Can cervicogenic headaches be treated with steroids?

Treatment of Cervicogenic Headache with Steroids

Steroids are not recommended as a first-line treatment for cervicogenic headaches, but they may be considered as an interventional option when other treatments fail.

Understanding Cervicogenic Headache

Cervicogenic headache (CGH) is defined as a headache secondary to disorders of the cervical spine and its elements including bony, disc, and/or soft tissue components 1. It affects approximately 4% of the general population and up to 20% of patients with chronic headaches 1. The pain typically originates from nociceptive sources in the upper cervical spine, including cervical muscles, disc spaces, facet joints, and nerve roots.

First-Line Treatment Approaches

1. Non-steroidal anti-inflammatory drugs (NSAIDs)

   • First-line pharmacological treatment 1, 2
   • Options include:
     • Ibuprofen 400-600mg
     • Naproxen sodium 500-550mg
   • Should be taken early in the headache phase for maximum effectiveness

2. Non-pharmacological approaches

   • Physical therapy interventions
   • Regular exercise
   • Maintaining regular sleep schedule
   • Identification and avoidance of triggers
   • Relaxation techniques

When to Consider Steroid Treatment

Steroid treatment may be considered when:

• First-line treatments have failed
• Patient has significant disability despite optimized acute therapy
• Conservative measures such as physical therapy have been unsuccessful

Steroid Treatment Options for Cervicogenic Headache

1. Cervical Epidural Steroid Injection (CESI)

• Can be used as both a diagnostic and therapeutic intervention 3
• Typically administered at C6-C7 or C7-T1 level
• Usually methylprednisolone 40 mg is injected into the epidural cervical space 4
• Short-term studies show marked clinical improvement in pain scores and reduced medication consumption in CGH patients 4
• However, evidence remains limited and controversial 3

2. Intraarticular Cervical Facet Steroid Injections

• Meta-analysis shows improvement in mean pain scores after treatment 5
• Overall effect size demonstrated a significant reduction in Visual Analog Scale scores (pooled mean difference: 3.299,95% CI: 2.045 to 4.552, P < 0.001) 5
• Should be considered when conservative treatments fail

Important Considerations and Limitations

• Diagnostic challenges: CGH diagnosis is challenging due to heterogeneous definitions, overlapping symptoms with other headache disorders, lack of definitive radiological findings, and high prevalence of abnormal imaging findings in asymptomatic patients 1

• Limited evidence: Scientific evidence for the effectiveness of steroid treatments in CGH is scarce 6

• Individualized approach: Response to treatment varies significantly among patients 6

• Medication overuse risk: To guard against medication-overuse headaches, limit acute treatments to no more than twice a week 1

• Alternative interventions: Consider nerve blocks, facet joint injections, or other interventional procedures if steroid injections are ineffective 6

Monitoring and Follow-up

• Assess treatment efficacy after 2-3 months
• Monitor for potential steroid-related side effects
• Consider alternative approaches if inadequate response

While steroids administered by cervical epidural or intraarticular facet injection have been used in clinical practice for CGH, they should not be considered first-line therapy due to limited evidence of effectiveness and potential risks. They may be appropriate in selected patients who have failed conservative management.