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
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: firstname.lastname@example.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
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-
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
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
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
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
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-
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
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
might result in a misidentification of the — spinal roots, nerves, rami, or
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-
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
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Cervical epidural steroid injections may management of cervicogenic headache, 670.
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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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groups. Headache. 1999;39:21-27.
ilar to repeated blockade of the C2 and gically correctable pathologic condition or
C3 nerves.49 This finding suggests that a history of refractoriness to all reasonable 13. Haldeman S, Dagenais S. Cervicogenic
repeated greater occipital nerve blockade nonsurgical treatment modalities. headaches: a critical review. Spine J. 2001;1(1):31-46.
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ment option before considering referral Comment SG, Kessels AG, Weber WE. Quality of life of
for more invasive or more expensive Cervicogenic headache is a relatively patients with cervicogenic headache: a compar-
ison with control subjects and patients with
interventions. common cause of chronic headache that migraine or tension-type headache. Headache.
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