How are cervicogenic headache symptoms managed?

From the Guidelines

Cervicogenic headache symptoms are best managed with physical therapy, as suggested by the 2024 clinical practice guideline for the management of headache 1.

Management Approach

The management of cervicogenic headaches involves a multidisciplinary approach that includes nonpharmacologic therapy, such as physical therapy, which has been suggested for the management of tension-type, migraine, or cervicogenic headache 1.

• Physical therapy focusing on cervical spine mobilization, postural correction, and strengthening exercises should be performed 2-3 times weekly for 4-6 weeks.
• Daily home exercises are essential for long-term improvement.

Additional Considerations

While there is insufficient evidence to recommend for or against certain behavioral interventions, such as biofeedback, cognitive behavioral therapy, or mindfulness-based therapies 1,

• Aerobic exercise or progressive strength training may be suggested for the prevention of tension-type and migraine headache 1.
• It is also important to note that there is insufficient evidence to recommend for or against dietary trigger avoidance for the prevention of headache 1.

Treatment Goals

The goal of treatment is to address the underlying cervical spine dysfunction, reduce inflammation, decrease muscle tension, and interrupt pain signals from cervical structures to the trigeminal nerve pathway.

• Improvement typically requires consistent treatment over several weeks, with some patients needing ongoing maintenance therapy.
• Heat application (15-20 minutes several times daily) and improving ergonomics at work and home are important self-management strategies.

From the Research

Cervicogenic Headache Symptoms

• Cervicogenic headache is a 'side-locked' or unilateral fixed headache characterised by a non-throbbing pain that starts in the neck and spreads to the ipsilateral oculo-fronto-temporal area 2
• The headache is mild to moderate, described as pulsatile or compressive, accompanied by nausea, vomiting, photophobia, phonophobia, and may present autonomic symptoms and dizziness 3
• Attacks or chronic fluctuating periods of neck/head pain may be provoked/worsened by sustained neck movements or stimulation of ipsilateral tender points 2

Management of Cervicogenic Headache Symptoms

• Various therapies have been used in the management of cervicogenic headache, including drug therapy with paracetamol and NSAIDs, infliximab and botulinum toxin type A; manual modalities and transcutaneous electrical nerve stimulation therapy; local injection of anaesthetic or corticosteroids; and invasive surgical therapies 2
• A reliable diagnosis of cervicogenic headache can be made based on the criteria established in 1998 by the Cervicogenic Headache International Study Group, and positive response after an appropriate nerve block is an essential diagnostic feature of the disorder 2
• Occipital nerve blocks, cervical facet joint injection, atlantoaxial (AA) joint injection, deep cervical plexus block, cervical epidural injection may be reasonable options in refractory cases of CeH 4
• Physiotherapy rehabilitation, anesthetic blocks, and selectively surgical procedures are also used in the management of cervicogenic headache 3
• Mainstay of management is physical therapy, and surgical interventions for cervical degenerative disease may relief an associated headache but such interventions are not performed solely for cervicogenic headache 5

Diagnostic Criteria

• The diagnosis of cervicogenic headache is based on clinical criteria mentioned by the International Headache Society (IHS) and Cervicogenic Headache International Study Group (CHISG) 5
• Cervical nerve block may confirm the nociceptive source in majority of cases and is included in CHISG criteria 5
• Non-invasive diagnostic methods like echogenicity of muscles, diffusion tensor imaging (DTI) and single-photon emission tomography (SPECT) are proposed by some authors for avoiding complications associated with blocks 5

Treatment Strategies

• Guidelines for developing a successful multidisciplinary pain management program using medication, physical therapy, osteopathic manipulative treatment, other nonpharmacologic modes of treatment, and anesthetic interventions are presented 6
• A curative therapy for cervicogenic headache will not be developed until increased knowledge of the aetiology and pathophysiology of the condition becomes available 2
• Limited evidence suggests that therapy with repeated injections of botulinum toxin type A may be the most safe and efficacious approach 2
• Radiofrequency ablation (RFA) was found to have favorable long-term outcomes, while better safety has been reported with pulsed therapy 4