Commonly, the cervicogenic headache is associated with degenerative change to the upper cervical spine. Studies have indicated that the most common origin of pain is from the derangement of the zygapophyseal joints of the occipito-atlanto-axial joints (O/C1, C1/2), with referral of pain into the head. The degenerative processes result in movement dysfunction or loss (both general and segmental) and irritation of pain sensitive structures.
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 sub occipital 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 mal-alignment, 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.
The most critical step in the treatment of cervicogenic headaches is obtaining an accurate diagnosis. Due to the complex and multiple etiologies of headache, a thorough evaluation must be performed. Most of the time, diagnosis is straight forward and no further diagnostic studies are necessary. Frequently, according to the history and physical, other tests such as: Cervical CT Scan, MRI, Neck films in flexion and extension, EMG and NCV may be necessary. Diagnostic and therapeutic injections such as cervical epidural steroids, cervical facet injections, and trigger point injections and C2 dorsal root ganglion injections may be necessary to establish an accurate diagnosis.
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.
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 critical component of any long-term effective pain-management regimen is a committed, active participation of the patient.
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. 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.
Medication management should be considered as and analgesics all play an adjunct to simultaneous interventions. Anti-inflamatories, muscle relaxants, play specific role in the treatment and rehabilitation of patients with cervicogenic headaches.
Surgery may be indicated in cases in which intractable pain is associated with significant joint, disc or critical cervical spine stenosis or instability.
Minimally invasive interventions such a cervical facet nerve rhizotomy, dorsal root neurolysis, Botox injections and occipital nerve stimulation, have a specific and promising role in the management of cervicogenic headaches.