Cervicogenic Headache A Review of Diagnostic and Treatment Strategies

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					                                                                                                    pain disorder that is refractory to treat-
                                                                                                    ment if it is not recognized. The condi-
                                                                                                    tion’s pathophysiology and source of
                                                                                                    pain have been debated,3-5 but the pain
                                                                                                    is likely referred from one or more mus-
                                                      Cervicogenic Headache:                        cular, neurogenic, osseous, articular, or
                                                      A Review of Diagnostic and                    vascular structures in the neck.6
                                                      Treatment Strategies                                The trigeminocervical nucleus is a
                                                                                                    region of the upper cervical spinal cord
                                                                                                    where sensory nerve fibers in the
                                                      David M. Biondi, DO
                                                                                                    descending tract of the trigeminal nerve
                                                                                                    (trigeminal nucleus caudalis) are believed
                                                                                                    to interact with sensory fibers from the
                                                                                                    upper cervical roots. This functional con-
                                                                                                    vergence of upper cervical and trigeminal
                                                                                                    sensory pathways allows the bidirec-
                                                                                                    tional referral of painful sensations
                                                                                                    between the neck and trigeminal sen-
                                                                                                    sory receptive fields of the face and head.6
Cervicogenic headache is a syndrome characterized by chronic hemicranial
pain that is referred to the head from either bony structures or soft tissues of                    Neck Pain as a Manifestation
the neck. The trigeminocervical nucleus is a region of the upper cervical spinal                    of Migraine
cord where sensory nerve fibers in the descending tract of the trigeminal nerve                     Neck pain and muscle tension are
(trigeminal nucleus caudalis) are believed to interact with sensory fibers from                     common symptoms of a migraine
the upper cervical roots. This functional convergence of upper cervical and                         attack.1,7-9 In a study of 50 patients with
trigeminal sensory pathways allows the bidirectional referral of painful sen-                       migraine, 64% reported neck pain or stiff-
sations between the neck and trigeminal sensory receptive fields of the face and                    ness associated with their migraine
head. A functional convergence of sensorimotor fibers in the spinal accessory                       attack, with 31% experiencing neck
nerve (CN XI) and upper cervical nerve roots ultimately converge with the                           symptoms during the prodrome; 93%,
descending tract of the trigeminal nerve and might also be responsible for the                      during the headache phase; and 31%,
referral of cervical pain to the head.                                                              during the recovery phase.1 In the study
     Diagnostic criteria have been established for cervicogenic headache, but its                   by Blau and MacGregor,1 7 patients
presenting characteristics occasionally may be difficult to distinguish from                        reported that pain was referred into the
primary headache disorders such as migraine, tension-type headache, or hem-                         ipsilateral shoulder and 1 patient
icrania continua.                                                                                   reported that pain extended from the
     This article reviews the clinical presentation of cervicogenic headache,                       neck into the low back region.
proposed diagnostic criteria, pathophysiologic mechanisms, and methods of                                 In another study of 144 migraine
diagnostic evaluation. Guidelines for developing a successful multidisciplinary                     patients from a university-based
pain management program using medication, physical therapy, osteopathic                             headache clinic, 75% of patients reported
manipulative treatment, other nonpharmacologic modes of treatment, and                              neck pain associated with migraine
anesthetic interventions are presented.                                                             attacks.8 Of these patients, 69% described
                                                                                                    their pain as “tightness”, 17% reported
                                                                                                    “stiffness” and 5% reported “throbbing.”
                                                                                                    The neck pain was unilateral in 57% of
Dr Biondi is the director of Headache Manage-                                                       respondents, 98% of whom reported that
ment Programs at Spaulding Rehabilitation Hos-
pital, a consultant to the Department of Neu-
rology, Massachusetts General Hospital, and
                                                      N    eck pain and cervical muscle ten-
                                                           derness are common and promi-
                                                      nent symptoms of primary headache
                                                                                                    it occurred ipsilateral to the side of
                                                                                                    headache. The neck pain occurred during
instructor in Neurology, Harvard Medical School,      disorders.1 Less commonly, head pain          the prodrome in 61%; the acute headache
Boston, Mass.
     Dr Biondi has a financial interest arrangement   may actually arise from bony structures       phase, in 92%; and the recovery phase, in
or affiliation with the following: Allergan Inc;      or soft tissues of the neck, a condition      41%.
AstraZeneca; Elan Pharmaceuticals, Inc; Glaxo-        known as cervicogenic headache.2 Cer-               Recurrent, unilateral neck pain
SmithKline; Merck & Co, Inc; Pfizer Inc; MedPointe
Pharmaceuticals; OrthoMcNeil Pharmaceutical,          vicogenic headache can be a perplexing        without headache is reported as a variant
Inc; and Endo Pharmaceuticals.
     Address correspondence to David M. Biondi,
DO, Spaulding Rehabilitation Hospital, 125 Nashua
St, Boston, MA 02114-1101.                                            This continuing medical education publication supported by
     E-mail: dbiondi@partners.org                                      an unrestricted educational grant from Merck & Co, Inc



S16 • JAOA • Supplement 2 • Vol 105 • No 4 • April 2005                                                              Biondi • Cervicogenic Headache
                                                                                                     of migraine.10 Careful history gathering
                                                                                                     in cases of recurrent neck pain discov-
     Checklist                                                                                       ered that previously overlooked symp-
                                                                                                     toms were either similar or identical to
                                                                                                     those associated with migraine.
        MAJOR CRITERIA                                                                                    Differences in neck posture, pro-
          Point I—Symptoms and Signs of Neck Involvement
                                                                                                     nounced levels of muscle tenderness, and
          (listed in a surmised sequence of importance; obligatory that
                                                                                                     the presence of myofascial trigger points
          one or more of phenomena are present)
          Precipitation of head pain, similar to the usually occurring                               were observed in subjects with migraine,
          (suffices as the sole criterion for positivity)*:                                          tension-type headache, or a combination
        — by neck movement and/or sustained awkward head positioning                                 of both, but not in a nonheadache control
          (suffices as the sole criterion for positivity within group, and/or:
                                                                                                     group. 1,11,12 A comparison of the
        — by external pressure over the upper cervical or occipital region on
          the symptomatic side                                                                       headache groups demonstrated no sig-
        (Provisionally, the combination of the following two points has been                         nificant differences in myofascial symp-
        set forth as a satisfactory combination within Point 1)                                      toms or signs, dispelling the common
           Restriction of the range of motion (ROM) in the neck*                                     belief that tension-type headache is asso-
           Ipsilateral neck, shoulder, or arm pain of a rather vague                                 ciated with a greater degree of muscu-
           nonradicular nature or, occasionally, arm pain of a radicular nature*                     loskeletal involvement than migraine.12
           Point II—Confirmatory Evidence
           by Diagnostic Anesthetic Blockades
                                                                                                     Headache as a Manifestation
                                                                                                     of Neck Disorders
        (This is an obligatory point in scientific works.)
                                                                                                     Head pain that is referred from the bony
           Point III—Unilaterality of the Head Pain, Without Sideshift                               structures or soft tissues of the neck is
                                                                                                     commonly called “cervicogenic
        (For scientific work, Point III should preferably be adhered to.)
                                                                                                     headache.” It is often a sequela of head or
        HEAD PAIN CHARACTERISTICS                                                                    neck injury but may also occur in the
          Point IV                                                                                   absence of trauma. The clinical features
        (None of the following points is obligatory)                                                 of cervicogenic headache may mimic
                                                                                                     those commonly associated with primary
           Moderate to severe, nonthrobbing, and nonlancinating pain,
           usually starting in the neck                                                              headache disorders such as tension-type
           Episodes of varying duration, or                                                          headache, migraine, or hemicrania con-
           Fluctuating, continuous pain                                                              tinua, and as a result, distinguishing
                                                                                                     among these headache types can be dif-
        OTHER CHARACTERISTICS OF SOME IMPORTANCE
                                                                                                     ficult.
          Point V
                                                                                                          The prevalence of cervicogenic
        (None of the following points is obligatory)
                                                                                                     headache in the general population is
           Only marginal effect or lack of effect of indomethacin                                    estimated to be between 0.4% and 2.5%,
           Only marginal effect or lack of effect of ergotamine and
           sumatriptan succinate                                                                     but in pain management clinics, the
            (c) female sex                                                                           prevalence is as high as 20% of patients
            (d) not infrequent occurrence of head or indirect neck trauma                            with chronic headache.13 The mean age
                by history, usually of more than only medium severity
                                                                                                     of patients with this condition is 42.9
        OTHER FEATURES OF LESSER IMPORTANCE                                                          years, and cervicogenic headache is four
          Point VI                                                                                   times more prevalent in women. Patients
          Various attack-related phenomena, only occasionally present:                               with cervicogenic headache have demon-
        — nausea                                                                                     strated substantial declines in quality of
        — phonophobia and photophobia
        — dizziness                                                                                  life measurements that are similar to
        — ipsilateral “blurred vision”                                                               those in patients with migraine and ten-
        — difficulties on swallowing                                                                 sion-type headache when compared with
        — ipsilateral edema, mostly in the periocular area                                           control subjects, but they demonstrate
           *The presence of all three points indicated with asterisk fortifies the diagnosis         the greatest loss in domains of physical
            (but still Point II is an additional obligatory point for scientific work).              functioning when compared with the
                                                                                                     groups with other headache disorders.14
                                                                                                          The Cervicogenic Headache Inter-
Figure 1. The Cervicogenic Headache International Study Group Diagnostic Criteria. (Modi-            national Study Group developed diag-
fied from Biondi DM: Cervicogenic headache: mechanisms, evaluation, and treatment strate-            nostic criteria that have provided a
gies. J Am Osteopath Assoc. 2000;100(9 Suppl):S7-14. Source: Sjaastad 0, Fredriksen TA, Pfaf-        detailed, clinically useful description of
fenrath V. Cervicogenic headache: diagnostic criteria. Headache. 1998;38:442-445.)                   the condition (Figure 1).15 The diagnosis


Biondi • Cervicogenic Headache                                                                 JAOA • Supplement 2 • Vol 105 • No 4 • April 2005 • S17
Figure 2. Clinical characteristics of cervico-                                                           Zygapophyseal joint, cervical nerve,
genic headache. (Modified from Biondi DM:                                                         or medial branch blockade is used to con-
Cervicogenic headache: mechanisms, evalu-                  Checklist                              firm the diagnosis of cervicogenic
ation, and treatment strategies. J Am                                                             headache and predict the treatment
Osteopath Assoc. 2000;100(9 Suppl):S7-14.)                                                        modalities that will most likely provide
                                                             Unilateral head or face pain
                                                             without sideshift; the pain may
                                                                                                  the greatest efficacy. The first three cer-
                                                             occasionally be bilateral            vical spinal nerves and their rami are the
                                                             Pain localized to the occipital,     primary peripheral nerve structures that
of cervicogenic headache can often be                        frontal, temporal or orbital         can refer pain to the head.
made without resorting to diagnostic                         regions                                     The suboccipital nerve (dorsal
neural blockade by completion of a                           Moderate to severe pain              ramus of C1) innervates the atlanto-occip-
careful history and physical examination                     intensity                            ital joint; therefore, a pathologic condition
(Figure 2).                                                  Intermittent attacks of pain         or injury affecting this joint is a poten-
                                                             lasting hours to days, constant      tial source for head pain that is referred
                                                             pain or constant pain with
Diagnostic Testing for                                       superimposed attacks of pain         to the occipital region.
Suspected Cervicogenic Headache                              Pain is generally deep and
                                                                                                         The C2 spinal nerve and its dorsal
Patients with cervicogenic headache will                     nonthrobbing; throbbing may          root ganglion have a close proximity to
often have altered neck posture or                           occur when migraine attacks are      the lateral capsule of the atlantoaxial
restricted cervical range of motion.16 The                   superimposed                         (C1–2) zygapophyseal joint and inner-
head pain can be triggered or reproduced                     Head pain is triggered by neck       vate the atlantoaxial and C2–3
by active neck movement, passive neck                        movement, sustained or               zygapophyseal joints; therefore, trauma
                                                             awkward neck postures; digital
positioning especially in extension or                       pressure to the suboccipital, C2,    to or pathologic changes around these
extension with rotation toward the side                      C3, or C4 regions or over the        joints can be a source of referred head
of pain, or on applying digital pressure to                  greater occipital nerve; valsalva,   pain. Neuralgia of C2 is typically
the involved facet regions or over the                       cough or sneeze might also           described as a deep or dull pain that usu-
                                                             trigger pain
ipsilateral greater occipital nerve. Mus-                                                         ally radiates from the occipital to pari-
                                                             Restricted active and passive neck
cular trigger points are usually found in                    range of motion; neck stiffness
                                                                                                  etal, temporal, frontal, and periorbital
the suboccipital, cervical, and shoulder                                                          regions. A paroxysmal sharp or shocklike
                                                             Associated signs and symptoms
musculature, and these trigger points                        can be similar to typical migraine   pain is often superimposed over the con-
can also refer pain to the head when                         accompaniments including:            stant pain. Ipsilateral eye lacrimation and
manually or physically stimulated. There                  — nausea;                               conjunctival injection are common asso-
are no neurologic findings of cervical                    — vomiting;                             ciated signs. Arterial or venous com-
radiculopathy, though the patient might                   — photophobia, phonophobia,             pression of the C2 spinal nerve or its
                                                            and dizziness;
report scalp paresthesia or dysesthesia.                  — others include ipsilateral blurred
                                                                                                  dorsal root ganglion has been suggested
     Diagnostic imaging such as radio-                      vision, lacrimation and               as a cause for C2 neuralgia in some
graphy, magnetic resonance imaging                          conjunctival injection or             cases.11,20-23 The third occipital nerve
(MRI), and computed tomography (CT)                         ipsilateral neck, shoulder            (dorsal ramus C3) has a close anatomic
                                                            or arm pain
myelography cannot confirm the diag-                                                              proximity to and innervates the C2–3
nosis of cervicogenic headache but can                                                            zygapophyseal joint. This joint and the
lend support to its diagnosis.17 One study                                                        third occipital nerve appear most vul-
reported no demonstrable differences in             ment.20 The differential diagnosis in cases   nerable to trauma from acceleration-
the appearance of cervical spine struc-             of suspected cervicogenic headache could      deceleration (“whiplash”) injuries of the
tures on MRI scans when 24 patients                 include posterior fossa tumor, Arnold-        neck.24 Pain from the C2–3 zygapophy-
with clinical features of cervicogenic              Chiari malformation, cervical spondy-         seal joint is referred to the occipital region
headache were compared with 20 control              losis or arthropathy, herniated interver-     but is also referred to the frontotemporal
subjects.18 Cervical disc bulging was               tebral disc, spinal nerve compression or      and periorbital regions. Injury to this
reported equally in both groups (45.5%              tumor, arteriovenous malformation, ver-       region is a common cause of cervicogenic
vs 45.0%, respectively).                            tebral artery dissection, and                 headache. The majority of cervicogenic
     A comprehensive history, review of             intramedullary or extramedullary spinal       headaches occurring after whiplash
systems, and physical examination                   tumors.                                       resolve within a year of the trauma.25
including a complete neurologic assess-                  A laboratory evaluation may be nec-             Of interest are reports that patients
ment will often identify the potential for          essary to search for systemic diseases        with chronic headache had experienced
an underlying structural disorder or sys-           that may adversely affect muscles, bones,     substantial pain relief after diskectomy at
temic disease.19 Imaging is then primarily          or joints (ie, rheumatoid arthritis, sys-     spinal levels as low as C5–6.26,27
used to search for suspected secondary              temic lupus erythematosus, thyroid or                Diagnostic anesthetic blockade for
causes of pain that may require surgery             parathyroid disorders, primary muscle         the evaluation of cervicogenic headache
or other more aggressive forms of treat-            disease, etc).                                can be directed to several anatomic struc-


S18 • JAOA • Supplement 2 • Vol 105 • No 4 • April 2005                                                           Biondi • Cervicogenic Headache
tures such as the greater occipital nerve                                                         the trigeminocervical nucleus and ulti-
(dorsal ramus C2), lesser occipital nerve,                                                        mately resulting in the referral of pain
atlanto-occipital joint, atlantoaxial joint,        Checklist                                     to trigeminal sensory fields of the head
C2 or C3 spinal nerve, third occipital                                                            and face.
nerve (dorsal ramus C3), zygapophyseal                                                                  Muscular trigger points, a hallmark
                                                      Pharmacologic
joint(s) or intervertebral discs based on                                                         of MPS, are discreet hyperirritable
the clinical characteristics of the pain and       (None of the listed medications are            regions of contracted muscle that have a
                                                   given an indication for this
findings of the physical examination.28            condition by the US Food and Drug              lowered pain threshold and refer pain
Fluoroscopic or interventional MRI-                Administration [FDA])                          to distant sites in predictable and repro-
guided blockade may be necessary to                  Tricyclic antidepressants                    ducible patterns.35,36 Anesthetic injections
assure accurate and specific localization            (amitriptyline hydrochloride,                into trigger point regions can assist in
of the pain source.29-31                             nortriptyline hydrochloride,                 the diagnostic evaluation and therapeutic
                                                     doxepin hydrochloride,
      Occipital neuralgia is a specific pain         desipramine hydrochloride, and
                                                                                                  management of referred head or face
disorder characterized by pain that is iso-          others)                                      pain from cervical muscular sources.35
lated to sensory fields of the greater or            Antiepileptic drugs (gabapentin,
lesser occipital nerves.32 The classic               carbamazepine, topiramate,                   Treatment of Cervicogenic
                                                     divalproex sodium, and others)
description of occipital neuralgia includes          Muscle relaxants (tizanidine
                                                                                                  Headache
the presence of constant deep or burning             hydrochloride, baclofen,                     The successful treatment of cervicogenic
pain with superimposed paroxysms of                  cyclobenzaprine hydrochloride,               headache usually requires a multifaceted
shooting or shocklike pain. Paresthesia              metaxalone, and others)                      approach using pharmacologic, non-
                                                     Nonsteroidal, anti-inflammatory
and numbness over the occipital scalp                drugs                                        pharmacologic, manipulative, anesthetic,
are usually present. It is often difficult to      — nonselective cyclooxygenase                  and occasionally surgical interventions37
determine the true source of pain in this            (COX) inhibitors (indomethacin,              (Figure 3). Medications alone are often
condition. In its classic description, the           ibuprofen, naproxen, and others)             ineffective or provide only modest ben-
                                                   — COX-2 selective inhibitor
pain of occipital neuralgia is believed to           (celecoxib)                                  efit for this condition.
arise from trauma to or entrapment of                                                                   Anesthetic injections can temporarily
the occipital nerve within the neck or                Nonpharmacologic                            reduce pain intensity but have their
scalp, but the pain may also arise from               Osteopathic manipulative                    greatest benefit by allowing greater par-
                                                      treatment or manual modes of
the C2 spinal root, C1–2, or C2–3                     therapy                                     ticipation in physical treatment modali-
zygapophyseal joints or pathologic                    Physical therapy                            ties. The success of diagnostic cervical
change within the posterior cranial fossa.            Transcutaneous electrical nerve             spinal nerve, medial branch, or
                                                      stimulation (TENS)
      Occipital nerve blockade, as it is typ-         Biofeedback/relaxation therapy
                                                                                                  zygapophyseal joint blockade can pre-
ically done in the clinic setting, often              Individual psychotherapy                    dict response to radiofrequency thermal
results in a nonspecific regional blockade                                                        neurolysis.38 Developing an individual-
rather than a specific nerve blockade and            Interventional                               ized treatment plan enhances successful
                                                     Anesthetic blockade
might result in a misidentification of the         — spinal roots, nerves, rami, or
                                                                                                  outcomes.
occipital nerve as the source of pain. This          branches
“false localization” might lead to unnec-          — muscular trigger points                      Pharmacologic Treatment
essary interventions aimed at the occip-             Neurolytic procedure                         Pharmacologic treatment modalities for
                                                   — radiofrequency thermal
ital nerve, such as surgical transection or          neurolysis                                   cervicogenic headache include many
other neurolytic procedures.5                        Botulinum toxin injections (not              medications that are used for the pre-
      A regional myofascial pain syn-                given an indication for this                 ventive or palliative management of ten-
drome (MPS) affecting cervical, pericra-             condition by the FDA)                        sion-type headache, migraine, and “neu-
                                                     Occipital nerve stimulator
nial, or masticatory muscles can be asso-                                                         ropathic” pain syndromes. The listed
ciated with referred head pain. Sensory               Surgical                                    medications have neither been approved
afferent nerve fibers from upper cervical             Neurectomy                                  by the US Food and Drug Administra-
regions have been observed to enter the               Dorsal rhizotomy                            tion (FDA) nor rigorously studied in con-
                                                      Microvascular decompression
spinal column by way of the spinal acces-             Nerve exploration and “release”             trolled clinical trials for the treatment of
sory nerve before entering the dorsal                 Joint fusion                                cervicogenic headache and are only sug-
spinal cord.33,34 The close association of                                                        gested as potential treatments based on
sensorimotor fibers of the spinal acces-                                                          the anecdotal experiences of clinicians
sory nerve with the spinal sensory nerves                                                         who treat this condition or similar pain
is believed to allow for a functional           Figure 3. Potential treatment interventions for   disorders. The side effects and labora-
exchange of somatosensory, proprio-             cervicogenic headache. (Modified from Biondi      tory monitoring guidelines provided are
ceptive, and nociceptive information            DM: Cervicogenic headache: mechanisms, eval-      not intended to be comprehensive, and
from the trapezius, sternocleidomastoid,        uation, and treatment strategies. J Am            consultation of standard references or
and other cervical muscles to converge in       Osteopath Assoc. 2000;100(9 Suppl):S7-14.)        product package inserts are recom-


Biondi • Cervicogenic Headache                                                              JAOA • Supplement 2 • Vol 105 • No 4 • April 2005 • S19
mended before prescribing any of these              migraine headache and may be effective        tion and warnings found in the product
medications.                                        for cluster headaches as well as other        package inserts.
      Many patients with cervicogenic               neurogenic pain syndromes. Serum drug               Narcotic analgesics are not gener-
headache overuse or become dependent                levels can be used as a therapeutic dosing    ally recommended for the long-term
on analgesics. Medication when used as              guide. Monthly monitoring of liver            management of cervicogenic headache39
the only mode of treatment for cervico-             transaminase levels and of complete           but may be cautiously prescribed for tem-
genic headache does not generally pro-              blood cell (CBC) counts for evidence of       porary pain relief to expedite the
vide substantial pain relief in most cases.         toxicity is recommended, especially           advancement of manual modes of
Despite this observation, the judicious             during the first 3 to 4 months of treat-      therapy or improve tolerance for anes-
use of medications can provide enough               ment or whenever dosages are escalated.       thetic interventions.
pain relief to allow greater patient par-                Gabapentin is indicated for the man-          Migraine-specific abortive medica-
ticipation in a physical therapy and reha-          agement of postherpetic neuralgia and         tions such as ergot derivatives or trip-
bilitation program. To improve compli-              has been used for management of other         tans are not effective for the chronic head
ance, medications are initially prescribed          neuropathic pain syndromes and                pain of cervicogenic headache but may
at a low dose and increased over 4 to 8             migraine. No specific laboratory moni-        relieve the pain of episodic migraine
weeks as necessary and tolerated.                   toring is usually necessary.                  attacks that can occur in some patients
      The cautious combining of medica-                  Topiramate is indicated for migraine     with cervicogenic headache.
tions from different drug classes or with           prophylaxis and has been anecdotally              Other Medications—Muscle relax-
complementary pharmacologic mecha-                  reported effective in the management of       ants, especially those with central
nisms may provide greater efficacy than             painful diabetic neuropathy and cluster       activity such as tizanidine hydrochlo-
using individual drugs alone (eg, an                headache. Intermittent monitoring of          ride and baclofen, may provide some
antiepileptic drug combined with a tri-             serum electrolyte levels might be needed      analgesic efficacy. Botulinum toxin, type
cyclic antidepressant [TCA]). Frequent              because of this medication’s diuretic         A injected into pericranial and cervical
follow-up visits for medication dosage              effect through carbonic anhydrase inhi-       muscles is a promising treatment for
adjustments, monitoring of serum drug               bition.                                       patients with migraine and cervicogenic
levels, and evidence of medication toxi-                 Carbamazepine is an effective med-       headache,37,40,41 but further clinical and
city are recommended.                               ication in the treatment of patients with     scientific study is needed.
                                                    trigeminal neuralgia and central neuro-
    Antidepressants—The TCAs have                   pathic pain. Serum drug levels can be         Physical and Manual Modes of
long been used for management of var-               used as a therapeutic dosing guide.           Therapy
ious neuropathic, musculoskeletal, head,            Monthly monitoring of liver transami-         Physical and manual modes of therapy
and face pain syndromes. Analgesic                  nase levels and of CBC counts is recom-       are important therapeutic modalities for
dosages are typically lower than those              mended, especially during the first 3 to      the acute rehabilitation of cervicogenic
required for the treatment of patients              4 months of treatment or whenever             headache.42 A controlled trial testing the
with depression. The serotonin and nore-            dosages are increased.                        effectiveness of therapeutic exercise and
pinephrine reuptake inhibitors (SNRIs)                   Several of the other newer AEDs          manipulative treatment for cases of cer-
such as venlafaxine hydrochloride and               might be used when other treatments           vicogenic headache found that efficacy
duloxetine hydrochloride have been                  are ineffective.                              was not substantially affected by age,
anecdotally observed helpful in the pro-                Analgesics—Simple analgesics such         gender, or headache chronicity in patients
phylactic management of migraine. Sim-              as acetaminophen or nonsteroidal anti-        with moderate to severe pain intensity.43
ilar observations have been reported for            inflammatory drugs (NSAIDs) may be            This finding suggests that all patients
venlafaxine in the treatment of painful             used as regularly scheduled medications       with cervicogenic headache could benefit
diabetic neuropathy, fibromyalgia, and              for round-the-clock management of             from manual modes of therapy and
regional myofascial pain syndromes,                 chronic pain or as needed for the man-        physical conditioning.
while duloxetine is indicated for the man-          agement of acute pain.                             Another study comparing an exer-
agement of painful diabetic neuropathy.                  The selective cyclooxyenase-2 (COX-      cise program with manipulative therapy
      The selective serotonin reuptake              2) antagonist celecoxib might have less       for cervicogenic headache reported sub-
inhibitors (SSRIs) are generally ineffective        gastrointestinal toxicity than nonselec-      stantial and sustained reductions of
for pain control.                                   tive NSAIDs, but renal toxicity after long-   headache frequency and intensity that
    Antiepileptic Drugs—The anti-                   term use remains as a concern. Recent         were similar in both treatment groups
epileptic drugs (AEDs) are believed to              reports have linked the long-term use of      but with a trend toward greater efficacy
be modulators or stabilizers of periph-             selective COX-2 antagonists with an           when the treatment modalities are com-
eral and central pain transmission and              increased risk of cardiovascular and cere-    bined.44
are commonly used for the management                brovascular events; therefore, the risk-           A review of the medical literature
of neuropathic, head, and face pain syn-            benefit ratio of their use requires strong    suggested that the efficacy of physical
dromes. Divalproex sodium is indicated              consideration. It is recommended that         treatment modalities for the long-term
for the preventive management of                    prescribers review the safety informa-        prevention and control of headaches


S20 • JAOA • Supplement 2 • Vol 105 • No 4 • April 2005                                                          Biondi • Cervicogenic Headache
appears greatest in patients who are           anesthetic may also provide temporary           Its presenting symptom complex can be
involved in ongoing exercise and phys-         pain relief and relaxation of local muscle      similar to that of the more commonly
ical conditioning programs.45                  spasm. If diagnostic blockade of cervical       encountered primary headache disor-
      Osteopathic manipulative tech-           nerve, medial branch, or zygapophyseal          ders such as migraine or tension-type
niques such as craniosacral, strain-           joint blockade is successful in providing       headache. Early diagnosis and manage-
counter strain, and muscle energy tech-        substantial, but temporary, pain relief,        ment by way of a comprehensive, mul-
niques are particularly well suited for        the treatment algorithm can then pro-           tidisciplinary pain treatment program
the management of cervicogenic                 ceed to consideration for a longer-acting       can significantly decrease the protracted
headache. High velocity, low amplitude         neurolytic procedure such as radiofre-          course of costly treatment and disability
manipulation can be carefully used in          quency thermal neurolysis.38,50,51              that is often associated with this chal-
some patients, though it is not unusual to          A course of physical therapy and           lenging pain disorder.
observe an increase in headache inten-         rehabilitation is recommended after
sity after manual modes of therapy of          anesthetic blockade and neurolytic pro-         References
this type, especially if it is delivered too   cedures to enhance functional restora-          1. Blau JN, MacGregor EA. Migraine and the neck.
vigorously. Physical treatment modali-         tion and effect a longer-lasting analgesic      Headache. 1994;34:88-90.
ties are generally better tolerated when       benefit.
                                                                                               2. Sjaastad 0, Saunte C, Hovdahl H, Breivik H, Gron-
initiated with gentle muscle stretching                                                        back E. “Cervicogenic” headache. A hypothesis.
and manual cervical traction. Therapy          Surgical Treatment                              Cephalalgia. 1983;3:249-256.
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Psychological and nonpharmacologic             cation of pain or anesthesia dolorosa is a      70
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Cervical epidural steroid injections may       management of cervicogenic headache,            670.
be indicated in patients with multilevel       but its safety and efficacy have not yet
                                                                                               11. Lebbink J, Speirings EL, Messinger HB. A ques-
disc or spine degeneration.47 Greater and      been determined. Overall, surgical pro-         tionnaire survey of muscular symptoms in chronic
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relief in some cases.48 A published report     sion of nerve roots or peripheral nerves        12. Marcus D, Scharff L, Mercer MA, Turk DC. Mus-
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                                                                                               groups. Headache. 1999;39:21-27.
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                                                                                               ison with control subjects and patients with
interventions.                                 common cause of chronic headache that           migraine or tension-type headache. Headache.
      Trigger point injections with a local    is often misdiagnosed or unrecognized.          2003;43:1034-1041.


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S22 • JAOA • Supplement 2 • Vol 105 • No 4 • April 2005                                                                             Biondi • Cervicogenic Headache

				
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