Cervicogenic Headache: Diagnostic Criteria
O. Sjaastad,* T.A. Fredriksen** and V. Pfaffenrath***
Depts. of Neurology* and Neurosurgery,** Trondheim University Hospital, Trondheim, Norway. Neurology Clinic,*** Leopoldstrasse 59/11, 8000 München 40, Germany. Reprint requests to: Prof. Ottar Sjaastad, Regionsykehuset i Trondheim, 7006 Trondheim, Norway. Accepted for Publication: October 4, 1990. SYNOPSIS
Criteria for the diagnosis of cervicogenic headache are proposed, which include unilateral head pain, symptoms and signs of neck involvement, non-clustering episodic moderate pain originating in the neck then spreading to the head, and response to root or nerve blockade; plus rarer and non-obligatory features such as autonomic disturbances, dizziness, phonophotophobia, monocular visual blurring, and difficulty swallowing. Key words: cervicogenic headache, diagnosis, criteria (Headache 30:725-726, 1990) Currently, neurologists in general are of the opinion that headache in the exceptional case may stem from various structures in the neck. The idea that rather frequently occurring headaches in many ways resembling common migraine (but, nevertheless, in all probability differing from migraine), may have their origin in the neck,1-3 is not yet generally accepted in neurological circles, but seems to be gaining ground. As far as nomenclature is concerned, the term "cervical headache" also has been used for headaches stemming from the neck. "Cervical" in this context could mean either: a) localized in the neck, or: b) pertaining to or originating in the neck. However, since the ache is a headache, it is not localized in the neck. "Cervical" should then imply "pertaining to" or "originating in the neck." Semantically, the correct word for this concept would be: "cervicogenic." Cervicogenic headache has not yet been accepted by the IHS classification committee.4 Preliminary diagnostic criteria for this headache were given by us 2-3 years ago.2,3 In the meantime, a considerable amount of clinical experience has accumulated. The aim of this communication, therefore, is to present the criteria, as we see them today. To further the general recognition and acceptance of this headache, it is of the utmost importance that as, uniform and as optimal operational criteria as possible are utilized. These criteria should be tried out on headache populations. Major Symptoms and Signs I Unilaterality of the head pain, without sideshift.* II Symptoms and signs of neck involvement: a) Provocation of attacks: 1) Pain, seemingly of a similar nature, triggered by neck movement and/or sustained awkward head positioning. 2) Pain similar in distribution and character to the spontaneously occurring pain elicited by external pressure over the ipsilateral upper, posterior neck region or occipital region.** b) Ipsilateral neck, shoulder, and arm pain of a rather vague, non-radicular nature. c) Reduced range of motion in the cervical spine. Pain characteristics. III IV V VI
Non-clustering pain episodes. Pain episodes of varying duration*** or fluctuating continuous pain.**** Moderate, non-excruciating pain, usually of a non-throbbing nature. Pain starting in the neck, eventually spreading to oculo-fronto-temporal areas, where the maximum pain often is located.*****
Other important criteria. VII Anaesthetic blockades of the major occipital nerve and/or of the C2 root on the symptomatic side abolish the pain transiently, provided complete anaesthesia is obtained.****** VIIIFemale sex. IX Head and/or neck trauma (whiplash) by history. Minor, more rarely occurring, non-obligatory symptoms and signs. Various attack-related phenomena: X Autonomic symptoms and signs: a) Nausea b) Vomiting
c) Ipsilateral edema, and-less frequently-flushing, mostly in the periocular area. XI Dizziness. XII Phono- and photo-phobia. XIII"Blurred vision" on the eye ipsilateral to the pain. XIV Difficulties on swallowing. Points I and II are obligatory for the diagnosis at the present time. As for the subgroups a-b in point II, the presence of at least one of them is considered to be obligatory for the diagnosis. It suffices that either a 1 or a 2 is present for subgroup Ila. The presence of IIc will further corroborate the diagnosis. Points III to VI characterize the pain. With the limited experience we have with this pain syndrome at the present time, we do not feel that it would be correct to make any of these points obligatory. It is, nevertheless, considered highly desirable that one-or preferably two-of them apply. Points VII through IX afford strong supportive evidence for the diagnosis. None of them are per se considered obligatory for the diagnosis; it is, however, considered highly desirable that one of them is present (preferably two of them). Points X-XIV are not obligatory for the diagnosis. COMMENTS
Cervicogenic headache is a headache form that at present can be differentiated clinically from other headaches with reasonable certainty. It is probably not a "disease" or "entity" sui generis, but a reaction pattern, the origin of the pain episodes possibly being one single or several structures in the neck or back of the head, such as nerves, ganglion, nerve roots, uncovertebral joints, intervertebral joints, discs, bone, periosteum, muscle, ligaments, etc.5,6 One misunderstanding is that pain episodes necessarily stem from bony structures. We are convinced that at the present time it is mandatory that the unilaterality is adhered to diagnostically, and a unilaterality without a sideshift at that, at least for scientific purposes. Otherwise, this headache will be mixed up with tension headache and common migraine. We are, nevertheless, not in doubt that there are bilateral cases of cervicogenic headache-we have observed such cases ourselves. When other, decisive diagnostic criteria have been Uncovered, a softening of the unilaterality criterion may be allowed. The scarcity of autonomic symptoms and signs in the ordinary sense, differentiates this headache from cluster headache,7 and so do other features, such as the temporal pattern, female preponderance (around 1:4[?]), etc. Hemicrania continua and cervicogenic headache have many traits in common as far as the developmental patterns are concerned, both entities apparently frequently starting with a remitting headache, which eventually develops into a chronic one. Both seem to exhibit a female preponderance.8 However, the response to indomethacin seems to be a decisive factor in the differential diagnosis. The lack of complete response to indomethacin could, therefore, have been added to the diagnostic criteria. In our estimation, it should preferably, if at all, be added at a later stage, when more information is at hand. The time has come when, in our estimation, there no longer is a question whether this type of headache exists-the question is from which structure (structures) does it stem, and how can it be abated. REFERENCES
1.
Sjaastad O, Saunte C, Hovdal H, Breivik H, Grønbæk E: "Cervicogenic" headache. An hypothesis. Cephalalgia 3:249-256, 1983.
2.
Fredriksen TA, Hovdal H, Sjaastad O: Cervicogenic headache: clinical manifestations. Cephalalgia 7:147-160, 1987.
3.
Pfaffenrath V, Dandekar R, Pöllmann W: Cervicogenic headache-the clinical picture, radiological findings and hypothesis on its pathophysiology. Headache 27:495-499, 1987.
4.
Headache classification committee of the IHS. Cephalalgia 1988; 8(Suppl 7):1-96.
5.
Sjaastad O, Bovim G: Cervicogenic headache. The headache of challenge in our time. In press.
6.
Jansen J, Bardosi A, Hildebrandt J, Lücke A: Cervicogenic, hemicranial attacks associated with vascular irritation or compression of the cervical nerve root C2. Clinical manifestations and morphological findings. Pain 30:203-212, 1989.
7.
Fredriksen TA: Studies on cervicogenic headache. Clinical manifestation and differentiation from other unilateral headache forms. Thesis. Trondheim: Tapir 1989.
8.
Bordini C, Antonaci F, Stovner L J, Schrader H, Sjaastad O: Hemicrania continua: A clinical review. In press.
O. Sjaastad,* T.A. Fredriksen** and V. Pfaffenrath***
Depts. of Neurology* and Neurosurgery,** Trondheim University Hospital, Trondheim, Norway. Neurology Clinic,*** Leopoldstrasse 59/11, 8000 München 40, Germany. Reprint requests to: Prof. Ottar Sjaastad, Regionsykehuset i Trondheim, 7006 Trondheim, Norway. Accepted for Publication: October 4, 1990. SYNOPSIS
Criteria for the diagnosis of cervicogenic headache are proposed, which include unilateral head pain, symptoms and signs of neck involvement, non-clustering episodic moderate pain originating in the neck then spreading to the head, and response to root or nerve blockade; plus rarer and non-obligatory features such as autonomic disturbances, dizziness, phonophotophobia, monocular visual blurring, and difficulty swallowing. Key words: cervicogenic headache, diagnosis, criteria (Headache 30:725-726, 1990) Currently, neurologists in general are of the opinion that headache in the exceptional case may stem from various structures in the neck. The idea that rather frequently occurring headaches in many ways resembling common migraine (but, nevertheless, in all probability differing from migraine), may have their origin in the neck,1-3 is not yet generally accepted in neurological circles, but seems to be gaining ground. As far as nomenclature is concerned, the term "cervical headache" also has been used for headaches stemming from the neck. "Cervical" in this context could mean either: a) localized in the neck, or: b) pertaining to or originating in the neck. However, since the ache is a headache, it is not localized in the neck. "Cervical" should then imply "pertaining to" or "originating in the neck." Semantically, the correct word for this concept would be: "cervicogenic." Cervicogenic headache has not yet been accepted by the IHS classification committee.4 Preliminary diagnostic criteria for this headache were given by us 2-3 years ago.2,3 In the meantime, a considerable amount of clinical experience has accumulated. The aim of this communication, therefore, is to present the criteria, as we see them today. To further the general recognition and acceptance of this headache, it is of the utmost importance that as, uniform and as optimal operational criteria as possible are utilized. These criteria should be tried out on headache populations. Major Symptoms and Signs I Unilaterality of the head pain, without sideshift.* II Symptoms and signs of neck involvement: a) Provocation of attacks: 1) Pain, seemingly of a similar nature, triggered by neck movement and/or sustained awkward head positioning. 2) Pain similar in distribution and character to the spontaneously occurring pain elicited by external pressure over the ipsilateral upper, posterior neck region or occipital region.** b) Ipsilateral neck, shoulder, and arm pain of a rather vague, non-radicular nature. c) Reduced range of motion in the cervical spine. Pain characteristics. III IV V VI
Non-clustering pain episodes. Pain episodes of varying duration*** or fluctuating continuous pain.**** Moderate, non-excruciating pain, usually of a non-throbbing nature. Pain starting in the neck, eventually spreading to oculo-fronto-temporal areas, where the maximum pain often is located.*****
Other important criteria. VII Anaesthetic blockades of the major occipital nerve and/or of the C2 root on the symptomatic side abolish the pain transiently, provided complete anaesthesia is obtained.****** VIIIFemale sex. IX Head and/or neck trauma (whiplash) by history. Minor, more rarely occurring, non-obligatory symptoms and signs. Various attack-related phenomena: X Autonomic symptoms and signs: a) Nausea b) Vomiting
c) Ipsilateral edema, and-less frequently-flushing, mostly in the periocular area. XI Dizziness. XII Phono- and photo-phobia. XIII"Blurred vision" on the eye ipsilateral to the pain. XIV Difficulties on swallowing. Points I and II are obligatory for the diagnosis at the present time. As for the subgroups a-b in point II, the presence of at least one of them is considered to be obligatory for the diagnosis. It suffices that either a 1 or a 2 is present for subgroup Ila. The presence of IIc will further corroborate the diagnosis. Points III to VI characterize the pain. With the limited experience we have with this pain syndrome at the present time, we do not feel that it would be correct to make any of these points obligatory. It is, nevertheless, considered highly desirable that one-or preferably two-of them apply. Points VII through IX afford strong supportive evidence for the diagnosis. None of them are per se considered obligatory for the diagnosis; it is, however, considered highly desirable that one of them is present (preferably two of them). Points X-XIV are not obligatory for the diagnosis. COMMENTS
Cervicogenic headache is a headache form that at present can be differentiated clinically from other headaches with reasonable certainty. It is probably not a "disease" or "entity" sui generis, but a reaction pattern, the origin of the pain episodes possibly being one single or several structures in the neck or back of the head, such as nerves, ganglion, nerve roots, uncovertebral joints, intervertebral joints, discs, bone, periosteum, muscle, ligaments, etc.5,6 One misunderstanding is that pain episodes necessarily stem from bony structures. We are convinced that at the present time it is mandatory that the unilaterality is adhered to diagnostically, and a unilaterality without a sideshift at that, at least for scientific purposes. Otherwise, this headache will be mixed up with tension headache and common migraine. We are, nevertheless, not in doubt that there are bilateral cases of cervicogenic headache-we have observed such cases ourselves. When other, decisive diagnostic criteria have been Uncovered, a softening of the unilaterality criterion may be allowed. The scarcity of autonomic symptoms and signs in the ordinary sense, differentiates this headache from cluster headache,7 and so do other features, such as the temporal pattern, female preponderance (around 1:4[?]), etc. Hemicrania continua and cervicogenic headache have many traits in common as far as the developmental patterns are concerned, both entities apparently frequently starting with a remitting headache, which eventually develops into a chronic one. Both seem to exhibit a female preponderance.8 However, the response to indomethacin seems to be a decisive factor in the differential diagnosis. The lack of complete response to indomethacin could, therefore, have been added to the diagnostic criteria. In our estimation, it should preferably, if at all, be added at a later stage, when more information is at hand. The time has come when, in our estimation, there no longer is a question whether this type of headache exists-the question is from which structure (structures) does it stem, and how can it be abated. REFERENCES
1.
Sjaastad O, Saunte C, Hovdal H, Breivik H, Grønbæk E: "Cervicogenic" headache. An hypothesis. Cephalalgia 3:249-256, 1983.
2.
Fredriksen TA, Hovdal H, Sjaastad O: Cervicogenic headache: clinical manifestations. Cephalalgia 7:147-160, 1987.
3.
Pfaffenrath V, Dandekar R, Pöllmann W: Cervicogenic headache-the clinical picture, radiological findings and hypothesis on its pathophysiology. Headache 27:495-499, 1987.
4.
Headache classification committee of the IHS. Cephalalgia 1988; 8(Suppl 7):1-96.
5.
Sjaastad O, Bovim G: Cervicogenic headache. The headache of challenge in our time. In press.
6.
Jansen J, Bardosi A, Hildebrandt J, Lücke A: Cervicogenic, hemicranial attacks associated with vascular irritation or compression of the cervical nerve root C2. Clinical manifestations and morphological findings. Pain 30:203-212, 1989.
7.
Fredriksen TA: Studies on cervicogenic headache. Clinical manifestation and differentiation from other unilateral headache forms. Thesis. Trondheim: Tapir 1989.
8.
Bordini C, Antonaci F, Stovner L J, Schrader H, Sjaastad O: Hemicrania continua: A clinical review. In press.
