From the Guidelines
For patients presenting with occipital headache and cervical pain, I strongly recommend ordering an MRI of the head and neck without contrast as the initial imaging modality, as it is usually appropriate for assessment of new or increasing radiculopathy due to improved nerve root definition. This approach is supported by the American College of Radiology's appropriateness criteria for cervical neck pain or cervical radiculopathy 1. The use of MRI without contrast is preferred for evaluating radiculopathy and can help identify structural issues such as herniated discs, bone abnormalities, or muscle injuries.
When considering the use of contrast, it is essential to weigh the benefits against the potential risks, particularly in patients with severe kidney disease or contrast allergy. However, for most patients, an MRI without contrast is a reasonable initial step. If the initial MRI without contrast does not provide a clear diagnosis, or if there is suspicion of infection, malignancy, or other conditions that may require contrast enhancement, a follow-up MRI with contrast may be considered.
Key points to consider when ordering an MRI for occipital headache and cervical pain include:
- The presence of "red flag" symptoms, which may necessitate more urgent or specialized imaging
- The patient's medical history, including any prior cervical spine surgery or known conditions that may affect the choice of imaging modality
- The specific symptoms and physical examination findings, which can help guide the radiologist in focusing on relevant anatomical areas, such as the cervical spine and posterior fossa structures. As noted in the ACR appropriateness criteria, imaging may not always be indicated for evaluation of cervicogenic headache without neurologic deficit 1, highlighting the importance of careful patient selection and consideration of clinical context when ordering diagnostic tests.
From the Research
Evaluation of Occipital Headache and Cervical Pain
To evaluate occipital headache and cervical pain, it is essential to consider the underlying causes of these symptoms.
- Vertebral artery dissection (VAD) is a potential cause of occipital headache and cervical pain, as seen in studies 2, 3.
- Occipital neuralgia is another possible cause of occipital pain, characterized by paroxysmal lancinating pain in the distribution of the greater, lesser, or third occipital nerves 4.
- Compression of the lesser and greater occipital nerves by the posterior cervical muscles and their fascial attachments at the occipital ridge can also lead to unremitting head and neck pain 5.
Diagnostic Approach
The diagnostic approach for occipital headache and cervical pain may involve:
- Magnetic Resonance Imaging (MRI) of the head and neck, including surface anatomy scanning (SAS) imaging, to rule out VAD and other potential causes 2.
- Computed Tomography (CT) neck with contrast or Digital Subtraction Angiography (DSA) to diagnose VAD 3.
- MRI or CT angiogram to evaluate the vascular structures in the neck and head.
Use of Contrast in MRI
The use of contrast in MRI for the evaluation of occipital headache and cervical pain is not explicitly mentioned in the provided studies. However, contrast agents may be used to enhance the visibility of certain structures or lesions, such as vascular abnormalities or tumors.
Clinical Considerations
When evaluating occipital headache and cervical pain, it is crucial to consider the clinical presentation and medical history of the patient.
- Patients with persistent, severe, and unilateral pain in the occipitocervical area should undergo MRI examination, including SAS imaging, to rule out VAD 2.
- Young patients with craniocervical pain, even in the absence of neurological symptoms, should be considered for VAD diagnosis 3.
- A thorough physical examination and medical history should be taken to identify potential causes of occipital headache and cervical pain, such as occipital neuralgia or cervical spine disorders 4, 5, 6.