HEADACHE and MIGRAINE OVERVIEW

– Dr. LeGault, Pittsburgh Chiropractor in North Hills, PA elaborates on how and why headaches may occur.

  • Cervicogenic headache is a relatively common cause of chronic headache that is often misdiagnosed or unrecognized.
  • Cervicogenic headache is a syndrome characterized by chronic hemicranial pain that is referred to the head from either bony structures or soft tissues of the neck.
  • The trigeminocervical nucleus is a region of the upper cervical spinal cord where sensory nerve fibers in the descending tract of the trigeminal nerve (trigeminal nucleus caudalis) are believed to interact with sensory fibers from the upper cervical roots.
  • This functional convergence of upper cervical and trigeminal sensory pathways allow the bi-directional referral of painful sensations between the neck and trigeminal sensory receptive fields of the face and head.
  • A functional convergence of sensorimotor fibers in the spinal accessory nerve (CN XI) and upper cervical nerve roots ultimately converge with the descending tract of the trigeminal nerve and might also be responsible for the referral of cervical pain to the head

Prevalence – How common?

  • General population is estimated to be between 0.4% and 2.5%
  • In pain management clinics, the prevalence is as high as 20% of patients with chronic headache
  • Mean age of patients is 42.9 years
  • Four times more prevalent in women

Pathophysiology – Why it happens?

  • First three cervical spinal nerves and their rami are the primary peripheral nerve structures that can refer pain to the head
    • Suboccipital nerve (dorsal ramus C1)
    • C2 spinal nerve and its dorsal root ganglion
    • Third occipital branch of the third cervical nerve (dorsal ramus C3)

Diagnostic Criteria from North American Cervicogenic Headache Society

Key signs/symptoms

  • Precipitation of head pain
    • Due to neck movement and/or sustained awkward head positioning
    • Due to external pressure over upper cervical or occipital region on symptomatic side
    • Decrease range of motion in neck
  • Ipsilateral neck, shoulder, or arm pain of a vague non-radicular nature or radicular arm pain

Testing

  • Extension with rotation toward the side of pain
  • Applying digital pressure to involved facet regions or over the ipsilateral greater occipital nerve
  • Muscular trigger points are found in suboccipital, cervical, and shoulder musculature
  • Imaging modalities useful for differential dx.

Treatment

Note: Medications alone are often ineffective or provide only modest benefit for this condition.

  • Conservative tx. (Natural Headache Treatments)
    • Cervical adjustments
    • Therapeutic exercise
    • Biofeedback
    • Relaxation/Massage
    • Cognitive-behavioral therapy
  • Non-conservative tx.
    • Trigger point injections – Anesthetic
    • Radio-frequency thermal neurolysis
    • Epidural steroid injections may be indicated in patients with multilevel disc or spine degeneration
    • Pharmacologic route
      • Anti-depressants
      • Anti-epileptics
      • Analgesics
      • Muscle relaxants