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Cervicogenic headaches

Cervicogenic headaches are secondary headaches. Secondary headaches are those caused by an underlying condition, such as neck injuries, infections, or severe high blood pressure. This sets them apart from primary headaches, such as migraines and cluster headaches.

The pain caused by a cervicogenic headache begins in the neck and the back of the head and radiates towards the front of the head. It is chronic unilateral dull headache with ipsilateral shoulder and arm pain with a restricted range of movements of the neck. People may confuse cervicogenic headaches with migraines and tension headaches, both of which can cause neck pain.

Typically, people who have cervicogenic headaches experience a headache accompanied by neck pain and stiffness. Certain neck movements can provoke cervicogenic headaches.

In most cases, cervicogenic headaches develop on one side of the head, starting from the back of the head and neck and radiating toward the front.


Some other symptoms of a cervicogenic headache include:

  1. A reduced range of motion in the neck
  2. pain on one side of the face or head
  3. pain and stiffness of the neck
  4. pain around the eyes
  5. pain in the neck, shoulder, or arm on one side
  6. head pain that is triggered by certain neck movements or positions
  7. sensitivity to light and noise
  8. nausea
  9. blurred vision



            It is a rare entity occurring in men and women equally in their early 30’s. It accounts for 1-4% of all headaches.



(1) Occipital CGH (Cervicogenic headaches)

(2) Occipito-temporo-maxillary CGH and 

(3) Supra-orbital CGH are the three types of headache based on the region of pain. The three types overlap frequently. 


Sources of pain:

One or more of the following may be the source of pain in CGH.

  1. Facet joints
  2. Atlanto-occipital joint
  3. Intervertebral discs
  4. Neck muscles
  5. Cervical nerves


The trigeminocervical nucleus which receives afferents from the trigeminal nerve and the upper cervical spinal nerves (C1-C3) transmits pain to the trigeminal region of the face through the efferent trigemino-thalamic tract.


Causes of pain:

  1. Trauma: Whiplash injury from rear-end car accidents causing zygo-apophyseal joint injury account for 53% of CGH. Fall or sports injury causing facet joint dislocation, fractures can be other traumatic causes for CGH.
  2. Inflammatory conditions: Rheumatoid arthritis, Cervical disc disease also produce CGH.
  3. Degenerative conditions: Cervical degenerative disc disease or osteoarthritis of the facet joints are degenerative causes of CGH.
  4. Neoplastic conditions: Malignant or benign tumours of the neck can cause compression of the spinal nerves leading to CGH. 


  1. Age group: Early 30’s
  2. Pain
  3. Unilateral dominant headache, originates in the neck and radiates to the eye, the temple and the ear.
  4. Intermittent pain initially which becomes continuous
  5. Dull ache – mild to moderate in intensity
  6. Associated features – pain in the ipsilateral shoulder and arm with reduced neck flexibility; blurriness and swelling of the eye.
  7. Aggravating factors – abnormal postures of neck and neck strain such as pressure on the neck, weight-lifting, coughing and sneezing.
  8. Relieving factors – local anaesthetic blockade of selective nerve roots
  9. History of trauma


  1. Tenderness over C1-C3 joints
  2. Spasm and trigger points in upper trapezius, levator scapulae, scales and suboccipital extensors.
  3. Weakness of the deep flexors of the neck
  4. Increased activity of the superficial flexors
  5. Atrophy of the suboccipital extensors
  6. Flexion-rotation test: The patient should be pain-free at the time of testing. The neck of the patient is passively held in complete flexion followed by rotation of the neck to each side until they feel resistance or until the patient complaints of pain. The range of movement is assessed. The test is considered positive when the estimated range is reduced by 10° or more from the anticipated normal range (44°).


The diagnostic criteria are as follows as described by the IHS:

  1. Any headache fulfilling criterion C
  2. Clinical, laboratory and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck, known to be able to cause headache
  3. Evidence of causation demonstrated by at least two of the following:
  1. Headache has developed in temporal relation to the onset of the cervical disorder or appearance of the lesion
  2. Headache has significantly improved or resolved in parallel with improvement in or resolution of the cervical disorder or lesion
  3. Cervical range of motion is reduced and headache is made significantly worse by provocative manoeuvres
  4. Headache is abolished following diagnostic blockade of a cervical structure or its nerve supply


Management is interprofessional involving physical therapists, psychologists and pain specialists.

  1. Physical therapy options
  2. Cervical spine manipulation or mobilization
  3. Thoracic spine thrust manipulation exercises
  4. C1-C2 Self-sustained Natural Apophyseal Glide(SNAG)
  5. Trigger point therapy
  6. Re-education of posture
  7. Psychological interventions – Biofeedback, Relaxation and Cognitive behavioural therapy

Medical pain management

  1. Tri-cyclic antidepressants: low dose
  2. Muscle -relaxants
  3. Botulinum toxin injection : to reduce hypertonia of muscles

Interventional pain management

  1. Cervical epidural steroid injections
  2. Trigger point injections
  3. Selective nerve root injections
  4. Radiofrequency thermal neurolysis


Red flags

  • Sudden onset severe new headache;
  • A worsening pattern of a pre-existing headache without any precipitating factors;
  • Headache associated with fever, neck stiffness, skin rash, and with a history of cancer, HIV, or other systemic illness;
  • Headache associated with focal neurologic signs other than typical aura;
  • Moderate or severe headache triggered by straining; and
  • New onset headache during or following pregnancy.


Patients with one or more red flags should be referred for an immediate medical consultation and further investigation