Dr. Silberstein, Director of the Jefferson Headache Center at Thomas Jefferson University, receives honorariums from Allergan, Avanir Pharmaceuticals, Curelator, Depomed, Dr. Reddy's Laboratories, eNeura, INSYS Therapeutics, Lilly USA, Supernus Pharmacerticals, Thernica and Trigemina for consulting. He is also the principal investigator for a clinical trials conducted by Alder Biopharmaceuticals, Amgen, electroCore Medical, Lily USA and Teva.)
This article includes discussion of headache associated with cervical spine dysfunction, cephale cervicale, cervical headache, cervical pain syndrome, cervicogenic headache, and cervical myofascial pain. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.
The author reviews the variety of headaches associated with cervical spine dysfunction. There are many pain generators located in the cervical spine. In this article, headaches with a potential origin in the neck are reviewed, including cervicogenic headache, taking into account the accepted criteria found in the International Classification of Headache Disorders. Sjaastad's concept of cervicogenic headache is also presented. Rare, but well-defined, potential causes of headache of cervical origin, such as developmental or acquired lesions of the craniovertebral junction as well as other more controversial cervical entities, are also discussed. Concepts on anatomy, pathophysiology, treatments, and mechanisms underlying cervicogenic headache have been updated.
• Headaches caused by disorders of the neck can present with different clinical features, making it difficult to describe a set of chief complaints to define them.
• Side-locked pain, provocation of typical headache by digital pressure on neck muscles and by head movement, and posterior-to-anterior radiation of pain are features that help distinguish cervicogenic headache from other primary headaches.
• The term “cervicogenic headache” was first introduced to the medical literature by Sjaastad and colleagues in 1983, and their diagnostic criterion continues to be a debate among specialists in the field.
• The two main diagnostic criteria for cervicogenic headache, one proposed by the International Headache Society and the other by the Cervicogenic Headache International Study Group (CHISG), differ from each other.
Historical note and terminology
Headache is one of the most common reasons for visits to the emergency room and out-patient treatment. Primary headache, such as migraine and tension-type headache, is a disorder unto itself; no underlying disease process is present. Secondary headache is a manifestation of an underlying disease process (Biller 2009). A variety of headaches are frequently associated with the occurrence of neck pain (Antonaci et al 2001).
The International Classification of Headache Disorders (ICHD) is a detailed hierarchical classification of all headache-related disorders published by the International Headache Society (IHS). This schematic headache classification is divided into 3 parts containing 14 sections. The first part identifies the primary headache disorders. The second part describes headaches attributed to an underlying (secondary) condition. It is under this section of the ICHD that headaches attributed to disorders of cervical structures, including cervicogenic headache, are described. The third part characterizes painful cranial neuropathies, other facial pains, and other headaches. The ICHD, 3rd edition (ICHD-3 beta), which is the most updated version, defines “headache attributed to a disorder of the neck” in section 11.2 as a “headache caused by a disorder involving any structure in the neck, including bony, muscular and other soft tissue elements.” Section 11.2 further subdivides into (1) cervicogenic headache, (2) headache attributed to retropharyngeal tendonitis, and (3) headache attributed to craniocervical dystonia. The Appendix diagnosis “headache attributed to cervical myofascial pain (A11.2.5) awaits further evidence that this type of headache is more closely related to other cervicogenic headaches than to tension-type headache.” Some overlap does exist between these 2 categories. In the context of cervicogenic headache, prolonged nociceptive inputs from peripheral structures play an important role in the development of sensitization mechanisms of the central nervous system. The neurophysiological basis of the convergence between trigeminal nociception and upper cervical afferents onto neurons in the brainstem is now well understood. The ICHD-3 beta states that headache caused by cervical radiculopathy is a logical cause of headache. Headaches caused by head and neck trauma are classified separately under section 5 (Headache Classification Subcommittee of the International Headache Society 2013).
Bärtschi-Rochaix reported what seems to have been the first clinical description of cervicogenic headache (Bartschi-Rochaix 1968), but it was not until 1983 that Sjaastad and his school defined diagnostic criteria for this syndrome (Sjaastad et al 1983; Antonaci et al 2005). There is lack of agreement between the ICHD classification and the one proposed by Sjaastad's group. The International Headache Society recognizes cervicogenic headache as a distinct disorder whereas the Sjaastad school stipulates that cervicogenic headache is not a “disease” or entity sui generis but a reaction pattern (Sjaastad et al 1983; Sjaastad et al 1990; Sjaastad et al 1998; Sjaastad 1992). Both criteria are described in this article.
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