Cervicogenic Headache

  • Adam NasseryEmail author
  • Nathaniel M. Schuster


Accurate diagnosis and appropriate treatment of cervicogenic headache is pertinent to many medical specialties including pain medicine and neurology. The diagnosis may be challenging given shared characteristics with other headache disorders such as migraine and occipital neuralgia. When confronted with a patient who suffers cervicogenic headache, the heterogeneity of available treatments can be perplexing to any provider. This chapter outlines how to initially approach a patient with headache, parsing a primary from secondary headache disorder given the absence or presence of alarming signs or symptoms. The epidemiology and pathophysiology of cervicogenic headache are then reviewed along with available treatments subject to scrutiny in the literature. Interventional and noninterventional treatment modalities including pharmacotherapy, nerve blockade, botulinum toxin treatment, radiofrequency ablation, and neuromodulation will be appraised based on the level of available evidence. Other overlapping pain syndromes such as myofascial pain and occipital neuralgia will also be discussed in an effort to demystify this phenomenon whose estimated annual prevalence is 4.1%.


Cervicogenic headache Myofascial pain Occipital neuralgia Migraine Cervicalgia Whiplash Nerve blockade Trigger point injection Medial branch blockade Radiofrequency ablation Neuromodulation 


  1. 1.
    Solomon S, Lipton RB. The basics of headache classification and diagnosis. In: Robbins MS, Grosberg BM, Lipton RB, editors. Headache. Oxford: John Wiley & Sons; 2013.Google Scholar
  2. 2.
    Grosberg BM, Friedman BW, Solomon S. Approach to the patient with headache. In: Robbins MS, Grosberg BM, Lipton RB, editors. Headache. Oxford: John Wiley & Sons; 2013.Google Scholar
  3. 3.
    Arnold M. Headache classification committee of the international headache society (IHS) the international classification of headache disorders, 3rd edition. Cephalalgia. 2018;38(1):1–211.Google Scholar
  4. 4.
    Dodick DW. Diagnosing headache: clinical clues and clinical rules. Adv Stud Med. 2003;3(2):87–92.Google Scholar
  5. 5.
    Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. The Cervicogenic Headache International Study Group. Headache. 1998;38(6):442–5.PubMedGoogle Scholar
  6. 6.
    Sjaastad O, Bakketeig LS. Prevalence of cervicogenic headache: Vaga study of headache epidemiology. Acta Neurol Scand. 2008;117(3):173–80.PubMedGoogle Scholar
  7. 7.
    Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Stewart WF. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68(5):343–9.PubMedGoogle Scholar
  8. 8.
    Shimohata K, Hasegawa K, Onodera O, Nishizawa M, Shimohata T. The clinical features, risk factors, and surgical treatment of cervicogenic headache in patients with cervical spine disorders requiring surgery. Headache. 2017;57(7):1109–17.PubMedGoogle Scholar
  9. 9.
    Lord SM, Barnsley L, Wallis BJ, Bogduk N. Third occipital nerve headache: a prevalence study. J Neurol Neurosurg Psychiatry. 1994;57(10):1187–90.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Bartsch T, Goadsby PJ. Increased responses in trigeminocervical nociceptive neurons to cervical input after stimulation of the dura mater. Brain. 2003;126(Pt 8):1801–13.PubMedGoogle Scholar
  11. 11.
    Calhoun AH, Ford S, Millen C, Finkel AG, Truong Y, Nie Y. The prevalence of neck pain in migraine. Headache. 2010;50(8):1273–7.PubMedGoogle Scholar
  12. 12.
    Bigal ME, Ashina S, Burstein R, Reed ML, Buse D, Serrano D, et al. Prevalence and characteristics of allodynia in headache sufferers: a population study. Neurology. 2008;70(17):1525–33.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Holle D, Diener HC. Acute treatments for migraine. In: Robbins MS, Grosberg BM, Lipton RB, editors. Headache. Oxford: John Wiley & Sons; 2013.Google Scholar
  14. 14.
    Young WB. Preventive treatments for migraine. In: Robbins MS, Grosberg BM, Lipton RB, editors. Headache. Oxford: John Wiley & Sons; 2013.Google Scholar
  15. 15.
    Crystal SC, Henry KA. Treatment of tension-type headache. In: Robbins MS, Grosberg BM, Lipton RB, editors. Headache. Oxford: John Wiley & Sons; 2013.Google Scholar
  16. 16.
    Haldeman S, Dagenais S. Cervicogenic headaches: a critical review. Spine J. 2001;1(1):31–46.PubMedGoogle Scholar
  17. 17.
    Fernandez-de-las-Penas C, Cuadrado ML. Therapeutic options for cervicogenic headache. Expert Rev Neurother. 2014;14(1):39–49.PubMedGoogle Scholar
  18. 18.
    Gross A, Kay TM, Paquin JP, Blanchette S, Lalonde P, Christie T, et al. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2015;1:Cd004250.PubMedGoogle Scholar
  19. 19.
    Wheeler AH. Myofascial pain disorders: theory to therapy. Drugs. 2004;64(1):45–62.PubMedGoogle Scholar
  20. 20.
    Wheeler AH, Aaron GW. Muscle pain due to injury. Curr Pain Headache Rep. 2001;5(5):441–6.PubMedGoogle Scholar
  21. 21.
    Scott NA, Guo B, Barton PM, Gerwin RD. Trigger point injections for chronic non-malignant musculoskeletal pain: a systematic review. Pain Med. 2009;10(1):54–69.PubMedGoogle Scholar
  22. 22.
    Robbins MS, Kuruvilla D, Blumenfeld A, Charleston LT, Sorrell M, Robertson CE, et al. Trigger point injections for headache disorders: expert consensus methodology and narrative review. Headache. 2014;54(9):1441–59.PubMedGoogle Scholar
  23. 23.
    Fernandez-de-Las-Penas C, Simons D, Cuadrado ML, Pareja J. The role of myofascial trigger points in musculoskeletal pain syndromes of the head and neck. Curr Pain Headache Rep. 2007;11(5):365–72.PubMedGoogle Scholar
  24. 24.
    France S, Bown J, Nowosilskyj M, Mott M, Rand S, Walters J. Evidence for the use of dry needling and physiotherapy in the management of cervicogenic or tension-type headache: a systematic review. Cephalalgia. 2014;34(12):994–1003.PubMedGoogle Scholar
  25. 25.
    Nicol AL, Wu II, Ferrante FM. Botulinum toxin type a injections for cervical and shoulder girdle myofascial pain using an enriched protocol design. Anesth Analg. 2014;118(6):1326–35.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Hascalovici JR, Robbins MS. Peripheral nerve blocks for the treatment of headache in older adults: a retrospective study. Headache. 2017;57(1):80–6.PubMedGoogle Scholar
  27. 27.
    Dougherty C. Occipital neuralgia. Curr Pain Headache Rep. 2014;18(5):411.PubMedGoogle Scholar
  28. 28.
    Caputi CA, Firetto V. Therapeutic blockade of greater occipital and supraorbital nerves in migraine patients. Headache. 1997;37(3):174–9.PubMedGoogle Scholar
  29. 29.
    Gawel MJ, Rothbart PJ. Occipital nerve block in the management of headache and cervical pain. Cephalalgia. 1992;12(1):9–13.PubMedGoogle Scholar
  30. 30.
    Bovim G, Sand T. Cervicogenic headache, migraine without aura and tension-type headache. Diagnostic blockade of greater occipital and supra-orbital nerves. Pain. 1992;51(1):43–8.PubMedGoogle Scholar
  31. 31.
    Ashkenazi A, Young WB. The effects of greater occipital nerve block and trigger point injection on brush allodynia and pain in migraine. Headache. 2005;45(4):350–4.PubMedGoogle Scholar
  32. 32.
    Afridi SK, Shields KG, Bhola R, Goadsby PJ. Greater occipital nerve injection in primary headache syndromes--prolonged effects from a single injection. Pain. 2006;122(1–2):126–9.PubMedGoogle Scholar
  33. 33.
    Busch V, Jakob W, Juergens T, Schulte-Mattler W, Kaube H, May A. Occipital nerve blockade in chronic cluster headache patients and functional connectivity between trigeminal and occipital nerves. Cephalalgia. 2007;27(11):1206–14.PubMedGoogle Scholar
  34. 34.
    Bigo A, Delrieu F, Bousser MG. Treatment of vascular pain of the face by methylprednisolone injection into the area of the greater occipital nerve: 16 cases. Rev Neurol. 1989;145(2):160–2.PubMedGoogle Scholar
  35. 35.
    Peres MF, Stiles MA, Siow HC, Rozen TD, Young WB, Silberstein SD. Greater occipital nerve blockade for cluster headache. Cephalalgia. 2002;22(7):520–2.PubMedGoogle Scholar
  36. 36.
    Ambrosini A, Vandenheede M, Rossi P, Aloj F, Sauli E, Pierelli F, et al. Suboccipital injection with a mixture of rapid- and long-acting steroids in cluster headache: a double-blind placebo-controlled study. Pain. 2005;118(1–2):92–6.PubMedGoogle Scholar
  37. 37.
    Ashkenazi A, Matro R, Shaw JW, Abbas MA, Silberstein SD. Greater occipital nerve block using local anaesthetics alone or with triamcinolone for transformed migraine: a randomised comparative study. J Neurol Neurosurg Psychiatry. 2008;79(4):415–7.PubMedGoogle Scholar
  38. 38.
    Saadah HA, Taylor FB. Sustained headache syndrome associated with tender occipital nerve zones. Headache. 1987;27(4):201–5.PubMedGoogle Scholar
  39. 39.
    Vincent MB, Luna RA, Scandiuzzi D, Novis SA. Greater occipital nerve blockade in cervicogenic headache. Arq Neuropsiquiatr. 1998;56(4):720–5.PubMedGoogle Scholar
  40. 40.
    Inan N, Ceyhan A, Inan L, Kavaklioglu O, Alptekin A, Unal N. C2/C3 nerve blocks and greater occipital nerve block in cervicogenic headache treatment. Funct Neurol. 2001;16(3):239–43.PubMedGoogle Scholar
  41. 41.
    Naja ZM, El-Rajab M, Al-Tannir MA, Ziade FM, Tawfik OM. Repetitive occipital nerve blockade for cervicogenic headache: expanded case report of 47 adults. Pain Pract. 2006;6(4):278–84.PubMedGoogle Scholar
  42. 42.
    Naja ZM, El-Rajab M, Al-Tannir MA, Ziade FM, Tawfik OM. Occipital nerve blockade for cervicogenic headache: a double-blind randomized controlled clinical trial. Pain Pract. 2006;6(2):89–95.PubMedGoogle Scholar
  43. 43.
    Anthony M. Cervicogenic headache: prevalence and response to local steroid therapy. Clin Exp Rheumatol. 2000;18(2 Suppl 19):S59–64.PubMedGoogle Scholar
  44. 44.
    Ashkenazi A, Blumenfeld A, Napchan U, Narouze S, Grosberg B, Nett R, et al. Peripheral nerve blocks and trigger point injections in headache management – a systematic review and suggestions for future research. Headache. 2010;50(6):943–52.PubMedGoogle Scholar
  45. 45.
    Cuadrado ML, Aledo-Serrano A, Navarro P, Lopez-Ruiz P, Fernandez-de-Las-Penas C, Gonzalez-Suarez I, et al. Short-term effects of greater occipital nerve blocks in chronic migraine: a double-blind, randomised, placebo-controlled clinical trial. Cephalalgia. 2017;37(9):864–72.PubMedGoogle Scholar
  46. 46.
    Gul HL, Ozon AO, Karadas O, Koc G, Inan LE. The efficacy of greater occipital nerve blockade in chronic migraine: a placebo-controlled study. Acta Neurol Scand. 2017;136(2):138–44.PubMedGoogle Scholar
  47. 47.
    Leroux E, Valade D, Taifas I, Vicaut E, Chagnon M, Roos C, et al. Suboccipital steroid injections for transitional treatment of patients with more than two cluster headache attacks per day: a randomised, double-blind, placebo-controlled trial. Lancet Neurol. 2011;10(10):891–7.PubMedGoogle Scholar
  48. 48.
    Cohen SP, Peterlin BL, Fulton L, Neely ET, Kurihara C, Gupta A, et al. Randomized, double-blind, comparative-effectiveness study comparing pulsed radiofrequency to steroid injections for occipital neuralgia or migraine with occipital nerve tenderness. Pain. 2015;156(12):2585–94.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Cohen SP, Huang JH, Brummett C. Facet joint pain--advances in patient selection and treatment. Nat Rev Rheumatol. 2013;9(2):101–16.PubMedPubMedCentralGoogle Scholar
  50. 50.
    van Eerd M, Patijn J, Lataster A, Rosenquist RW, van Kleef M, Mekhail N, et al. 5. Cervical facet pain. Pain Pract. 2010;10(2):113–23.PubMedGoogle Scholar
  51. 51.
    Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Med. 2007;8(4):344–53.PubMedGoogle Scholar
  52. 52.
    Lord SM, Barnsley L, Wallis BJ, Bogduk N. Chronic cervical zygapophysial joint pain after whiplash. A placebo-controlled prevalence study. Spine. 1996;21(15):1737–44; discussion 44-5.PubMedGoogle Scholar
  53. 53.
    Centeno C, Williams CJ, Markle J, Dodson E. A new Atlanto-occipital (C0-C1) joint injection technique. Pain Med. 2017; [Epub ahead of print].Google Scholar
  54. 54.
    Datta S, Manchikanti L. It is time to abandon atlanto-axial joint injections: do no harm! Anesthesiology. 2011;114(1):222–4; author reply 4.PubMedGoogle Scholar
  55. 55.
    Finlayson RJ, Etheridge JP, Chalermkitpanit P, Tiyaprasertkul W, Nelems B, Tran DQ, et al. Real-time detection of periforaminal vessels in the cervical spine: an ultrasound survey. Reg Anesth Pain Med. 2016;41(2):130–4.PubMedGoogle Scholar
  56. 56.
    Kariya K, Usui Y, Higashi N, Nakamoto T, Shimbori H, Terada S, et al. Anatomical basis for simultaneous block of greater and third occipital nerves, with an ultrasound-guided technique. J Anesth. 2018 Aug;32(4):483–92.PubMedGoogle Scholar
  57. 57.
    Wahezi SE, Silva K, Shaparin N, Lederman A, Emam M, Haramati N, et al. Currently recommended TON injectate volumes concomitantly block the GON: clinical implications for managing cervicogenic headache. Pain Physician. 2016;19(7):E1079–86.PubMedGoogle Scholar
  58. 58.
    Govind J, King W, Bailey B, Bogduk N. Radiofrequency neurotomy for the treatment of third occipital headache. J Neurol Neurosurg Psychiatry. 2003;74(1):88–93.PubMedPubMedCentralGoogle Scholar
  59. 59.
    Stovner LJ, Kolstad F, Helde G. Radiofrequency denervation of facet joints C2-C6 in cervicogenic headache: a randomized, double-blind, sham-controlled study. Cephalalgia. 2004;24(10):821–30.PubMedGoogle Scholar
  60. 60.
    Haspeslagh SR, Van Suijlekom HA, Lame IE, Kessels AG, van Kleef M, Weber WE. Randomised controlled trial of cervical radiofrequency lesions as a treatment for cervicogenic headache [ISRCTN07444684]. BMC Anesthesiol. 2006;6:1.PubMedPubMedCentralGoogle Scholar
  61. 61.
    Dodick DW, Silberstein SD, Reed KL, Deer TR, Slavin KV, Huh B, et al. Safety and efficacy of peripheral nerve stimulation of the occipital nerves for the management of chronic migraine: long-term results from a randomized, multicenter, double-blinded, controlled study. Cephalalgia. 2015;35(4):344–58.PubMedGoogle Scholar
  62. 62.
    Saper JR, Dodick DW, Silberstein SD, McCarville S, Sun M, Goadsby PJ. Occipital nerve stimulation for the treatment of intractable chronic migraine headache: ONSTIM feasibility study. Cephalalgia. 2011;31(3):271–85.PubMedPubMedCentralGoogle Scholar
  63. 63.
    Doran J, Ward M, Ward B, Paskhover B, Umanoff M, Mammis A. Investigating complications associated with occipital nerve stimulation: a MAUDE study. Neuromodulation. 2018;21(3):296–301.PubMedGoogle Scholar
  64. 64.
    Lambru G, Shanahan P, Watkins L, Matharu MS. Occipital nerve stimulation in the treatment of medically intractable SUNCT and SUNA. Pain Physician. 2014;17(1):29–41.PubMedGoogle Scholar
  65. 65.
    Schuster NM, Rapoport AM. New strategies for the treatment and prevention of primary headache disorders. Nat Rev Neurol. 2016;12(11):635–50.PubMedGoogle Scholar
  66. 66.
    Silberstein SD, Dodick DW, Saper J, Huh B, Slavin KV, Sharan A, et al. Safety and efficacy of peripheral nerve stimulation of the occipital nerves for the management of chronic migraine: results from a randomized, multicenter, double-blinded, controlled study. Cephalalgia. 2012;32(16):1165–79.PubMedGoogle Scholar
  67. 67.
    Wilbrink LA, Teernstra OP, Haan J, van Zwet EW, Evers SM, Spincemaille GH, et al. Occipital nerve stimulation in medically intractable, chronic cluster headache. The ICON study: rationale and protocol of a randomised trial. Cephalalgia. 2013;33(15):1238–47.PubMedGoogle Scholar
  68. 68.
    De Agostino R, Federspiel B, Cesnulis E, Sandor PS. High-cervical spinal cord stimulation for medically intractable chronic migraine. Neuromodulation. 2015;18(4):289–96.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of NeurologyAlbert Einstein College of Medicine, Montefiore HospitalNew YorkUSA
  2. 2.Department of AnesthesiologyUniversity of California, San Diego, Center for Pain MedicineLa JollaUSA

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