From the Guidelines
For patients presenting with occipital headache and cervical pain, I strongly recommend an MRI of the cervical spine as the initial imaging study. This recommendation is based on the most recent and highest quality evidence, which suggests that MRI has superior intrinsic soft-tissue contrast and good spatial resolution, making it the preferred method to evaluate the cervical spine in the setting of suspected nerve root impingement 1. The study by Brown et al, as cited in the ACR Appropriateness Criteria, found that MRI correctly predicted 88% of lesions, outperforming CT myelography, plain myelography, and CT 1.
Some key points to consider when evaluating occipital headache and cervical pain include:
- The clinical presentation, including the presence of neurological symptoms, history of trauma, duration of symptoms, and red flag signs that might indicate serious underlying pathology
- The potential for degenerative findings on MRI, which are commonly observed in asymptomatic patients 1
- The importance of correlating imaging findings with clinical symptoms and physical examination results
In terms of alternative imaging modalities, CT scanning may be considered if MRI is contraindicated or unavailable, particularly if bony abnormalities are suspected. However, MRI of the cervical spine remains the preferred initial imaging study due to its superior visualization of soft tissues and potential space-occupying lesions that could cause occipital headache and cervical pain 1.
From the Research
Imaging Study for Occipital Headache and Cervical Pain
- The imaging study indicated for occipital headache and cervical pain is Magnetic Resonance Imaging (MRI) 2, 3.
- MRI, including surface anatomy scanning (SAS) imaging, should be considered for patients with persistent, severe, and unilateral pain in the occipitocervical area 2.
- Both MRI and Magnetic Resonance Angiography (MRA) should be performed for patients who complain of persistent, unilateral pain in the occipital/nuchal regions to prevent vertebral artery dissection (VAD) being missed during diagnosis 3.
- Cerebral angiography and thin-slice T1-weighted MRI may be additionally performed in selected cases 3.
Diagnosis of Vertebral Artery Dissection
- Vertebral artery dissection (VAD) presenting as isolated occipital headache and/or neck pain is being increasingly diagnosed because of the development of MRI 2.
- Patients with VAD may experience sudden onset severe occipital/nuchal pain, but only 55% of patients with VAD demonstrate typical occipital/nuchal pain with sudden onset 3.
- The pain associated with VAD is often persistent and ipsilateral, and may be severe enough to disable daily life activities 2, 3.
Other Considerations
- Occipital neuralgia or cervicogenic headache should be considered as contributing factors in patients with coexisting or misdiagnosed migraine 4.
- Accurate diagnosis of occipital neuralgia or cervicogenic headache can lead to substantial headache relief through occipital nerve blocks in patients with coexisting or misdiagnosed migraine 4.