Article Type : Research Article
Authors : Castejón OJ, Galindez P and Salones de Castejón M
Keywords : Cervicogenic headache; Mixed cervicogenic headache; Migraine; Headache
Clinical study of eleven
patients, ranging from 34 to 81 years-old, with cervicogenic headaches were
studied with intense headaches and the neck as a source of pain irradiated to
occipital and temporal regions and backwards, which exhibited NMR images of
cervical and lumbar spine pathology, osteoporosis, gallstones and colecystitis.
The following associated cardiovascular, neurological, neurobehavioral and
metabolic diseases comorbidities were found such as blood hypertension,
diabetes, obesity, hypothyroidism, partial epilepsy, tremor, familial stress,
memory and sleep disorders, and dizziness. We found in addition mixed
cervicogenic headache and migraine in 50% of cases studied. The headache and
the associated images of cervical pathology have been clinically interpreted as
cardinal signs of cervicogenic headache.
Hilton described the
concept of headaches originating from the cervical spine in 1860. In 1983
Sjaastad introduced the term "cervicogenic headache" (CGH).
Diagnostic criteria have been established by several expert groups, with
agreement that these headaches start in the neck or occipital region and are
associated with tenderness of cervical paraspinal tissues. Almost any pathology
affecting the cervical spine has been implicated in the genesis of CGH as a result
of convergence of sensory input from the cervical structures within the spinal
nucleus of the trigeminal nerve. The main differential diagnoses are tension
type headache and migraine headache. No specific pathology has been noted on
imaging or diagnostic studies which correlates with CGH. Further research will
help to clarify the theory, diagnosis, and treatment options for patients with
CGH [1].
Hülse and Seifert [2]
point out that it is discussed controversially whether cervicogenic pain in the
head and/or neck is a pathogenic entity. The good results obtained with manual
therapy in patients with head and neck pain contradict the refusal of the
majority of the neurologists to accept the diagnosis "cervicogenic
headache." Cervicogenic headache (CGH) is pain referred to the head from a
source in the cervical spine or mediated by cervical nerves. Clinical features
allow for no more than a diagnosis of probable cervicogenic headache.
Definitive diagnosis requires evidence of a cervical source of pain [3-5]. On
the contrary, Vincent considers that cervicogenic headache (CGH) is a
well-recognized syndrome [6]. Proposed diagnostic criteria differentiate CGH
from migraine and tension-type headache (TTH) in most of the cases. The best
differentiating factors include side-locked unilateral pain irradiating from
the back and evidence of neck involvement-attacks may be precipitated by
digital pressure over trigger spots in the cervical/nuchal areas or sustained
awkward neck positions. Migrainous traits may be present in some cases.
Frese and Evers conclude
that CGH is not just a migraine variant triggered by neck dysfunction but a
functional entity [7]. Becker postulate that it is clear that the cervical
region contains many pain-sensitive structures, and that these are prone to
injury [8]. The anatomical and physiological mechanisms are in place to allow
referral of pain to the head including frontal head regions and even the orbit
in patients with pain originating from many of these neck structu res. The
present study describes eleven patients with cervicogenic headaches (CGH) and
mixed cervicogenic headaches and migraine (CGHM), and pathological diseases of
cervical spine, and the associated neurological, neurobehavioral and
metabolical diseases in an attempt to get deeper insight into the
pathophysiology and pathogenesis of CGH.
Eleven patients ranging
from 34 to 81 years-old were studied at the Clinical Neuroscience Outpatient
Clinic of Clinical Neuroscience Institute. Maracaibo. Venezuela. San Rafael
Clinical Home and the Biological Research Institute. Faculty of Medicine, Zulia
University. Cervicogenic headaches and associated pathologies were diagnosed
according to the International Headache Society-IIIb criteria. The Helsinki
declaration principles for research in human being were adopted.
Case 1:
EO, 54 years old, F. Neck pain irradiated to occipital and temporal regions,
shoulders and backwards. Blood hypertension, hypothyroidism, dizziness,
Familial Stress, Degenerative disc disease of cervical and lumbar spine.
Diagnosis: Cervicogenic headache; Hypothyroidism and Blood
hypertension.
Case 2:
CB, 81 years old, F. Intense headache irradiated to neck and backwards. Blood
hypertension, Diabetes, Obesity, Cervical osteophytes and osteoporosis,
gallstones and cholecystitis.
Diagnosis: Cervicogenic headache; Blood hypertension; Diabetes; Obesity
Case 3:
MO, 34 years old. F. Intense headache irradiated to the neck, partial seizures
and crisis oculogiras, fine involuntary movements of right arm and limb, mood
changes. NMR images showed discal protusion of cervical spine cord at the level
of C3 and C4. Patient received anticonceptive treatment.
Diagnosis: Cervicogenic headache; Partial epilepsy and
involuntary movements
Case 4:
YP, 47 years old, F. Neck pain referred to head since five years ago.
Photophobia and scintillating scotoma, blurred vision, subcutaneous hematomas
in arms and legs. Dyslipidemia, polyuria, polydipsia. Normal blood pressure.
Diagnosis: Mixed Cervicogenic headache and migraine and
dyslipidemia
Case 5:
EB, 37 years old, F. Neck pain irradiated to head and shoulders inducing
holocraneal headache, left eye pain, blood hypertension, dizziness, sleep
apnoea, memory disorders, and vision disturbances,
Diagnosis: Mixed Cervicogenic
headache and migraine; Blood hypertension; Diabetes; Obesity
Case 6:
VL, 51 years-old, F. Intense neck pain and temporo-occiptal headache and
transitory loss of consciousness irradiated to right arm, dizziness, vertigo,
sonofobia. NMR images showed multisegmentary cervical osteopathy and
arthropathy with non-compressive posterior disc displacement.
Diagnosis: Mixed
Cervicogenic headache; Dizziness; Vertigo; Sonofobia; Cervical osteopathic and
arthropathy
Case 7:
JL, 54 years-old, F. Holocraneal headache and neck pain irradiated to head and
shoulders after motor vehicle accident (Whiplas injury). Hyperthyroidism,
tachycardia, depression by familial stress and conjugal separation, insomnia.
NMR images showed posterior protrusion of intervertebral disc at C5 and C6 with
compression of spinal cord.
Diagnosis: Cervicogenic headache and Posttraumatic headache;
Tension headache; hyperthyroidism and depression
Case 8:
MM, 44 years-old, F. Chronic cervicogenic headache since eight years, blood
hypertension and hypertensive crisis, memory disorders, depression,
dyslipidemia. Cervical RMN images showed cervical degenerative discopathy
without disc protrusions. Lumbar RNM images depicted chronic radicular motor
lesions
Diagnosis: Chronic
cervicogenic headache; High blood pressure; Memory disorders; depression; dyslipidemia.
Case 9:
MO, 34 years-old. Intense daily headache and cervical pain, partial epilepsy,
depression, tremor in right hand and leg, cold sweat, mood changes, sleep
disorders. NMR images showed prominent disc protrusion at C3-C4 levels.
Prominent magna cistern and right rotation of dorsal vertebral column.
Diagnosis: Cervicogenic headaches; Partial epilepsy; Depression,
Tremor in right hand and leg interpreted as parkynsonism
Case 10:
EO, 54 years-old, F. Holocraneal headache irradiated to the facial region and
shoulders, neck pain, dizziness, hypothyroidism, high blood pressure,
tachycardia. NMR images showed degenerative discopathy of cervical, dorsal and
lumbar vertebral column.
Diagnosis: Mixed cervicogenic headache; hypothyroidism;
dizziness and high blood pressure.
Case 11:
MN, 56 years old, F. Intense headache and neck pain, high blood pressure,
diabetes, Fat liver, Gall lithiasis and colecistitis. NMR images showed curvature
of cervical spine, osteophytes and osteoporosis.
Diagnosis: Cervicogenic headache; Diabetes; Liver and gall
bladder pathology and curvature of cervical spine; osteophites and osteoporosis
The above clinical study
showed patients, ranging from 34 to 81 years old, with intense headaches and
the neck as a source of intense pain irradiated to occipital and temporal
regions and backwards and NMR images of cervical and lumbar pathology,
osteoporosis, gallstones and colecystitis. The following associated
comorbidities were found including neurological, neurobehavioral and metabolic
diseases such as blood hypertension, diabetes, obesity, hypothyroidism, partial
epilepsy, tremor, familial stress, memory and sleep disorders, dizzines. We
found in addition mixed cervicogenic headache and migraine. The associated
images of cervical pathology have been clinically interpreted as cardinal signs
of cervicogenic headache.
In the present paper we
have studied eleven adult and aging patients, ranging from 34 to 81 years old
with cervicogenic headache. There is an opinion that with increasing cervical
degenerative joint disease with ageing, cervicogenic headaches become more
frequent. In addition to cervicogenic headache, musculoskeletal dysfunction was
also found in headaches classifiable as migraine or tension-type headache [9].
Cervicogenic headache
(CEH) originates from disorders of the neck but is recognized as a referred
pain in the head. Primary sensory afferents from the cervical roots C1-C3
converge with afferents from the occiput and trigeminal afferents on the same
second-order neuron in the upper cervical spine. Consequently, the anatomical
structures innervated by the cervical roots C1-C3 are potential sources of CGH.
CGH can origin from different muscles and ligaments of the neck, from
intervertebral discs, and, particularly, from the atlanto-occipital,
atlantoaxial, and C2/C3 zygapophyseal joints. In addition, the vertebral and
internal carotid arteries, and the dura mater of the upper spinal cord and
posterior cranial fossa might participate. Cervicogenic headache is defined as
headaches originating from cervical spine structures including cervical facet
joints, cervical intervertebral discs, skeletal muscles, connective tissues,
and neurovascular structures. According to this hypothesis, functional
convergence of the upper cervical and trigeminal sensory pathways allows the
bidirectional (afferent and efferent) referral of pain to the occipital,
frontal, temporal, and/or orbital regions [3-5, 7,10-13]. According to Gasik, [14]
the pain may spread to the neck, occipital area of skull, area of jaw and
eyeballs, and arms. There are many theories trying to explain spreading of the
pain outside the area innervated by C1, C2 and C3 cervical roots. Their common
denominator is communication between fibres running in those roots and neurons
of trigeminal nerve. Many authors describe a possibility of such connection
through the jelly-like nucleus of the trigeminal nerve located in the back
funiculi of spinal cord. In this mechanism, the pain conducted via occipital
nerves may affect activity of neurons of the trigeminal nerve and influence
areas innervated by the trigeminal nerve. According to some authors, the
necessary condition to make a diagnosis of cervicogenic headache is finding the
changes of spondylosis nature of the cervical spine section in additional
examinations
According to Baron et al.
[15], cervicogenic headache frequently coexists with complaints of dizziness,
tinnitus, nausea, imbalance, hearing complaints, and ear/eye pain. Controversy
exists as to whether this constellation of symptoms may be cervically mediated.
A wider spectrum of cervically mediated symptoms may exist by influence of
trigeminocervical and vestibular circuitry through cervical afferent
neuromodulation.
Iskra et al. [16]
postulate a manual differential diagnosis between cervicogenic headaches and
migraine. According to these Authors the analysis of literature suggests that
manipulative effects on neck structures in cases of migraine can reduce the
intensity and the duration of pain, and the frequency of attacks by no more
than 20%, and the therapeutic effectiveness of manual therapy for CGH is much
higher.
The patients with
cervicogenic headache often had bilateral pain. The regions mainly concentrated
in the temporal region, with occipital, head or orbit pains [17].
A notable portion of
patients with cervicogenic headache can have an atypical presentation mimicking
a primary type headache. However, cervicogenic headaches with atypical
presentation can be difficult to diagnose and manage at the initial visit of
the patients. Etiopathophysiology of this type of headache could be explained
by the theories including discogenic, convergence and sensitization-desensitization
theories [12].
Avigan et al. [18] made a
systematic review evidencing the heterogeneity in the clinical characteristics
used to diagnose CGH in participants recruited in randomized controlled trials
and how well the diagnostic criteria used align with the most recent edition
(3rd) of the International Classification of Headache Disorders
According to Jull et al. [19],
restricted movement, in association with palpable upper cervical joint
dysfunction and impairment in the cranio-cervical flexion test (CCFT), had 100%
sensitivity and 94% specificity to identify cervicogenic headache.
Musculoskeletal disorders are considered the underlying cause of cervicogenic
headache, but neck pain is commonly associated with migraine and tension-type
headaches.
The cervical region
contains many pain-sensitive structures, and that these are prone to injury.
The anatomical and physiological mechanisms are in place to allow referral of
pain to the head including frontal head regions and even the orbit in patients
with pain originating from many of these neck structures. Clinical studies have
shown that pain from cervical spine structures can in fact be referred to the
head. Finally, clinical treatment trials involving patients with proven painful
disorders of upper cervical zygapophysial joints have shown significant
headache relief with treatment directed at cervical pain generators. In
conclusion, painful disorders of the neck can give rise to headache, and the
challenge is to identify these patients and treat them successfully [8].
Postmortem studies show
that a spectrum of injuries can befall the zygapophysial joints in motor
vehicle accidents. Biomechanics studies of normal volunteers and of cadavers
reveal the mechanisms by which such injuries can be sustained. Studies in
cadavers and in laboratory animals have produced these injuries. Clinical
studies have shown that zygapophysial joint pain is very common among patients
with chronic neck pain after whiplash, and that this pain can be successfully
eliminated by radiofrequency neurotomy [20].
Cervicogenic headache
(CEH) affects 22-25% of the adult population with females being four times more
affected than men. CEHs are thought to arise from musculoskeletal impairments
in the neck with symptoms most commonly consisting of suboccipital neck pain,
dizziness, and lightheadedness [21].
Cervicogenic headache
and dizziness
We have reported
dizziness in five patients (50%). Cervicogenic dizziness (CGD) is hard to
diagnose as there is no objective test [22]. Cervicogenic cephalic syndrome
(CCS) comprises a group of diseases, consists of cervicogenic headache and
dizziness [23].
Cervicogenic headache
and blood hypertension
In the present study we
have found blood hypertension in five patients with CGH (50%). According to
Vincent [6], CGH may depend in addition on a central predisposition
counterpart, leading to the activation of the trigeminovascular system and pain
generation
Cervicogenic diseases
and metabolic diseases
Metabolic diseases such
hypothyroidism, diabetes and obesity were found in the patients examined, which
con be considered precipitating risk factors in the elderly population. We have
not found previous reported on cervicogenic headaches and interactions with
these metabolic entities.
According to La Grew et
al. [24], those diagnosed with cervicogenic headache were more likely to be
female (P = 0.041), report a higher maximum pain level on presentation (P =
0.015), have a diagnosis of diabetes prior to presentation (P = 0.011), The
lack of data on some of the patients who presented with headache may have led
to underdiagnosis of the true incidence of cervicogenic headache. Future work
should look to re-examine the incidence of CGH in a larger cohort to validate
the findings here and further define risk factors for post-procedural CGH.
Cervicogenic diseases
and vertigo
We have found vertigo in
one patient with cervicogenic headache. Thompson-Harvey and Hain [25] identify
patient features distinguishing cervical vertigo from vestibular causes of vertigo
and vestibular migraine. Cervical vertigo subjects may resemble migraine
subjects who also have evidence of neck injury. These observations indicates
that cervicogenic headache with vertigo should be differentiated from
vestibular vertigo and vestibular migraine.
Pollak and Pollak, [26]
postulate that headache is also frequent in benign paroxysmal positional
vertigo (BPPV). The most common is tension-type headache, followed by migraine
and cervicogenic headache. Head pain seems to be an independently associated
epiphenomenon of BPPV that can worsen patients' distress.
Mixed cervicogenic
headache and migraine
The presence of
photophobia, sonophobia, scintillating scotoma, blurred vision, dizziness,
vomits were interpreted as symptoms related to migrainous traits [6] present in
the patients examined of mixed cervigogenic headache and migraine.
Cervicogenic headache
and neurobehavioral disorders
We have reported
depression in three cases with CGH and in one case with stress-related disorder
(27%). Presumably one consequence of these associations is the hypothesis that
estrogens have a role in the pathophysiology of both disorders, as have been
postulated by Peterlin et al. [27] between migraine and depression. Until now,
the studies into the possible mechanisms underlying these associations remains
limited as concluded in previous several studies, which means that the
cervigogenic headache has migrainous trait. Prospective epidemiological studies
suggest a common genetic, biochemical or environmental background behind
primary headaches and depression. This theory is supported by the role of the
same neurotransmitter systems (mostly serotonin and dopamine) in headaches as
well as in depression [28], Pain, anxiety and depression also are comorbidities
in migraine [29-31]. Furthermore, it is a common belief that in migraine
without aura, neck symptoms frequently occur and that dizziness and CGH may
pathogenetically be intimately related [32].
Cervicogenic headache
affects a significant portion of the entire population. This type of headache
especially with atypical presentation is often hard to diagnose and manage
since its etiopathophysiology is not been yet well understood. Bir et al., [12]
have investigated the prevalence of cervicogenic headache with atypical
presentation and discussed the etiology of it, and the outcome of surgical
intervention on this type of headache in patients with cervical degenerative
disease
Cervicogenic headache
and Whiplash injury
We have observed a
patient with whiplash injury after a car accident. This variety of cervicogenic
headache has been earlier studied by Drottning et al. [33], who clarify the
long-term natural course of cervicogenic headache (CGH) after whiplash injury.
We have observed patients with intense headaches and the neck as a
source of pain irradiated to occipital and temporal regions and backwards
correlated with NMR images of cervical spine pathology. The following
associated cardiovascular, neurological, neurobehavioral and metabolic diseases
comorbidities were found such as blood hypertension, diabetes, obesity,
hypothyroidism, partial epilepsy, tremor, familial stress, memory and sleep
disorders, and dizziness. We found in addition mixed cervicogenic headache and
migraine in 36% of cases studied. The headache and the associated images of
cervical pathology has been clinically interpreted as cardinal signs of
cervicogenic headache.
This paper has being carried pot with a subvention obtained from
Castejon Foundation, and the Biological Research Institute, Faculty of
Medicine, Zulia University. Maracaibo. Venezuela.