Sometimes migraineurs will experience headaches that don’t respond to migraine treatment. When this happens frequently, doctors may consider the possibility of another headache disorder. One such disorder originates with problems in the upper cervical spine. The problem isn’t actually in the head or brain; it’s in the neck. It’s called “referred pain.” The problem is in the neck, but the pain is felt in the head.
What is it?
It’s called cervicogenic headache (CGH) and is classified as a secondary headache because there is a known cause. Many times CGH will follow a specific pattern that gives clues to your doctor about where to start looking for the problem. For example, neck pain that radiates to the lower jaw or over the top of the head and into the eye may indicated the problem lies in the muscles, joints, or nerves of the neck. The pain from CGH is usually not throbbing. Symptoms also include tightness of muscles in the back, neck, shoulder, and upper chest. Look up these muscle groups for a better understanding: upper trapezius, scalene, levator scapulae, sternocleidomastoid, pectoralis major and minor, as well as the sub-occipital extensors.1
As you can see, a lot of symptoms overlap with other headache disorders. It takes a true headache specialist to determine if the problem is CGH, Migraine, Hemicrania Continua, or Occipital Neuralgia. To paint an even more complicated picture, most patients with Chronic Daily Headache meet the diagnostic criteria for more than one headache disorder. CGH typically does not respond to the same treatments as migraine. So, when migraine-specific treatments fail, CGH may be considered as an alternate diagnosis.1, 2
I am a good example of this complexity. Originally diagnosed with Migraine without aura in 1985, I now have multiple headache disorders: Migraine with Aura, Migraine without Aura, Chronic Migraine, Episodic Cluster Headaches, and Cervicogenic Headaches. It is common for me to experience attacks from two or more headache disorders at the same time as they tend to trigger one another.
How is it different from migraine?
Migraine is a primary headache disorder. Unlike CGH, there is no known cause for Migraine. While neck pain and stiffness can be a prodrome symptom of migraine, it is not necessarily an indication of CGH. Only about 18% of headache patients who report neck pain actually meet the criteria for CGH1. If it is present, sometimes the referred pain of CGH can be a migraine trigger. In that case, successful treatment should lead to fewer migraine attacks. Not all migraineurs experience CGH. Even if you are diagnosed with both disorders, one did not cause the other. Do not believe anyone who tells you that problems in your cervical spine are the cause of migraine attacks. There is no research to back up such a claim. However, some patients with CGH are misdiagnosed with migraine and treated for the wrong headache disorder for years. Since CGH does not respond to typical migraine treatments, it is very important to get an accurate diagnosis.
How is it diagnosed?
Diagnosis starts with a clinical interview and physical exam. If the doctor notices stiffness and muscle tightness in your neck, he or she may order an EMG and/or MRI to look for possible joint damage and/or nerve compression in the cervical spine (neck). The results of these tests will help narrow down where to use a nerve block. If the nerve block is successful at stopping the headache, then a diagnosis is confirmed. Relief from a diagnostic nerve block is usually immediate.1, 2, 3
How is it connected to migraine?
Diagnosis can be tricky if you have more than one type of headache. For example, let’s say you have CGH due to a bulging disc between C5 and C6. This damage and the referred pain happen to trigger migraine attacks. The bulging disc didn’t cause migraine, but it is certainly a trigger. In theory, if this were your only trigger, then getting treatment would reduce the severity and frequency of migraine attacks. This isn’t always the case.
How is it treated?
Nerve blocks are used to confirm a suspected diagnosis of CGH. They can also be used to prevent future attacks. Some doctors us x-ray guided epidural injections, Botox, physical therapy, or chiropractic adjustments. Lasting relief typically depends upon the long-term use of specific exercises to strengthen neck muscles and maintain healthy posture. In cases of intractable CGH, radiofrequency ablation of the affected nerves or an occipital nerve stimulator may be considered. Manipulative therapies (massage, chirorpractic, myofascial release, etc.) have been subjected to several studies to determine their effectiveness at treating various headache disorders. Only CGH has been shown to respond to such treatments.1
I started my journey of migraine treatment with chiropractic adjustments. Over many years I had x-rays and exams that confirmed bulging and degenerating discs as well as improper curvature of the cervical spine. One after another, a half dozen chiropractors claimed to know the cause of my “headaches” and promised to make me better. One by one they were defeated by my dysfunctional neurology. They would swear my spine was functioning properly yet I kept getting migraine attacks. Not a single one ever did more than produce temporary pain relief. Sometimes their treatments actually triggered a migraine attack. After many years I finally reached my limit when the last one started making treatment recommendations that were known triggers. He also made some claims about the cause of migraine that I knew to be incorrect. When I gently challenged him with the known scientific data, he refused to budge. That was the end of me and chiropractic care.
I also worked with a neurologist a few years ago who was convinced that physical therapy and continued exercises would eliminated many of my headaches. He was frustrated when I continued to experience the same 10-12 migraine attacks each month that I’d been getting all of my life. After physical therapy, my neck and shoulders felt a lot better. I had more strength and better range of motion, too. I don’t regret physical therapy – which was actually myofascial release therapy. It just didn’t stop me from getting both migraine and cluster headache attacks. Only a few of my headache attacks were actually a result of problems in my neck.
In my case, CGH has been a minor contributing factor to the frequency and severity of migraine attacks. For some patients, CGH plays a much larger role. If you have been diagnosed with Chronic Migraine or Chronic Daily Headache and are not responding to typical migraine treatments, then perhaps it is time for a second opinion to rule out CGH.3