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The neck and headaches

PainSci » bibliography » Bogduk 2014
Tags: etiology, pro

Two articles on PainSci cite Bogduk 2014: 1. The Complete Guide to Chronic Tension Headaches2. What Happened To My Barber?

PainSci commentary on Bogduk 2014: ?This page is one of thousands in the bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.

This is an advanced tutorial on cervicogenic headache (CH), technical and information dense, but also expert, clear, and valuable. Bogduk begins with a case study of a patient who experienced complete relief from headache with anaesthesia of her right third occipital nerve.

He moves on with an explanation of the mechanism for CH, which is “convergence” — nerves signals from neck tissues merge with nerve signals from the head, and the brain can’t sort it out and decides to sound the alarm (pain) about either/both locations. “Stimulation of trigeminal afferents sensitizes the response to cervical input, and stimulation of cervical afferents sensitizes trigeminal input.” He then gets much more specific and detailed, but the rule of thumb is that “any of the structures innervated by the C1-C3 spinal nerves could be a source of headache. … The structures for which there is the most abundant and most rigorous evidence lie within the catchment of the C1-C3 spinal nerves.

The clinical features of CH are “dull, aching pain” almost anywhere one side the head, especially when the pain started in the neck. Pain radiating to the shoulder and arm, fluctuating continuous pain, moderate intensity, non-throbbing, and a history of neck trauma all raise clinical suspicion of CH. But there basically are no smoking-gun symptoms, just a bunch of clinical clues, none of which is remotely diagnostic. Manual examination is not helpful (see King). So CH is “is essentially a headache for which a cervical source of pain needs to be shown,” which can only be done with nerve blocks.

Bogduk compares and constrasts CH with some other possible diagnoses, like headache associated with neck-tongue syndrome, and C2 neuralgia. He dismisses “occipital neuralgia.”

Bogduk discusses causes of CH, noting several possible-but-rare ones: tumours, infections, rheumatoid arthritis, congenital deformity. He notes that trigger points have not been validated as a cause of CH. Painful intervertebral discs are also a bit of a question mark. The only well-studied cause is trauma to the C2-3 facet joints, especially from whiplash. That joint is the most common, followed by the lateral atlantoaxial joint and the C3-4 zygapophysial joint.

There are not many promising treatment options for CH, but exercise is: “Of conservative therapies, there is strong evidence for only 1 intervention, which is exercise therapy… Most patients in primary care should benefit from this intervention.” Evidence about spinal manipulation, the primary manual therapy option, is discouraging (see Jull). The various nerve block options all have short term potential, but none seem to provide reliable long-term relief: “If C2-3 blocks are negative, the next step is to test for lateral atlantoaxial joint pain with C1-2 blocks. If these blocks are positive, treatment by arthrodesis can be consid- ered, because this is the only treatment of lateral atlantoaxial joint pain that has been found to provide complete relief of pain.”

~ Paul Ingraham

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

Cervicogenic headache is pain referred to the head from a source in the cervical spine or mediated by cervical nerves. Clinical features allow for no more than a diagnosis of probable cervicogenic headache. Definitive diagnosis requires evidence of a cervical source of pain. For most treatments, the evidence is limited or poor. Many patients with probable cervicogenic headache can be managed with exercise therapy, with or without manual therapy. Intractable cervicogenic headache can be investigated with controlled diagnostic blocks of the upper cervical joints and treated with thermal radiofrequency neurotomy. Other interventions are experimental or speculative.

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