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To diagnose a cervicogenic headache, perform a thorough physical examination focusing on the head and neck, assess the patient's headache history, and consider diagnostic imaging and nerve blocks if necessary.
Cervicogenic headache often presents as unilateral or bilateral headache associated with neck movement and reduced neck mobility; diagnosis is supported if the headache responds to treatments targeting the cervical spine.[1]
Physical examination should include checking for tenderness in the cervical paraspinal and trapezius muscles, which is indicative of cervicogenic headache.[1]
MRI of the cervical spine without contrast should be considered if cervicogenic headache is suspected, especially to rule out other causes.[1]
Diagnostic nerve blocks, such as occipital nerve blocks, can be both diagnostic and therapeutic for cervicogenic headache.[1]
The cervical flexion-rotation test (CFRT) has shown moderate diagnostic accuracy in differentiating cervicogenic headache from other types of headache.[2]
Additional info
When diagnosing cervicogenic headache, it's crucial to differentiate it from other headache types such as migraines or tension-type headaches, which can present with overlapping symptoms. The response to specific treatments targeting the cervical spine can be a key indicator in confirming the diagnosis. Imaging studies like MRI are particularly useful when the clinical presentation is ambiguous or when there is a lack of response to initial conservative treatments. Additionally, nerve blocks can provide both diagnostic clarity and symptomatic relief, which is particularly useful in a clinical setting where immediate patient response can guide further management strategies. The use of the cervical flexion-rotation test can further aid in the diagnosis by providing a specific physical examination tool with a good balance of sensitivity and specificity.
References
Reference 1
1.
Elsevier ClinicalKey Clinical Overview
Diagnosis
Cervicogenic headache presents as a unilateral or bilateral headache, is associated with reduced range of motion of the neck, and is exacerbated by neck movement. Response to treatments targeting the primary cervical spine disease helps confirm the diagnosis
Giant cell arteritis is a systemic vasculitis that commonly involves cranial arteries. New-onset progressive headache with jaw claudication and a history of polymyalgia rheumatica should raise suspicion for arteritis. Elevated erythrocyte sedimentation rate and inflammation of the arterial wall on the temporal artery biopsy are the tests used to confirm the diagnosis
Workup
Vital signs can show evidence for infectious etiology and hypertension. Obesity or notable weight gain should prompt the consideration of idiopathic intracranial hypertension
Perform a thorough examination of the head and neck areas, noting tenderness in response to pressure along the temporal arteries (giant cell arteritis) and occipital nerves (occipital neuralgia). Check cervical paraspinal and trapezius muscles for focal tenderness (cervicogenic headache)
Evaluate meningeal signs
Kernig sign: while in a supine position, hip and knee are flexed to 90° and knee is slowly extended. The appearance of resistance or pain during extension of the patient’s knees beyond 135° constitutes a positive Kernig sign
Brudzinski sign: with 1 hand behind the patient’s head and the other on chest, passively flexing the neck causes reflex flexion of the patient’s hips and knees. This constitutes a positive Brudzinski sign
The fundoscopic examination is a very important part of the examination for evaluation of headache disorders
Signs of papilledema may signal high intracranial pressure.
Spontaneous venous pulsations confirm the absence of high intracranial pressure
Conduct a neurologic examination, including cranial nerve, motor reflexes, and sensory and cerebellar examinations
Workup
Side locked headache, trigeminal autonomic cephalalgias, hypnic headache, and new daily persistent headache (especially in older adults) should be evaluated with MRI of the brain with and without contrast. For trigeminal autonomic cephalalgias, vascular imaging (either magnetic resonance angiography of head and neck or CT angiography) should be added to the workup
In patients presenting with early morning headaches resolving in less than 4 hours, sleep apnea might be the underlying cause, so a sleep study should be added to the workup
MRI of the cervical spine without contrast is added to the imaging when cervicogenic headache is suspected
Treatment
Procedures for chronic headache syndromes include:
OnabotulinumtoxinA injections
Occipital nerve blocks
Trigger point injections
Sphenopalatine ganglion block
OnabotulinumtoxinA injections are approved by the FDA for chronic migraine and have effectively been used for intractable chronic migraine
Occipital nerve blocks and trigger point injections can help for the diagnosis and the treatment of cervicogenic headache. If the level of cervical spine disease is moderate to severe or pain does not respond to occipital nerve blocks and trigger point injections, then a pain management specialist, orthopedic physician, and neurosurgeon should be consulted
Reference 2
2.
Demont A, Lafrance S, Benaissa L, Mawet J. Cervicogenic Headache, an Easy Diagnosis? A Systematic Review and Meta-Analysis of Diagnostic Studies. Musculoskeletal Science & Practice. 2022;62:102640. doi:10.1016/j.msksp.2022.102640.
Publish date: December 4, 2022.
BACKGROUND: The diagnosis of cervicogenic headache (CGH) remains a challenge for clinicians as the diagnostic value of detailed history and clinical findings remains unclear. OBJECTIVES: To update and evaluate available evidence of the prevalence and the diagnostic accuracy of the detailed history and clinical findings for CGH in adults with headache. DESIGN: Systematic review with meta-analysis. METHODS: CINAHL, Cochrane Central, Embase, PEDro and PubMed were searched for studies before March 2022 that reported detailed history and/or clinical findings related to the diagnosis of cervicogenic headache. Study selection, risk of bias assessment (QUADAS-2 and PROBAST), and data extraction were performed. Meta-analyses for the cervical flexion-rotation test (CFRT) was performed. Certainty of the evidence was assessed with the GRADE approach. RESULTS: Eleven studies were included. Moderate certainty evidence indicated that the CFRT differentiated CGH from lower cervical facet-induced headache, migraine, concomitant headaches or asymptomatic subjects (Se 83.0% [95%CI:70.0%-92.0%]; Sp 83.0% [95%CI:71.0%-91.0%]; positive LR 5.0 [95%CI:2.6-9.5]; negative LR 0.2 [95%CI:0.1-0.4]; n = 4 studies; n = 182 participants). Several diagnostic classifications and test clusters based on headache history and clinical findings can be useful, despite uncertain accuracy, in formulating the diagnosis of CGH. CONCLUSION: Evidence support to undertake an evaluation of headache history and signs and symptoms and a physical examination of the patient neck to diagnose CGH.
