What is the difference between cervicogenic headache and tension headache (HA)?

From the Guidelines

Cervicogenic headaches and tension headaches are distinct entities with different characteristics, origins, and treatment approaches, and a proper diagnosis is crucial to guide management. The primary difference between cervicogenic headache and tension headache lies in their underlying causes and presentations. Cervicogenic headaches originate from disorders in the cervical spine or soft tissues of the neck, typically presenting as unilateral pain that radiates from the neck to the frontotemporal region, often worsening with neck movements, and may be accompanied by reduced neck range of motion, neck tenderness, and sometimes arm pain 1. In contrast, tension headaches present as bilateral, pressing or tightening pain of mild to moderate intensity, often described as a "band-like" sensation around the head, not aggravated by routine physical activity, and rarely associated with symptoms like nausea or vomiting.

Key Characteristics

• Cervicogenic headaches:
  • Unilateral pain radiating from the neck to the frontotemporal region
  • Worsens with neck movements
  • Reduced neck range of motion
  • Neck tenderness
  • Sometimes arm pain
• Tension headaches:
  • Bilateral, pressing or tightening pain
  • Mild to moderate intensity
  • "Band-like" sensation around the head
  • Not aggravated by routine physical activity
  • Rarely associated with nausea or vomiting

Treatment Approaches

The treatment of cervicogenic headaches often involves physical therapy focusing on neck mobilization, postural correction, and strengthening exercises, sometimes combined with medications like NSAIDs (ibuprofen 400-600mg every 6-8 hours or naproxen 500mg twice daily), while tension headaches are primarily managed with NSAIDs, acetaminophen (500-1000mg every 4-6 hours), and stress reduction techniques. For cervicogenic headaches, nerve blocks or trigger point injections may be considered in resistant cases. Tension headaches may also benefit from preventive medications like amitriptyline (10-25mg nightly) for frequent episodes, as suggested by recent guidelines 1.

Diagnostic Considerations

Proper diagnosis is crucial as treatment approaches differ significantly based on the underlying cause of the headache. Imaging studies such as radiographs of the cervical spine, CT cervical spine without IV contrast, or facet injection/medial branch block cervical spine may be appropriate for the initial imaging of patients with cervicogenic headache and new or increasing nontraumatic cervical or neck pain and with no neurologic deficit 1. However, the use of MRI cervical spine without IV contrast in this patient population is controversial and may be considered on a case-by-case basis.

From the Research

Differences between Cervicogenic Headache and Tension Headache

• Cervicogenic headache is a type of headache that originates in the cervical spine, characterized by unilateral pain that starts in the neck and spreads to the ipsilateral oculo-fronto-temporal area 2, 3, 4.
• Tension headache, on the other hand, is a primary headache disorder that is often associated with concomitant neck pain, cervical spine sensitivity, and limited cervical range of motion 5.
• The key difference between the two is that cervicogenic headache is caused by a disorder in the neck, whereas tension headache is a primary headache disorder with a component of cervical involvement, but not caused by it 5.

Diagnostic Criteria

• Cervicogenic headache can be diagnosed based on the criteria established by the Cervicogenic Headache International Study Group, which includes a positive response to an appropriate nerve block 2.
• Tension headache is diagnosed based on the presence of concomitant neck pain, cervical spine sensitivity, forward head posture, limited cervical range of motion, and positive flexion-rotation test 5.

Treatment Options

• Cervicogenic headache can be treated with various therapies, including manual modalities, transcutaneous electrical nerve stimulation, local injection of anesthetic or corticosteroids, and invasive surgical therapies 2, 4, 6.
• Tension headache can be managed with physical therapies, including upper cervical spine mobilization or manipulation, soft tissue interventions, and exercises targeting the cervical spine 5.

Pathophysiology

• The pathophysiology of cervicogenic headache is thought to depend on the effects of various local pain-producing or eliciting factors, such as intervertebral dysfunction, cytokines, and nitric oxide 2.
• The pathophysiology of tension headache is not fully understood, but it is thought to involve a complex interplay of factors, including muscle tension, stress, and cervical musculoskeletal dysfunctions 5.