Chapter 41 Cervicogenic Headache

Question 1

Cervicogenic headache was initially defined as

Answer 1

unilateral headache that is provoked by neck movement or pressure
over tender points in the neck with associated reduced range of movement of the cervical spine. The headache occurs in nonclustering episodes and is usually nonthrobbing
in nature, originating from the neck, and spreading
over the head.

Question 2

It is sometimes difficult to differentiate among cervicogenic headache, migraine, and tension-type
headache based only on the clinical presentation. Establish the diagnosis of cervicogenic headache

Answer 2

diagnostic blockade of the nerve supply of these
cervical structures or intra-articular injection of local anesthetic into the affected joint help establish the diagnosis; in fact, this is now considered a major criterion for the diagnosis of cervicogenic headache.

Question 3

diagnostic criteria for cervicogenic headache by the International Headache Society (IHS)

Answer 3

A. Pain, referred from a source in the neck and perceived in one or more regions of the head and/or
face, fulfills criteria C and D.
B. Clinical, laboratory, and/or imaging evidence of
a disorder or lesion within the cervical spine or soft
tissues of the neck is known to be, or generally accepted as, a valid cause of headache.
C. There is evidence that the pain can be attributed to
the neck disorder or lesion based on at least one of
the following:
1. Demonstration of clinical signs that implicate a
source of pain in the neck.
2. Abolition of headache following diagnostic block
of a cervical structure or its nerve supply using
placebo or other adequate controls. Abolition of
headache means complete relief of headache,
indicated by a score of 0 on a visual analog scale.
D. Pain resolves within 3 months after successful treatment of the causative disorder or lesion.

Question 4

Symptoms not unique

to cervicogenic headache

Answer 4

neck pain, focal neck tenderness, history of neck trauma, mechanical
exacerbation of pain, unilaterality, coexisting shoulder pain, and reduced range of motion in the neck are not unique to cervicogenic headache

Question 5

Cervicogenic headache

Answer 5

referred pain from cervical
structures innervated by the upper three cervical spinal
nerves.

Question 6

sources of cervicogenic headache

Answer 6

atlanto-occipital joint, atlantoaxial (AA) joints, C2–C3 zygapophysial joint, C2–C3 intervertebral disc, and upper cervical spinal nerves and roots.

Question 7

Other serious causes

of occipital headaches that should be ruled out

Answer 7

posterior cranial fossa lesions and vertebral artery dissection or aneurysm

Question 8

trigeminocervical nucleus

Answer 8

The spinal nucleus of the trigeminal nerve extends caudally to the outer lamina of the dorsal horn of the upper three to four cervical spinal segments. it receives afferents from the trigeminal nerve as well as the upper three cervical
spinal nerves

Question 9

accounts for the cervical-trigeminal pain referral.

Answer 9

Convergence between afferents from the trigeminal nerve as well as the upper three cervical spinal nerves.

Question 10

cervical-trigeminal pain referral

Answer 10

pain originating from cervical structures supplied by the
upper cervical spinal nerves could be perceived in areas
innervated by the trigeminal nerve branches such as the
orbit and the fronto- temporoparietal region

Question 11

Clinical presentations suggestive of pain originating from the lateral atlantoaxial
joint include

Answer 11

occipital or suboccipital pain, focal tenderness
over the suboccipital area, restricted painful rotation
of C1 on C2, and pain provocation by passive rotation of C1.

Question 12

The pathology of lateral atlantoaxial joint pain is usually

Answer 12

post-traumatic or osteoarthritis

Question 13

treatment of pain originating from the lateral atlantoaxial joint

Answer 13

Intra-articular steroids (effective in the short-term)
favorable long-term outcome after both pulsed and thermal radiofrequency lesioning of the AAJ capsule. In intractable cases not responsive to more
conservative management, arthrodesis of the lateral atlantoaxial joint may be indicated.

Question 14

anatomy of the joint in relation to the surrounding

vascular and neural structures

Answer 14

The vertebral artery is lateral to the atlantoaxial joint as it courses through the C2 and C1 foramina. Then it curves medially to go through the foramen magnum crossing the medial posterior
aspect of the atlanto-occipital joint. The C2 dorsal root ganglion and nerve root with its surrounding dural sleeve crosses the posterior aspect of the middle of the joint.

Question 15

Atlantoaxial joint intra-articular injection has the potential for serious complications

Answer 15

during atlantoaxial joint injection, the needle should be directed toward the posterolateral aspect of the joint. This will avoid injury to the C2 nerve root medially or the vertebral artery laterally. Spinal cord injury and syringomyelia are potential serious complications if the needle is directed farther medially.

Question 16

Injection of a contrast agent should be performed under

Answer 16

real-time fluoroscopy, preferably with digital subtraction, prior to the injection of the local anesthetic, as negative
aspiration is of low sensitivity

Question 17

Inadvertent puncture of the

C2 dural sleeve

Answer 17

CSF leak or high spinal spread of the local anesthetic may occur with atlantoaxial joint injection
if the needle is directed a few millimeters medially.

Question 18

The C2–C3 zygapophyseal joint is innervated by

Answer 18

the third occipital nerve, which is the superficial medial branch of
the dorsal ramus of C3

Question 19

C2–C3 ZYGAPOPHYSEAL JOINT AND THIRD

OCCIPITAL HEADACHE diagnosis

Answer 19

Tenderness over the C2–C3 joint is the only suggestive physical examination finding and a diagnostic third occipital nerve block is mandatory to confirm the diagnosis.

Question 20

The third occipital nerve

Answer 20

the superficial medial branch of C3 dorsal ramus. It supplies the C2–C3 zygapophysial joint
while crossing the joint laterally. Also it supplies part of the semispinalis capitis muscle, and its cutaneous branch supplies a small area of skin below the occiput.

Question 21

treatment of headache stemming from the C2–C3 joint.

Answer 21

Third-occipital
radiofrequency ablation (RFA) was shown to be effective

Question 22

improve the results of Third-occipital radiofrequency ablation (RFA)

Answer 22

There is usually incomplete lesioning of the third occipital nerve because of its variable anatomy. The use of the three needles technique to accommodate all variations in the anatomy of the third occipital nerve from just lateral to the
joint line to above or below the joint and creating consecutive lesions no more than one electrode width from adjacent lesions

Question 23

Complications of Third-occipital radiofrequency ablation (RFA)

Answer 23

Numbness in the cutaneous distribution of the third occipital nerve is very common after RFA, whereas dysesthesia and hypersensitivity (typically at the border of the area of numbness). Temporary ataxia has been reported in
most patients as third occipital neurotomy partially denervates the semispinalis capitis muscles with the resultant interference of the tonic neck reflexes.

Question 24

diagnostic criteria of occipital neuralgia

Answer 24

A. Paroxysmal stabbing pain, with or without persistent
ache between paroxysms, in the distribution(s)
of the greater, lesser, and/or third occipital nerves.
B. Tenderness over the affected nerve.
C. Pain eased temporarily by local anesthetic block of
the nerve.

Question 25

Occipital neuralgia was long thought to be the result of

Answer 25

entrapment of the greater occipital nerve as it emerges from the trapezius muscle

Question 26

Treatment of Occipital neuralgia

Answer 26

surgical nerve release
gives only short-term relief in about 80% of cases, whereas nerve excision provides short-term relief in about 70% of patients

Question 27

The greater and lesser occipital nerve

Answer 27

The greater occipital nerve is the terminal branch of the
dorsal ramus of C2 with contribution from C3, whereas the lesser occipital nerve is a branch of the dorsal ramus of C3 with contributions from C2

Question 28

Treatment of occipital nerve

Answer 28

Cryoneurolysis, radiofrequency ablation, and
more permanent neuroablative approaches such as dorsal rhizotomy at C1–C3 and partial posterior rhizotomy at C1–C3 showed variable responses.

Question 29

Percutaneous occipital nerve stimulation

Answer 29

offers the potential for a minimally invasive, low-risk, and reversible approach to managing occipital neuralgia and some types of intractable primary headache

Question 30

A percutaneous occipital
trial of peripheral nerve stimulation is performed
using

Answer 30

subcutaneous electrodes placed superficial to the

cervical muscular fascia in the suboccipital area.

Question 31

if the percutaneous occipital

trial of peripheral nerve stimulation is effective

Answer 31

a permanent implant may be carried out using the
same electrode lead type or paddle-type surgical lead and attached to a pulse generator implanted in the infraclavicular area, flank, upper buttock, or abdomen

Question 32

The most frequent complication of the subcutaneous

techniques of neurostimulation is

Answer 32

lead migration necessitating
revision the electrodes placement, painful
stimulation-induced muscle contraction that is related to
the depth of the implanted lead (e.g., deep placement at the level of the suboccipital muscles).

Question 33

C2 neuralgia

Answer 33

a distinctive type of occipital neuralgia caused by lesions affecting the C2 nerve root or dorsal ganglion, such as neuroma, meningioma, or anomalous vessels

Question 34

C2 root lies

Answer 34

posterior to the lateral atlantoaxial joint; thus, disorders or inflammation of this joint may lead to irritation or entrapment of the nerve
root

Question 35

C2 neuralgia manifests as

Answer 35

intermittent lancinating

occipital pain that is associated with lacrimation, ciliary injection, and rhinorrhea.

Question 36

C2 neuralgia Diagnosis

Answer 36

Abolition of pain by selective C2 nerve root block is essential to make an accurate diagnosis.

Question 37

Treatment of C2 neuralgia indicated in intractable cases that respond poorly to pharmacotherapy and other conservative management

Answer 37

Thermocoagulation, decompression, or C2 ganglionectomy

Question 38

CERVICAL MYOFASCIAL PAIN

proposed as a cause of headache

Answer 38

Trigger points in the posterior neck muscles, especially the

trapezius, sternocleidomastoid, and the splenius capitis

Question 39

CERVICAL MYOFASCIAL PAIN

tender points usually overlie

Answer 39

the zygapophyseal

joints

Question 40

CERVICAL DISCOGENIC PAIN

C2–C3 provocative discography, but not at the lower levels, can reproduce

Answer 40

cervicogenic headache

Question 41

CERVICAL DISCOGENIC PAIN

Treatment

Answer 41

Radiofrequency
lesioning was shown to be effective in obtaining
some pain relief

Question 42

in CERVICAL DISCOGENIC PAIN, cervical disc interventions are not commonly performed
because of the potential for

Answer 42

esophageal penetration leading to discitis or vascular injury.