Flashcards in Chapter 41 Cervicogenic Headache Deck (42):
Cervicogenic headache was initially defined as
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.
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
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.
diagnostic criteria for cervicogenic headache by the International Headache Society (IHS)
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
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.
Symptoms not unique
to cervicogenic headache
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
referred pain from cervical
structures innervated by the upper three cervical spinal
sources of cervicogenic headache
atlanto-occipital joint, atlantoaxial (AA) joints, C2–C3 zygapophysial joint, C2–C3 intervertebral disc, and upper cervical spinal nerves and roots.
Other serious causes
of occipital headaches that should be ruled out
posterior cranial fossa lesions and vertebral artery dissection or aneurysm
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
accounts for the cervical-trigeminal pain referral.
Convergence between afferents from the trigeminal nerve as well as the upper three cervical spinal nerves.
cervical-trigeminal pain referral
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
Clinical presentations suggestive of pain originating from the lateral atlantoaxial
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.
The pathology of lateral atlantoaxial joint pain is usually
post-traumatic or osteoarthritis
treatment of pain originating from the lateral atlantoaxial joint
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.
anatomy of the joint in relation to the surrounding
vascular and neural structures
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.
Atlantoaxial joint intra-articular injection has the potential for serious complications
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.
Injection of a contrast agent should be performed under
real-time fluoroscopy, preferably with digital subtraction, prior to the injection of the local anesthetic, as negative
aspiration is of low sensitivity
Inadvertent puncture of the
C2 dural sleeve
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.
The C2–C3 zygapophyseal joint is innervated by
the third occipital nerve, which is the superficial medial branch of
the dorsal ramus of C3
C2–C3 ZYGAPOPHYSEAL JOINT AND THIRD
OCCIPITAL HEADACHE diagnosis
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.
The third occipital nerve
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.
treatment of headache stemming from the C2–C3 joint.
radiofrequency ablation (RFA) was shown to be effective
improve the results of Third-occipital radiofrequency ablation (RFA)
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
Complications of Third-occipital radiofrequency ablation (RFA)
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.
diagnostic criteria of occipital neuralgia
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
Occipital neuralgia was long thought to be the result of
entrapment of the greater occipital nerve as it emerges from the trapezius muscle
Treatment of Occipital neuralgia
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
The greater and lesser occipital nerve
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
Treatment of occipital nerve
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.
Percutaneous occipital nerve stimulation
offers the potential for a minimally invasive, low-risk, and reversible approach to managing occipital neuralgia and some types of intractable primary headache
A percutaneous occipital
trial of peripheral nerve stimulation is performed
subcutaneous electrodes placed superficial to the
cervical muscular fascia in the suboccipital area.
if the percutaneous occipital
trial of peripheral nerve stimulation is effective
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
The most frequent complication of the subcutaneous
techniques of neurostimulation is
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).
a distinctive type of occipital neuralgia caused by lesions affecting the C2 nerve root or dorsal ganglion, such as neuroma, meningioma, or anomalous vessels
C2 root lies
posterior to the lateral atlantoaxial joint; thus, disorders or inflammation of this joint may lead to irritation or entrapment of the nerve
C2 neuralgia manifests as
occipital pain that is associated with lacrimation, ciliary injection, and rhinorrhea.
C2 neuralgia Diagnosis
Abolition of pain by selective C2 nerve root block is essential to make an accurate diagnosis.
Treatment of C2 neuralgia indicated in intractable cases that respond poorly to pharmacotherapy and other conservative management
Thermocoagulation, decompression, or C2 ganglionectomy
CERVICAL MYOFASCIAL PAIN
proposed as a cause of headache
Trigger points in the posterior neck muscles, especially the
trapezius, sternocleidomastoid, and the splenius capitis
CERVICAL MYOFASCIAL PAIN
tender points usually overlie
CERVICAL DISCOGENIC PAIN
C2–C3 provocative discography, but not at the lower levels, can reproduce
CERVICAL DISCOGENIC PAIN
lesioning was shown to be effective in obtaining
some pain relief