What is the recommended diagnostic work‑up and initial management for an adult patient with unilateral head pain that originates in the neck, worsens with neck movement or sustained posture, is reproduced by cervical palpation, and lacks migraine or tension‑type features, assuming no red‑flag signs?

Cervicogenic Headache: Diagnostic Work-up and Initial Management

Direct Answer

For an adult with unilateral head pain originating in the neck that worsens with neck movement and is reproduced by cervical palpation without red flags, the diagnosis is clinical and does not require imaging; initiate physical therapy with cervical spine mobilization and motor control exercises as first-line treatment. 1

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Diagnostic Approach

Clinical Diagnosis is Paramount

The diagnosis of cervicogenic headache is primarily clinical and should be made based on characteristic features without routine imaging 1. Key diagnostic criteria include:

• Unilateral fixed pain starting in the neck and extending to the ipsilateral oculo-fronto-temporal region 1, 2
• Pain provoked by cervical movements rather than posture, with reduced cervical range of motion and associated myofascial tenderness 3, 1
• Cervical spine tenderness on palpation, paraspinal and suboccipital muscle tenderness, and limitation of cervical motion 1, 4
• Pain with sustained awkward head positions that stresses cervical structures 4, 5

Critical Differential Diagnoses to Exclude

Before confirming cervicogenic headache, systematically exclude:

• Spontaneous intracranial hypotension: Headache absent or mild (1-3/10) on waking, onset within 2 hours of becoming upright, and >50% improvement within 2 hours of lying flat 3
• Postural tachycardia syndrome (PoTS): Heart rate increase >30 beats/minute during standing test 3, 1
• Orthostatic hypotension: Systolic blood pressure drop >20 mmHg and/or diastolic drop >10 mmHg on standing 3, 1
• Migraine: Pain provoked by movement rather than posture, with migrainous biology including aura and typical trajectory 3

Imaging is NOT Routinely Indicated

There is no evidence that medical imaging is diagnostic for cervicogenic headache 3, 1. Critical points:

• Degenerative changes do not correlate with symptoms: Studies show no difference in cervical disc bulges or degenerative disc disease between symptomatic and control patients 3
• High false-positive rate: Cervical spondylotic changes are present in 85% of asymptomatic individuals over 30 years 4
• CT and MRI are not first-line: In the absence of red flags or neurological symptoms, cross-sectional imaging is not appropriate 3

When to Image

Obtain MRI cervical spine without contrast only if:

• Symptoms persist beyond 6-8 weeks despite appropriate conservative management 4
• Red flags are present: constitutional symptoms, elevated inflammatory markers, history of malignancy, immunosuppression, IV drug use, intractable pain, progressive neurological deficits, or vertebral body tenderness 4

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Initial Management

First-Line Treatment: Physical Therapy

Physical therapy with cervical spine mobilization and motor control exercises is the primary recommended treatment 1. This approach is supported by:

• American College of Physicians recommendation for physical therapy as first-line treatment 1
• Large multicentre clinical trial evidence: A combined program of manual therapy and motor control exercises is effective with long-term maintained results 1, 6
• Focus on cervical-scapular strength and stability to minimize invasive interventions and maximize long-term therapeutic success 1

Specific Physical Therapy Components

• Cervical spine mobilization and manipulation 1, 6
• Motor control exercises targeting deep neck flexor function 6
• Progressive strength training for cervical and scapular muscles 1
• Aerobic exercise may provide additional benefit 1

Second-Line Options for Refractory Cases

If physical therapy fails after adequate trial (typically 6-8 weeks):

• Greater occipital nerve block: Effective for short-term treatment and serves both diagnostic and therapeutic purposes 1
• Percutaneous interventions: Facet joint injections or cervical epidural steroid injections offer diagnostic confirmation and therapeutic benefit 1

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Critical Pitfalls to Avoid

Diagnostic Pitfalls

• Do not rely on imaging findings alone: The presence of degenerative changes should be interpreted in light of expected age-related changes and correlated with clinical symptoms 3, 4
• Avoid provocative injections for diagnosis: Cervical provocative discography or anesthetic facet/nerve blocks have no evidence to support their use diagnostically, with frequent false-positives due to anesthetic leakage 3
• Do not miss spontaneous intracranial hypotension: This can present with neck pain and headache but has a distinct orthostatic pattern requiring different management 3

Treatment Pitfalls

• Do not delay physical therapy: This is the evidence-based first-line treatment, not a "last resort" after failed medications 1, 6
• Avoid over-reliance on medications: While NSAIDs and acetaminophen may provide symptomatic relief, they do not address the underlying cervical dysfunction 2

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Anatomical Basis

The pathophysiology involves convergence of nociceptive afferents from cervical spinal nerves C1-C3 with trigeminal afferents in the trigeminocervical nucleus in the upper cervical spinal cord 7, 8. This explains why:

• Pain from cervical structures (C1-C3 innervated) is referred to the head 7, 8
• Potential sources include atlantooccipital, atlantoaxial, and C2/C3 zygapophyseal joints, intervertebral discs, muscles, and ligaments 7, 8