In the present paper we
have studied eleven adult and aging patients, ranging from 34 to 81 years old
with cervicogenic headache. There is an opinion that with increasing cervical
degenerative joint disease with ageing, cervicogenic headaches become more
frequent. In addition to cervicogenic headache, musculoskeletal dysfunction was
also found in headaches classifiable as migraine or tension-type headache [9].
Cervicogenic headache
(CEH) originates from disorders of the neck but is recognized as a referred
pain in the head. Primary sensory afferents from the cervical roots C1-C3
converge with afferents from the occiput and trigeminal afferents on the same
second-order neuron in the upper cervical spine. Consequently, the anatomical
structures innervated by the cervical roots C1-C3 are potential sources of CGH.
CGH can origin from different muscles and ligaments of the neck, from
intervertebral discs, and, particularly, from the atlanto-occipital,
atlantoaxial, and C2/C3 zygapophyseal joints. In addition, the vertebral and
internal carotid arteries, and the dura mater of the upper spinal cord and
posterior cranial fossa might participate. Cervicogenic headache is defined as
headaches originating from cervical spine structures including cervical facet
joints, cervical intervertebral discs, skeletal muscles, connective tissues,
and neurovascular structures. According to this hypothesis, functional
convergence of the upper cervical and trigeminal sensory pathways allows the
bidirectional (afferent and efferent) referral of pain to the occipital,
frontal, temporal, and/or orbital regions [3-5, 7,10-13]. According to Gasik, [14]
the pain may spread to the neck, occipital area of skull, area of jaw and
eyeballs, and arms. There are many theories trying to explain spreading of the
pain outside the area innervated by C1, C2 and C3 cervical roots. Their common
denominator is communication between fibres running in those roots and neurons
of trigeminal nerve. Many authors describe a possibility of such connection
through the jelly-like nucleus of the trigeminal nerve located in the back
funiculi of spinal cord. In this mechanism, the pain conducted via occipital
nerves may affect activity of neurons of the trigeminal nerve and influence
areas innervated by the trigeminal nerve. According to some authors, the
necessary condition to make a diagnosis of cervicogenic headache is finding the
changes of spondylosis nature of the cervical spine section in additional
examinations
According to Baron et al.
[15], cervicogenic headache frequently coexists with complaints of dizziness,
tinnitus, nausea, imbalance, hearing complaints, and ear/eye pain. Controversy
exists as to whether this constellation of symptoms may be cervically mediated.
A wider spectrum of cervically mediated symptoms may exist by influence of
trigeminocervical and vestibular circuitry through cervical afferent
neuromodulation.
Iskra et al. [16]
postulate a manual differential diagnosis between cervicogenic headaches and
migraine. According to these Authors the analysis of literature suggests that
manipulative effects on neck structures in cases of migraine can reduce the
intensity and the duration of pain, and the frequency of attacks by no more
than 20%, and the therapeutic effectiveness of manual therapy for CGH is much
higher.
The patients with
cervicogenic headache often had bilateral pain. The regions mainly concentrated
in the temporal region, with occipital, head or orbit pains [17].
A notable portion of
patients with cervicogenic headache can have an atypical presentation mimicking
a primary type headache. However, cervicogenic headaches with atypical
presentation can be difficult to diagnose and manage at the initial visit of
the patients. Etiopathophysiology of this type of headache could be explained
by the theories including discogenic, convergence and sensitization-desensitization
theories [12].
Avigan et al. [18] made a
systematic review evidencing the heterogeneity in the clinical characteristics
used to diagnose CGH in participants recruited in randomized controlled trials
and how well the diagnostic criteria used align with the most recent edition
(3rd) of the International Classification of Headache Disorders
According to Jull et al. [19],
restricted movement, in association with palpable upper cervical joint
dysfunction and impairment in the cranio-cervical flexion test (CCFT), had 100%
sensitivity and 94% specificity to identify cervicogenic headache.
Musculoskeletal disorders are considered the underlying cause of cervicogenic
headache, but neck pain is commonly associated with migraine and tension-type
headaches.
The cervical region
contains many pain-sensitive structures, and that these are prone to injury.
The anatomical and physiological mechanisms are in place to allow referral of
pain to the head including frontal head regions and even the orbit in patients
with pain originating from many of these neck structures. Clinical studies have
shown that pain from cervical spine structures can in fact be referred to the
head. Finally, clinical treatment trials involving patients with proven painful
disorders of upper cervical zygapophysial joints have shown significant
headache relief with treatment directed at cervical pain generators. In
conclusion, painful disorders of the neck can give rise to headache, and the
challenge is to identify these patients and treat them successfully [8].
Postmortem studies show
that a spectrum of injuries can befall the zygapophysial joints in motor
vehicle accidents. Biomechanics studies of normal volunteers and of cadavers
reveal the mechanisms by which such injuries can be sustained. Studies in
cadavers and in laboratory animals have produced these injuries. Clinical
studies have shown that zygapophysial joint pain is very common among patients
with chronic neck pain after whiplash, and that this pain can be successfully
eliminated by radiofrequency neurotomy [20].
Cervicogenic headache
(CEH) affects 22-25% of the adult population with females being four times more
affected than men. CEHs are thought to arise from musculoskeletal impairments
in the neck with symptoms most commonly consisting of suboccipital neck pain,
dizziness, and lightheadedness [21].
Cervicogenic headache
and dizziness
We have reported
dizziness in five patients (50%). Cervicogenic dizziness (CGD) is hard to
diagnose as there is no objective test [22]. Cervicogenic cephalic syndrome
(CCS) comprises a group of diseases, consists of cervicogenic headache and
dizziness [23].
Cervicogenic headache
and blood hypertension
In the present study we
have found blood hypertension in five patients with CGH (50%). According to
Vincent [6], CGH may depend in addition on a central predisposition
counterpart, leading to the activation of the trigeminovascular system and pain
generation
Cervicogenic diseases
and metabolic diseases
Metabolic diseases such
hypothyroidism, diabetes and obesity were found in the patients examined, which
con be considered precipitating risk factors in the elderly population. We have
not found previous reported on cervicogenic headaches and interactions with
these metabolic entities.
According to La Grew et
al. [24], those diagnosed with cervicogenic headache were more likely to be
female (P = 0.041), report a higher maximum pain level on presentation (P =
0.015), have a diagnosis of diabetes prior to presentation (P = 0.011), The
lack of data on some of the patients who presented with headache may have led
to underdiagnosis of the true incidence of cervicogenic headache. Future work
should look to re-examine the incidence of CGH in a larger cohort to validate
the findings here and further define risk factors for post-procedural CGH.
Cervicogenic diseases
and vertigo
We have found vertigo in
one patient with cervicogenic headache. Thompson-Harvey and Hain [25] identify
patient features distinguishing cervical vertigo from vestibular causes of vertigo
and vestibular migraine. Cervical vertigo subjects may resemble migraine
subjects who also have evidence of neck injury. These observations indicates
that cervicogenic headache with vertigo should be differentiated from
vestibular vertigo and vestibular migraine.
Pollak and Pollak, [26]
postulate that headache is also frequent in benign paroxysmal positional
vertigo (BPPV). The most common is tension-type headache, followed by migraine
and cervicogenic headache. Head pain seems to be an independently associated
epiphenomenon of BPPV that can worsen patients' distress.
Mixed cervicogenic
headache and migraine
The presence of
photophobia, sonophobia, scintillating scotoma, blurred vision, dizziness,
vomits were interpreted as symptoms related to migrainous traits [6] present in
the patients examined of mixed cervigogenic headache and migraine.
Cervicogenic headache
and neurobehavioral disorders
We have reported
depression in three cases with CGH and in one case with stress-related disorder
(27%). Presumably one consequence of these associations is the hypothesis that
estrogens have a role in the pathophysiology of both disorders, as have been
postulated by Peterlin et al. [27] between migraine and depression. Until now,
the studies into the possible mechanisms underlying these associations remains
limited as concluded in previous several studies, which means that the
cervigogenic headache has migrainous trait. Prospective epidemiological studies
suggest a common genetic, biochemical or environmental background behind
primary headaches and depression. This theory is supported by the role of the
same neurotransmitter systems (mostly serotonin and dopamine) in headaches as
well as in depression [28], Pain, anxiety and depression also are comorbidities
in migraine [29-31]. Furthermore, it is a common belief that in migraine
without aura, neck symptoms frequently occur and that dizziness and CGH may
pathogenetically be intimately related [32].
Cervicogenic headache
affects a significant portion of the entire population. This type of headache
especially with atypical presentation is often hard to diagnose and manage
since its etiopathophysiology is not been yet well understood. Bir et al., [12]
have investigated the prevalence of cervicogenic headache with atypical
presentation and discussed the etiology of it, and the outcome of surgical
intervention on this type of headache in patients with cervical degenerative
disease
Cervicogenic headache
and Whiplash injury
We have observed a
patient with whiplash injury after a car accident. This variety of cervicogenic
headache has been earlier studied by Drottning et al. [33], who clarify the
long-term natural course of cervicogenic headache (CGH) after whiplash injury.