Can cervicogenic headaches cause scalp tenderness?

Cervicogenic Headaches and Scalp Tenderness

Yes, cervicogenic headaches can cause scalp tenderness, as it is a recognized symptom associated with referred pain from cervical structures to the head region. 1, 2

Pathophysiology and Mechanism

Cervicogenic headache is defined by the International Headache Society as a headache secondary to disorders of the cervical spine and its elements, including bony, disc, and soft tissue components 1. The mechanism behind scalp tenderness in cervicogenic headaches involves:

• Pain referral pathway: Nociceptive input from the upper cervical spine (including muscles, disc spaces, facet joints, and nerve roots) converges with trigeminal sensory pathways in the trigeminocervical nucleus 3
• Bidirectional referral: This functional convergence allows pain to be referred from cervical structures to the head, including the scalp region 3
• Common presentation: Pain typically starts in the neck and spreads to the ipsilateral oculo-fronto-temporal area, often accompanied by tenderness in the scalp region 4

Diagnostic Considerations

When evaluating scalp tenderness in suspected cervicogenic headache:

• Characteristic features:

  • Unilateral "side-locked" headache (typically fixed to one side)
  • Pain starting in the neck and spreading to the head
  • Provocation by neck movements or sustained awkward head positions
  • Tenderness to palpation over cervical structures 5
  • Scalp tenderness, particularly in the region where pain is referred 1

• Differential diagnosis to consider when evaluating scalp tenderness:

  • Giant cell arteritis - presents with temporal artery tenderness in 36% of cases 1
  • Migraine - can also cause scalp tenderness but typically has different triggers
  • Tension-type headache - more diffuse pain pattern
  • Intracranial hypotension - characterized by orthostatic headache 1
  • Cervicogenic dizziness - may co-occur with cervicogenic headache 2

Clinical Approach

When evaluating a patient with scalp tenderness and suspected cervicogenic headache:

1. Assess for red flags that might indicate more serious pathology:

   • Trauma history
   • Malignancy
   • Prior neck surgery
   • Systemic diseases (ankylosing spondylitis, inflammatory arthritis)
   • Intractable pain despite therapy 1

2. Physical examination:

   • Evaluate for temporal artery abnormalities (to rule out giant cell arteritis) 1
   • Assess cervical range of motion (typically reduced in cervicogenic headache) 2
   • Identify tender points in the neck that reproduce headache symptoms 5
   • Evaluate for myofascial tenderness in both neck and scalp regions 2

3. Diagnostic testing:

   • Imaging is generally not diagnostic for cervicogenic headache due to high prevalence of abnormal findings in asymptomatic patients 1
   • Diagnostic blocks may be necessary to confirm cervical origin of pain 6

Management Approach

For cervicogenic headache with scalp tenderness:

1. First-line treatments:

   • Exercise therapy including postural correction exercises 2
   • Manual therapy targeting cervical structures 2
   • NSAIDs at lowest effective dose for shortest duration 2

2. Second-line treatments:

   • Local injections of anesthetic or corticosteroids 4
   • Botulinum toxin type A injections (may be most efficacious approach based on limited evidence) 4
   • Vestibular rehabilitation when balance issues co-exist 2

3. Refractory cases:

   • Consider referral to specialist center 1
   • Surgical approaches including decompression and radiofrequency lesions may be considered in carefully selected cases 4

Important Caveats

• Scalp tenderness alone is not diagnostic of cervicogenic headache and must be evaluated in context of other symptoms
• Diagnosis of cervicogenic headache remains challenging due to overlapping symptoms with other headache disorders 1
• Prevalence estimates range from 0.7% to 13.8% of the general population, with higher rates (15-20%) among those with chronic headaches 7, 1
• The condition affects patients with a mean age of 42.9 years and has a 4:1 female predominance 7

Remember that cervicogenic headache with scalp tenderness typically responds poorly to common headache medications, making accurate diagnosis and targeted treatment essential for symptom management 7.