Wrong.

Multiple studies (refs 16-20) have shown that there is significant overlap in the symptoms described for all headache types, and differentiating one from the other is a significant challenge.

For example: intense throbbing one sided pain accompanied by nausea and sensitivity to light and/or sound. Sounds like a migraine right? 
Well, yes, but that is taken directly from the symptom list for cervicogenic headache in the IHS classification.  

The same follows for the other primary headache types. Based on symptoms alone you cannot determine if the neck is causing the headache or if it is truly ‘primary’ headache (primary headache – unknown cause, not existing due to a known condition).

So based on symptoms, the neck is still well and truly in the frame as the source of symptoms.

Neck pain accompanies 60-70% of all headache types (5-7). Amazingly, the presumption is that in almost all of these cases, the neck is fine, and the pain is just a symptom of an overactive brainstem (trigemino-cervical nucleus) where the nerves from the upper part of the neck mix with the nerves from the head and face. As Professor Andrew Charles of UCLA describes (21):

"There again is another paradigm shift. We always thought that migraine came in through the trigeminal nerve or was mediated by inputs from the face, but now there is growing recognition that the upper cervical nerve roots may be playing an equally important role, and many, many migraine patients get neck pain either before, during or after their attack."

Amazingly, Professor Charles then goes on to dismiss seeking treatment for the neck, as it is only dealing with symptoms, and return to the 'migraine has no known cause' paradigm. It begs the question that if the medications aren't treating the cause (as they don't know what it is) then are they only treating symptoms as well? By having the neck assessed, the possible 'important role' that the upper cervical nerve roots are playing can be examined, treated, and in a vast majority of cases lead to a successful resolution, rather than progress down the natural evolution of the medication pathway which for many involves adaptation, increasing doses, then progression to stronger classes of drugs, many of which are blunt instruments having effects on multiple body systems or blanketing all activity in the brain rather than being specifically targeted to headache.

We aren't 'anti-medication'. For a small group of sufferers medication is their only option. 
We believe the logical place to start is to exclude, and only if indicated, treat the neck and prevent many from going down the pharmacological pathway.

Good scientific method at this point would acknowledge that the neck as a source of symptoms is at the very least, a possibility, a sound hypothesis that must tested rather than dismissed without investigation.
 
This is precisely why under the International Headache Society (IHS) classification system for headaches, to diagnose a primary headache (migraine, tension-type headache, cluster headache) other known causes for those symptoms (including the neck) MUST be excluded. 


Sadly this part of the diagnosis is either ignored, or grossly inadequate and a misdiagnosis occurs. A potentially treatable and manageable problem then goes undetected or inappropriately managed with often-severe consequences.

At the very least, exclude your neck as a potential source of your symptoms by starting the online assessment NOW.

Contact Us NOW for Your FREE Online Assessment

Be warned, there is an 80% chance we won’t be able to exclude your neck and will offer you treatment for the cause of your headaches!

So how has your neck been excluded prior to your diagnosis? Occasionally imaging will be used (X-ray, CT, MRI) but unfortunately these only rule out major structural problems, and fail to diagnose a multitude of musculoskeletal abnormalities. 

According to the IHS the ‘gold standard’ for diagnosing whether or not your neck is causing the problem is to do diagnostic joint blocks to eliminate the neck as a referral source. If your pain is abolished then the neck is the source of pain.
These however are expensive and invasive and so instead of fulfilling the diagnostic guidelines, the assumption is made that you have primary headache even when there are obvious neck problems, and your journey into a lifetime of powerful ‘pain masking’ or ‘brain numbing’ medications begins.

As mentioned earlier, good science would seek to prove (rather than assume) that the neck isn't the source of symptoms and exclude it to arrive at the diagnosis of primary headache.
 So what happens when we apply the ‘gold standard’ to a group of people with ‘primary headache’? We get astounding results. After applying this exact method Peter Rothbart(1) reported:

“Approximately 800 new headache patients per year are examined at our clinic. An estimated 80% of these patients are diagnosed (using the gold standard diagnostic joint block) with cervicogenic headache. Of these patients, almost none are referred with this diagnosis. They are usually referred with diagnoses such as tension-type headache and migraine headache”.

Further researchers injected corticosteroids (2,3,4) into branches of the C2 spinal nerve. These studies have shown they can extinguish the pain of migraine, migraine with aura, tension-type headache and cluster headache by eliminating a neck based source of referral. These techniques are considered the “gold standard” for diagnosing headache originating in the neck.


At the very least this should be considered a 'fail' for those trying to prove the neck isn't causing the problem. It strengthens the hypothesis that the neck is potentially the source and warrants much closer attention. Sadly this isn't the case and a logical and increasingly scientifically valid answer the primary headache problem remains ignored.

prevalence

Despite the fact that neck pain accompanies 60-70% of all headache types (7-9) cervicogenic headache has been one of the most hotly debated categories to the extent, believe it or not, that some within the headache community question whether it actually exists. 

It was not actually accepted by the IHS as an official ‘headache type’ until the revised classification system was published in 2004.

For those who do concede it exists, the official prevalence ranges from 0.1% to 4% of the population. This compares to migraine at 15-20% and tension headache at 25-35%. Seems low doesn’t it? The fact is that the criteria used to diagnose a cervicogenic headache make it almost impossible to exist!

The numbers from this clinic support the research outlined above with diagnostic blocks, putting the prevalence above 80% however almost all of these cases 'look like' migraine, tension-type headache or cluster headache and the diagnosis is incomplete (the neck not suitably excluded).

epidemiology

Given that the ‘headache community’ still grapple with the concept that this is actually a proper type of headache, it is hardly surprising that little research has been conducted on it to determine how widespread it is. One look at the IHS diagnostic criteria (see next section) will tell most researchers that it is going to be hard to find. 

Monteira (10) strictly adhered to the IHS classification and not surprisingly found that only 0.4% of the population had diagnosable cervicogenic headache. 

Using slightly more relaxed criteria (9) we see the prevalence climb to 15-17%.

international headache society classification

Buried deep within the bowels of the International Headache Societies Classification of Headache, well past the ‘stars’ of the show, Migraine and Tension-Type Headache, and even past the unheralded “Headache due to disorder of homeostasis” is:

“Headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures”.

As we look through the criteria to diagnose a cervicogenic headache it will become clearer why it is almost impossible to diagnose.

Diagnostic criteria:

A.     Pain, referred from a source in the neck and perceived 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 as, a valid cause of headache.

C.     Evidence that the pain can be attributed to the neck disorder or lesion based on at least one of the following:

1.     Demonstration of clinical signs that implicate a source of pain in the neck

2.     Abolition of headache following diagnostic blockade of a cervical structure or its nerve supply using placebo or other adequate controls

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

That all sounds o.k. but then there are the notes which explain what “counts” and what doesn’t. 

Criteria C must be fulfilled yet it is almost impossible. There are no clinical signs that have been ‘accepted’ as implicating the neck as the sole source of pain, and diagnostic blocks are too expensive and too invasive for everyone to have, so they don’t get done. 
This alone explains such a low incidence for cervicogenic headache. Sadly, when these criteria are fulfilled, and researchers use diagnostic blockade to abolish headache as highlighted above, rather than say the headache types are likely to be cervicogenic, the conclusion is that the diagnostic blocks aren't specific enough as they extinguish pain in migraine, cluster headache and tension-type headache. In other words, even when the criteria ARE fulfilled cervicogenic headache is still ignored.


The presumption, in the face of seemingly powerful evidence to the contrary, is that these other headache types ARE primary headache......so the tests must be wrong! No consideration is given to the (increasingly logical) possibility that the initial diagnosis is potentially inaccurate. This is poor science, but sadly, not the worst example we see in this area.

For criteria B we can include tumours, fractures and rheumatoid arthritis, but we cannot include osteoarthritis or disorders of the muscles (spams or trigger points – these get coded under ‘tension-type headache’). No explanation is given as to why one form of arthritis, or the most commonly found disorders (involving muscle dysfunction) are excluded from the cervicogenic diagnoses. The exclusion of osteoarthritis (spondylosis) is not particularly significant, however, to say that if the muscles in the top of your neck go into spasm or become increasingly tight and develop trigger points over a long period of time and cause a headache, then it’s a ‘Tension-type headache’ of unknown origin requiring pain modulating drugs, rather than a ‘cervicogenic headache’ with a probable cause in the top of the neck. In this case examination of the neck would not be sought at all. Little wonder you are not getting better.

Little wonder that so many ‘tension-type headache’ sufferers are struggling to cope with their ‘pain modulation’ when often the cause has been ignored. Also little wonder that research involving tension-type headache and assessment and treatment of the upper cervical spine has proven links between the two and show to be effective.

So we can count out criteria B, but that’s fine, we don’t need it. We do however need one of criteria C or D. For criteria C we need to use validated clinical tests that are acceptable to the international headache society. They haven’t accepted any standard clinical tests. Many researchers have developed such guidelines, as we will see with Sjaastad below, but these have not been accepted. Diagnostic blockades are the ‘Gold standard’ then, but far beyond the reach for common clinicians, and as we have seen, not accepted when they challenge the primary diagnosis.

Criteria D says we have to have pain resolving (and they state in the notes that it means complete abolition of pain, but we can accept >90% reduction in pain to a level of <5 on a 100 point scale. It sounds reasonable until you compare it to the natural history for most other musculoskeletal conditions in the body. Lets take a chronic lumbar disc disorder. In the sub-acute and chronic phases complete relief of pain is not often possible. By this standard of diagnoses that would mean that the disc is not referring the pain. Yet with surgical intervention we see relief for periods of time. If we can restore mobility and strength around an osteoarthritic joint in the mild to moderate phases we can see significant reductions in pain, but rarely complete abolition and the recurrence is high. If we apply the ‘logic’ of the cervicogenic headache criteria, then osteoarthritis could not be responsible for the pain and it must be coming from ‘sources unknown’.

Consider this farcical situation that the criteria create:

If you book now for an assessment and, like 90% of people we treat, have a significant reduction in symptoms in a 2 week period. According to the criteria your neck is still irrelevant. Even if we have the pain completely resolve within 3 months of treatment………..and still not be able to call it a cervicogenic headache because unless I have diagnostic blockades I cannot fulfill criteria C. Even though your headache or migraine is gone.
 
We also see cases where symptoms have reduced by 50% or more rather than be abolished. Logic would suggest, and its what we describe to clients – that your neck has formed part of the problem, and now having treated that component, the contribution from the neck isn’t relevant. There is no room in the classification system for the neck causing ‘part’ of the problem. Its and all or nothing approach, which again flies in the face of principles of anatomy and physiology.

You now see exactly why there is debate in the ‘headache community’ about the existence of this form of headache (strictly adhering to the criteria it is almost impossible for it to exist). Furthermore, compare it to the criteria for diagnosing migraine, tension-type headache and cluster headache and they are based purely on symptom appearance and behavior. No valid clinical testing required.

signs and symptoms

Some researchers (9) have sought to develop ‘acceptable clinical tests’ and a unique symptom list. These are used as the clinical standard by manual therapists, but these have not been accepted and validated by the official IHS committee and have not been incorporated into the official classification system.

·      Unilateral or unilaterally dominant headache, that is side-locked (does not swap sides), associated with ipsilateral (same sided) neck, shoulder or arm pain. This does allow for milder symptoms to be felt on the other side (unevenly bilateral) but not for evenly bilateral or alternating headache.

The explanation for not allowing bilateral headache is as follows:

‘At the very outset it was realized that if bilaterality was allowed as a criterion, the chances of including tension-type headache among cervicogenic cases would be greatly increased. More specifically, TTH then would become the main differential diagnostic alternative, with all the implicit difficulties involved. There was, in other words, also a “political” reason for our strictness and stubbornness in this matter.’

So Cervicogenic headaches are not allowed to be bilateral. This isn’t due to some ‘research’ that spinal disorders cannot refer or cause pain bilaterally (in fact quite the opposite is true), but it is just so we don’t tread on the toes of someone and open up the possibility that tension-type headache is in fact cervicogenic.

At least they were honest. Again we see good scientific method thrown out, giving way to politics. The loser of course is you. The patient. Instead of a thorough scientific reasoning process we have the assumption primary headache exists, even when abolished by diagnostic blocks, and a ban on headache coming from the neck to refer evenly bilaterally, or to generate spasm or tenderness in sub-occipital muscles. This quite simply, just makes no sense in any anatomical or physiological framework. 
It is fiction rather than science.
Unbelievably, this paper is from researchers who would be considered some of the ‘best friends’ of the cervicogenic headache cause.

We also don’t have any explanation as to why it must be sidelocked and not alternating. We see alternating behavior in spinal conditions relating to lumbar discs not infrequently, so there is a clear mechanism in the spine to create this symptoms behavior. Prior to this, and until recently, it was believed that migraines were vascular. No-one could explain why it was the blood vessels on one half of the brain suddenly dilating, but then, and without reason “normalise" and suddenly dilate on the opposite side. This vascular phenomenon has never been observed, yet was the accepted ‘theory’ until a few years back, yet we see and understand the discogenic mechanism producing the exact behavior of symptom shift from one side to the other, and it has not been considered for a second as a potential cause.


Mystified? Me too.

·      Pain begins in the neck and headache and is aggravated by neck movement or postures. 
·      Pain elicited by external pressure over the ipsilateral (same side) upper, posterior neck region or occipital region
·      Ipsilateral non-radicular neck, shoulder and arm pain
·      Reduced range of motion in the cervical spine
·      Non-clustering pain episodes
·      Pain episodes of varying duration or fluctuating, continuous pain
·      Moderate, non-excruciating pain, usually of a non-throbbing nature

……because musculoskeletal pain cannot be excruciating? I have seen clients unable to move with muscle spasm, and I defy anyone to tell them their pain was moderate, and not severe or excruciating. Again, a piece of fiction rather than criteria based on sound principles of anatomy and physiology.

·      Pain starting in the neck, eventually spreading to oculo-fronto-temporal areas where the maximum pain is usually located


If we apply this 'logic' to lumbar disc bulges and referral of symptoms to the leg a great many would not be appropriately diagnosed - many ONLY have leg symptoms and their back is symptom free. Again more criteria that defy current knowledge on anatomy and physiology.

·      Abolition of pain with anaesthetic blocks
·      Head and/or neck trauma
·      Nausea
·      Vomiting
·      Ipsilateral oedema and less frequently flushing mostly in the periocular area
·      Dizziness
·      Phono and photophobia
·      Ipsilateral blurred vision
·      Difficulties on swallowing

causes

Any problems affecting the upper cervical spine can potentially cause referred pain into the trigeminal field of the head and face. Often treatment aimed at decreasing muscle tension or spasm and restoring movement to stiff joints can provide short-term relief. Unfortunately most of these treatments are directed at the outward signs and symptoms and miss the underlying problem. Until using the Watson Headache ®    Approach I never even knew to look for the problem we now treat.

A very common problem stemming from a pressure imbalance between the second and third vertebrae causes a muscle spasm, which creates tightness and stiffness under the base of the skull. Approximately 30% of people we treat don’t perceive this at all. Most will feel a pressure or tightness under the base of the skull, and in 20% this will be quite painful. In all cases the muscle spasm and tightness in joints responds well to treatment, but without treating the underlying pressure problem the spasm returns, often in 2-3 days, and you are now stuck in an endless treatment cycle, getting at best, short term relief from manual therapy.

In many cases there is no one causal event or condition. The pressure problem builds over a long period of time due to continual postural stresses of sitting with the head forward or down. This starts in early childhood, continues through our school years and often into adulthood. There can of course be acute traumas – a whiplash for example, that may then create a sudden change.

prevention

This is always a challenge, even when we have a clear cause and effect that is accepted – such as in cigarette smoking. Despite the obvious risks because to it involves changing how we live, and especially how we sit, and what we do, throughout most of our lives, and in the absence of an obvious problem people are unlikely to change.


However, once we have successfully treated the pressure issue, it can be maintained, and by adhering to good posture principles and applying a specific stretch to maintain good pressure in the top of the neck, most will successfully prevent recurrences for long periods of time. 

prognosis

This depends greatly on what path you take with treatment. There is poor data on the effect of individual interventions from a medical point of view, however a study commissioned by Headache Australia and MSD (13) found approximately 80% of migraine sufferers are looking for more effective treatment.

That's a 20% success rate.

We find 80% have a pressure problem that is untreated and undetected in the upper cervical spine. 95% of these will see significant changes within 2 weeks of starting treatment, and over 95% are then discharged to self-management with the expectation of managing the condition successfully for long periods of time.

Referrences and Relevant research

1.      Rothbart P. (1996) The cervicogenic headache: A pain in the neck. The Canadian Journal of Diagnosis. Feb, 64-76.

2.      Afridi S, Shields K, Bhola R, Goadsby P (2006) Greater occipital nerve injection in primary headache syndromes: Prolonged effects from a single injection. Pain. 122; 126-129.

3.      Anthony M. (2000) Cervicogenic headache: Prevalence and response to local steroid therapy. Cli & Experimental Neurology; 18: S59-S64.

4.      Rozen T, (2007) Cessation of Hemiplegic Migraine Auras with Greater Occipital Nerve Blockade. Headache, 47, 6, 917-919.

5.      Fishbain, D., Cutler R, Cole B, et al (2001) International Headache Society headache diagnostic patterns in pain facility patients. Clin J Pain; 17: 78-93

6.      Hagen K, Einarsen C, Zwart J et al (2002) The co-occurrence of headache and musculoskeletal symptoms amongst 51,050 adults in Norway. Eur J Neurology; 9: 527-533.

7.      Henry P, Dartigues JF, Puymirat C, et al (1987) The association cervicalgia-headaches: An epidemiologic study. Cephalalgia; 7: 189-190.

8.      The International Classification of Headache Disorders, 3rd Edition (2013), Cephalalgia, 33 (9), 629-808

9.      Sjaastad O. and Fredriksen T.A. (2000) Cervicogenic Headache: Criteria, classification and epidemiology. Clinical and Experimental Rheumatology, 18, Supp 19, S3-S6.

10.    Monteira, P. J. (1995) Cefaleias. Estudo epidemiologica e clinic de uma populacao urbana. [Thesis] University of Porto (Portugal)

11.    Maciel, J.A. Jr and Carmo Ec, R.H. et al (1994) Cefaleia. Estudio Clinico de 1229 casos. Arch Nevro-Psiquiatria, 52 (Supp) OR-030.

12.    Jull, G. (2006) Diagnosis of Cervicogenic Headache. Guest Editorial. The Journal of Manual and Manipulative Therapy, 14, 3, 136-138.

13.    ‘MIA - Migraine Impact in Australia– survey by Stollznow Research, via national online panel, conducted in April 2011 amongst 507 Australians with migraine aged 18-64. The MIA survey was developed as a partnership initiative between Headache Australia and MSD. The survey was funded by MSD.

14. Watson, D.H. and Drummond, P.D (2012) Head Pain Referral During Examination of the Neck in Migraine and Tension-Type Headache. Headache: 52;1226-1235. 

15. Watson, D.H, and Drummond, P.D. (2014)  Cervical Referral of Head Pain in Migraineurs: Effect on the Nociceptive Blink Reflex. Headache: Journal of Head and Face Pain,  June, 1035-1045.

16.    Antonaci F, Fredriksen T, Sjaastad, O. (2001) Cervicogenic Headache: Clinical presentation, diagnostic criteria, and differential diagnosis. Curr Pain and Headache Reports, 5, 387-392.

17.    Fishbain D., Lewis J, Cole B, et al (2003) Do the proposed cervicogenic headache diagnostic criteria demonstrate specificity in terms of separating cervicogenic headache from migraine? Curr Pain & Headache Reports, 7, 387-394.

18.    Rokicki L, Semenchuk E, Bruehl S, et al (1999) An examination of the validity of the IHS classification system for migraine and tension-type headache in the college student population. Headache, 39: 720-727.

19.    Srikiatkhachorn A, Phanthumchinda K. (1997) Prevalence and clinical features of chronic daily headache in a headache clinic. Headache, 37, 277-280.

20.    Xiabin Y, Cook A, Hamill-Ruth R, Rowlingson J. (2005) Cervicogenic headache in patients with presumed migraine: Missed diagnosis or misdiagnosis? J Pain, 6: 700-703

21.    (4)Andrew Charles – Professor of Neurology at UCLA interviewed on "Health Report" on ABC. Available on podcast via http://www.abc.net.au/radionational/programs/healthreport/migraine-research/4039834