Cervicogenic Headache (อาการปวดศีรษะจากกระดูกคอ)

• ICD10:
  • G44.86 – Cervicogenic headache
  • M53.0 – Cervicocranial syndrome
  • M47.812 – Spondylosis without myelopathy or radiculopathy, cervical region
  • M54.2 – Cervicalgia
• ICD11:
  • 8A83 – Headache attributed to disorder of the neck
  • 8A83.0 – Cervicogenic headache
  • ME84.0 – Cervical spondylosis
  • ME84.1 – Other specified disorders of cervical spine

Overview

Cervicogenic headache (CGH) is a secondary headache caused by dysfunction or pathology in the cervical spine structures, including the upper cervical joints, muscles, and nerves. The pain is referred to the head through convergence between the trigeminal and upper cervical nociceptive pathways in the brainstem. CGH often presents as a dull, non-throbbing unilateral pain originating in the neck and spreading to the occipital, temporal, or orbital regions.

This condition is most frequently associated with cervical spondylosis, whiplash injury, or muscular imbalance. Unlike primary headache disorders such as migraine, CGH is typically aggravated by neck movement or prolonged abnormal posture, and may improve with diagnostic or therapeutic nerve blocks.

Early identification and management of the underlying cervical dysfunction are essential for preventing chronic pain syndromes. Treatment includes multimodal approaches—physical therapy, ergonomic modification, pharmacotherapy, and interventional procedures such as facet joint or occipital nerve block.

Epidemiology

Cervicogenic headache accounts for approximately 15–20% of all chronic headaches and is more common in women than men with a female-to-male ratio of 4:1. The typical age of onset is between 30 and 50 years, coinciding with degenerative changes in the cervical spine.

It is commonly seen in individuals with occupations requiring prolonged neck flexion or extension, such as computer users, drivers, or dentists. Athletes involved in contact sports are also at increased risk due to repetitive cervical strain or trauma.

A history of whiplash injury is a well-recognised predisposing factor, as is chronic cervical spondylosis. Comorbidities such as tension-type headache or migraine may coexist, complicating diagnosis. Due to overlapping symptoms with primary headaches, CGH is frequently underdiagnosed or misclassified.

Pathophysiology

The pathophysiology of cervicogenic headache is based on the anatomical and functional convergence between the upper cervical spinal nerves (C1–C3) and the trigeminal sensory system within the trigeminocervical nucleus in the upper cervical spinal cord and medulla. This convergence allows pain originating from cervical structures to be perceived as pain in the head or face.

Structures capable of producing headache pain (pain generators) include the atlanto-occipital (C0–C1) joint, atlanto-axial (C1–C2) joint, C2–C3 zygapophyseal joint, and the upper cervical muscles (semispinalis capitis, splenius capitis, trapezius, and sternocleidomastoid). Degeneration, inflammation, or abnormal mechanical stress in these areas can activate nociceptors.

The trigeminocervical complex is a key neuroanatomical structure where sensory fibres from the trigeminal nerve (particularly the ophthalmic branch, V1) and the upper cervical nerves converge. Nociceptive inputs from the neck are transmitted to second-order neurons that also receive trigeminal inputs, resulting in referred pain perceived in the orbital, temporal, or frontal regions.

Chronic activation of this system leads to central sensitisation—increased excitability of neurons within the trigeminocervical complex, which amplifies pain responses and causes allodynia (pain from non-painful stimuli). This mechanism explains the persistence and widespread radiation of pain in chronic CGH.

Biochemical factors such as Substance P, CGRP, and glutamate are involved in nociceptive transmission and neurogenic inflammation within cervical joints and muscles. Sustained muscle tension and postural strain exacerbate ischemia and metabolite accumulation, further stimulating pain pathways.

In some patients, cervical disc herniation or foraminal stenosis may compress the C2 or C3 dorsal root, leading to neuropathic pain radiating to the occipital or parietal region. Dysfunction in cervical proprioceptive input may also contribute to dizziness and imbalance.

Overall, cervicogenic headache represents a complex interaction of mechanical, neurophysiological, and inflammatory processes linking cervical structures to cranial pain perception.

Clinical Presentation

Cervicogenic headache typically presents as unilateral pain that originates in the neck and radiates to the occiput, temple, or around the eye. The pain is usually dull, pressing, or aching in nature, moderate to severe in intensity, and persistent rather than throbbing.

Key diagnostic features include reproduction of pain with neck movement, sustained posture, or pressure over cervical structures. Reduced range of motion in the cervical spine, associated shoulder or arm pain, and muscle tenderness are common.

Autonomic symptoms such as tearing or nasal congestion are uncommon, distinguishing it from cluster headache. Patients may also experience dizziness or lightheadedness due to altered cervical proprioception.

Investigation

Diagnosis of cervicogenic headache is primarily clinical but supported by imaging and diagnostic blocks. MRI of the cervical spine can identify degenerative changes, facet joint arthropathy, or disc herniation. Dynamic X-rays or CT may reveal instability or abnormal alignment at C1–C3 levels.

A diagnostic nerve block (e.g. C2–C3 facet joint or occipital nerve) provides confirmatory evidence if it abolishes the headache temporarily. Electromyography (EMG) can assess associated muscle dysfunction.

Diagnosis Criteria

According to the International Classification of Headache Disorders, 3rd edition (ICHD-3), Cervicogenic headache is diagnosed when all the following criteria are met:

• Headache fulfilling at least two of the following:
• Pain develops in temporal relation to cervical disorder onset.
• Pain improves following resolution of the cervical lesion.
• Reduced neck range of motion and provocation of pain with movement or pressure.
• Headache abolished by diagnostic cervical block.
• No better explanation by another ICHD-3 diagnosis.

Diffential Diagnosis

Treatment Overview

The management of Cervicogenic Headache (CGH) focuses on identifying and treating the underlying cervical pathology. Treatment is typically multimodal, combining pharmacologic, physical, and interventional approaches. The goals are to reduce pain, improve cervical mobility, and prevent chronic recurrence. First-line management involves non-invasive therapies such as physical therapy, posture correction, and ergonomic modification. Manual therapy techniques—including joint mobilisation, soft tissue manipulation, and trigger-point release—can alleviate muscle tension and restore joint mechanics.

Pharmacologic therapy is used adjunctively to reduce inflammation and muscle spasm. In refractory cases, diagnostic and therapeutic nerve blocks targeting the C2–C3 facet joint, third occipital nerve, or greater occipital nerve may provide rapid relief and confirm diagnosis. Radiofrequency ablation can offer prolonged benefit in patients with recurrent symptoms.

Surgical intervention is rarely indicated and reserved for patients with identifiable structural lesions (e.g., disc herniation or instability) that correlate with headache symptoms. Patient education regarding posture, activity modification, and stress reduction is critical for long-term success.

Pharmacology

Pharmacologic management of cervicogenic headache aims to control pain, reduce inflammation, and relax cervical musculature. The following classes of medication are used based on severity and chronicity of symptoms:

Emerging evidence supports the use of Botulinum toxin type A for refractory CGH, particularly when muscle hyperactivity contributes to pain. It reduces peripheral nociceptive input and may provide benefit for up to 3 months. Combination therapy—NSAIDs with muscle relaxants or physiotherapy—has demonstrated the greatest clinical benefit in chronic CGH.

Guideline (Evidence-Based Management)

According to the European Federation of Neurological Societies (EFNS, 2021) and American Headache Society (AHS, 2022), management of cervicogenic headache follows a stepwise approach:

Step 1: Conservative Management

• Postural correction: Educate patients about ergonomic positioning during work and rest.
• Physical therapy: Include cervical mobilisation, stretching, and strengthening exercises focusing on deep neck flexors.
• Manual therapy: Trigger point release, myofascial techniques, and traction to restore joint function.
• Heat/Cold therapy: Alternate applications to relieve muscle tension and inflammation.

Step 2: Pharmacologic Treatment

• Start with NSAIDs for pain control and muscle relaxants for tension relief.
• Use Amitriptyline (10–25 mg nightly) or Gabapentin for chronic or neuropathic pain components.
• Short-term corticosteroid therapy may be considered for acute inflammatory flares.

Step 3: Interventional Procedures

• Occipital nerve block: Diagnostic and therapeutic relief for 2–6 weeks.
• Facet joint or medial branch block (C2–C3): Confirms and alleviates pain of zygapophyseal origin.
• Radiofrequency ablation: For patients with recurrent, confirmed pain after diagnostic block.

Step 4: Multimodal and Maintenance Care

• Encourage exercise therapy for long-term prevention of recurrence.
• Address associated psychological stress and sleep disturbances.
• Reassess diagnosis periodically to exclude progressive cervical pathology.

Example Doctor’s Orders

Disclaimer: Example for educational purposes only, not for direct patient advice.

Prognosis

Cervicogenic headache generally carries a favourable prognosis when diagnosed early and treated appropriately. Most patients experience significant improvement with conservative management, including physical therapy and posture correction. However, recurrent or chronic CGH can persist if underlying cervical dysfunction remains uncorrected. Approximately 70–80% of patients report reduction in headache frequency following combined manual and pharmacologic therapy.

Prognostic factors for poor outcomes include long-standing cervical degeneration, poor posture, and psychological stress. Early multidisciplinary care involving neurologists, physiotherapists, and pain specialists optimises recovery and reduces chronicity.

Prevention

• Maintain proper posture during computer work or mobile use.
• Perform regular neck and shoulder stretching exercises.
• Use ergonomic chairs and monitor height adjustments.
• Avoid prolonged static positions and take breaks every 30–45 minutes.
• Manage stress through mindfulness or relaxation techniques.

Conclusion

Quiz (USMLE / OSCE)

Frequently Asked Questions (FAQ)

Can cervicogenic headache be cured completely?

Complete cure is rare, but most patients achieve excellent symptom control with proper treatment, posture correction, and exercise. Addressing the underlying cervical dysfunction significantly reduces recurrence.

How is cervicogenic headache differentiated from tension-type headache?

CGH pain originates in the neck, is unilateral, and provoked by neck movement or posture. Tension-type headache is typically bilateral and not associated with cervical joint pathology.

Is imaging always required for diagnosis?

No. Diagnosis is primarily clinical but imaging (MRI) helps rule out cervical disc disease, tumor, or inflammatory disorders when suspected.

Can physical therapy worsen symptoms?

If done aggressively or without proper assessment, therapy may aggravate symptoms. A gradual, guided rehabilitation programme under physiotherapist supervision is essential.

When should surgery be considered?

Only in rare cases with structural lesions (disc herniation, instability) directly correlating with pain and neurological findings.

References

1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (ICHD-3). Cephalalgia. 2018.
2. Antonaci F, et al. Cervicogenic headache: evaluation and management. Curr Pain Headache Rep. 2020.
3. American Headache Society (AHS) Guidelines for Secondary Headache. 2022.
4. European Federation of Neurological Societies (EFNS). Guidelines on the treatment of cervicogenic headache. 2021.
5. Biondi DM. Cervicogenic headache: mechanisms, evaluation, and treatment strategies. J Am Osteopath Assoc. 2020.

Author & Review

Compiled from peer-reviewed references and clinical guidelines. Adapted and reviewed by:

Teerawat Suwannee MD

Medical Doctor License 44780
นายแพทย์ธีรวัฒน์ สุวรรณี ว.44780

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