A Review of Diagnostic and
Journal of the American
April 2005, Vol. 105, No. 4
Supplement, pp. 16-22
David M. Biondi, D.O.
Key Points from Dan Murphy:
1. “Cervicogenic headache is a relatively common cause of chronic headache that is often misdiagnosed or unrecognized.”
2. Cervicogenic headache is chronic hemicranial pain that is referred to the head from tissues of the neck.
3. Head pain that is referred from the tissues of the neck is called cervicogenic headache.
4. Cervicogenic headache was not officially recognized until 1983.
5. The key neurological structure in cervicogenic headache is the trigeminocervical nucleus. The trigeminocervical nucleus is a region in the upper cervical spinal cord where sensory nerve fibers from the trigeminal nerve (cranial V) interact with sensory fibers from the upper cervical nerve roots.
6. The convergence of upper cervical and trigeminal sensory fibers is the basis for upper cervical problems causing pain in the face and head.
7. Cervicogenic headache is often a sequela of head or neck injury, but may occur in the absence of trauma. [Important]
8. The prevalence of cervicogenic headache is as high as 20% of patients with chronic headache.
9. Cervicogenic headache is four times more prevalent in women.
10. “Patients with cervicogenic headache will often have altered neck posture or restricted cervical range of motion.”
11. Cervicogenic headache pain can be “triggered or reproduced by active neck movement, passive neck positioning, especially in extension or extension with rotation toward the side of pain, or on applying digital pressure to the involved facet regions or over the ipsilateral greater occipital nerve.”
12. X-ray, magnetic resonance imaging (MRI), and computed tomography (CT) are non-diagnostic in cervicogenic headache patients.
13. Zygapophyseal joint, cervical nerve, or medial branch blockade is used to confirm the diagnosis of cervicogenic headache.
14. Trauma to or pathologic changes to the C1-C2-C3 joints can cause head pain.
15. The third occipital nerve (dorsal ramus C3) innervates the C2–C3 facet joint. The C2-C3 facet joint and the third occipital nerve are the most vulnerable to trauma from acceleration-deceleration whiplash injuries of the neck. [Important]
16. It can take a year or longer for post-whiplash cervicogenic headache to resolve.
17. Disc problems as low as C5–C6 can cause chronic cervicogenic headache.
18. The treatment of cervicogenic headache usually requires manipulation of the upper cervical facet joints. [Important]
19. Drugs alone are often ineffective for cervicogenic headache treatment.
20. “Many patients with cervicogenic headache overuse or become dependent on analgesics.”
21. COX-2 inhibitors [Celebrex] cause both gastrointestinal and renal toxicity after long-term use.
22. COX-2 inhibitors [Celebrex] cause an increased risk of cardiovascular and cerebrovascular events.
23. “All patients with cervicogenic headache could benefit from manual modes of therapy and physical conditioning.”
24. Manipulative techniques are particularly well suited for the management of cervicogenic headache, including high velocity, low amplitude manipulation.
25. Based upon this article, I have created the following form to assist in the diagnosis of cervicogenic headache.
Diagnostic Criteria for Cervicogenic Headache
(Developed by the Cervicogenic Headache International Study Group)
The patient must have at least one of the following:
1. The head pain must be preceded by:
￼ Neck movement or Sustained awkward head positioning
￼ External pressure over the upper cervical (C1-2-3-4) or occipital region on the symptomatic side
2. ￼ Restricted cervical spine range of motion (active and passive)
3. ￼ Ipsilateral neck, shoulder, or arm pain of a vague nonradicular nature or Occasional arm pain of a radicular nature
If all three criteria are present, one is essentially assured of cervicogenic headache.
Characteristics of Cervicogenic Headache
￼ Frequently, a history of indirect neck trauma [whiplash injury]
￼ Unilateral headache that does not change sides
￼ Occasionally, the pain may be bilateral
￼ The pain is located occipital, frontal, temporal, or orbital regions
￼ The pain can last hours to days
￼ The headache usually begins in the neck
￼ The headache is moderate to severe
￼ The headache is non-throbbing
￼ The headache is non-lancinating
The following features may also be occasionally noted:
￼ Difficulty swallowing
￼ Ipsilateral blurred vision
￼ Ipsilateral lacrimation
￼ Ipsilateral edema, especially in the periocular region
A 1978 graduate of Western States Chiropractic College, Dr. Dan Murphy is on the faculty of Life Chiropractic College West, and is the Vice President of the International Chiropractic Association. For more information, visit