What examination should be performed in a 45-year-old woman with unilateral left occipital head‑neck pain suggestive of cervicogenic headache or occipital neuralgia?

Clinical Examination for Cervicogenic Headache

The examination for cervicogenic headache should focus on identifying cervical movement-provoked pain, reduced neck range of motion with myofascial tenderness, and excluding critical red-flag conditions—routine imaging is not indicated unless red flags are present or symptoms persist beyond 6-8 weeks. 1

Essential Physical Examination Components

Cervical Spine Assessment

• Palpate for cervical spine tenderness, particularly at the upper cervical segments (C2-C7), paraspinal muscles, and suboccipital region 1, 2
• Assess cervical range of motion in all planes (flexion, extension, rotation, lateral bending) and document any limitation or pain provocation 1, 3
• Provoke pain through neck movements and sustained awkward head positions to reproduce the headache 1, 2
• Apply external pressure to hypersensitive occipital tendon insertions to identify mechanical precipitation of symptoms 4

Pain Pattern Documentation

• Confirm unilateral pain distribution starting posteriorly in the neck/occiput and radiating to the ipsilateral oculo-fronto-temporal area 1, 2
• Assess for ipsilateral arm discomfort, which commonly accompanies cervicogenic headache 4
• Document pain quality (typically dull or piercing, lasting hours to days) 5

Critical Red-Flag Screening

You must actively exclude these conditions before attributing symptoms to cervicogenic headache:

Vascular and Intracranial Emergencies

• Screen for thunderclap headache onset suggesting subarachnoid hemorrhage 1
• Assess for visual disturbances, weakness, or speech deficits that would indicate stroke or intracranial mass 1

Orthostatic and Autonomic Disorders

• Perform standing test: measure heart rate increase >30 beats/minute for postural tachycardia syndrome 1
• Check orthostatic vital signs: systolic drop >20 mmHg or diastolic drop >10 mmHg indicates orthostatic hypotension 1
• Assess positional headache pattern: >50% improvement within 2 hours of lying flat suggests spontaneous intracranial hypotension 1

Infection, Malignancy, and Inflammatory Disease

• Palpate for vertebral body tenderness indicating possible metastatic disease or infection 6
• Screen for constitutional symptoms (fever, weight loss, night sweats) 6
• Document history of malignancy, immunosuppression, or IV drug use 6
• Assess for progressive neurological deficits or myelopathic signs requiring urgent spinal cord evaluation 6

Diagnostic Confirmation Maneuvers

Occipital Nerve Assessment

• Palpate greater and lesser occipital nerve distributions for tenderness or paroxysmal lancinating pain, which may indicate occipital neuralgia rather than pure cervicogenic headache 3, 7
• Distinguish between continuous dull pain (more typical of cervicogenic headache) versus paroxysmal sharp pain (more typical of occipital neuralgia) 3, 7

Facet Joint Evaluation

• Apply pressure over cervical facet joints (C2-C7 levels) to reproduce pain, as facet dysfunction is a common mechanical source 6, 8

When Imaging Is Indicated

Imaging is NOT diagnostic for cervicogenic headache and should not be routine. 1

Appropriate Imaging Scenarios

• MRI cervical spine without contrast is reserved for symptoms persisting beyond 6-8 weeks despite conservative therapy 1, 6
• Immediate MRI cervical spine without contrast when any red-flag features are present (constitutional symptoms, elevated inflammatory markers, known malignancy, immunosuppression, IV drug use, intractable pain, progressive neurological deficits, vertebral body tenderness) 6
• Non-contrast head CT immediately for thunderclap headache suggesting subarachnoid hemorrhage 1

Why Routine Imaging Is Not Helpful

• Degenerative cervical changes are present in 85% of asymptomatic individuals over 30 years and correlate poorly with symptoms 1, 6
• Cervical disc bulges and degenerative disease do not differ between symptomatic cervicogenic headache patients and asymptomatic controls 9, 1
• CT and MRI are not recommended as first-line tests in the absence of red flags or neurological symptoms 9

Common Diagnostic Pitfalls

• Do not rely on imaging findings alone to diagnose cervicogenic headache—age-related degenerative changes are ubiquitous and must be interpreted in clinical context 1, 6
• Avoid provocative cervical injections for diagnosis, as they frequently produce false-positive results due to anesthetic leakage 1
• Do not miss spontaneous intracranial hypotension, which presents with distinct orthostatic improvement and can mimic cervicogenic headache 1
• Recognize that occipital nerve blocks can be effective in migraine, leading to false-positive diagnostic confirmation if used to "prove" cervicogenic headache 7

Confirmatory Testing (When Diagnosis Remains Uncertain)

• Anesthetic blockade of affected cervical structures (facet joints, occipital nerves) that eliminates frontal pain confirms cervical origin, though this should be interpreted cautiously given false-positive rates 2, 3
• Consider laboratory evaluation (ESR, CRP, WBC) if inflammatory or infectious etiology is suspected based on red-flag screening 6