Headache

Headaches caused by the cervical spine

Whether from chronic tension or acute whiplash injury, intervertebral disc disease or progressive facet joint arthritis, the neck can be a hidden and severely debilitating source of headaches. Such headaches are grouped under the term “cervicogenic headache,” indicating that the primary contributing structural source of the headache is the cervical spine. There are well mapped out patterns of headache relating to a multiplicity of muscular trigger points in the neck and shoulder-blade (or peri-scapular) region, as well as to disc and joint levels in the upper cervical spine. Even headaches located predominantly in the forehead, or behind, in and around the eyes are very often “referred”pain zones for pathology located in the back of the neck and at the base of the skull. This base of the skull area is called the suboccipital region, because it is below the occipital part of the head. The joints connecting the top two or three levels of the cervical spine to the base of the skull handle almost 50% of the total motion of the entire neck and head region, thus absorbing a continuous amount of repetitive stress and strain, in addition to bearing the primary load of the weight of the head. Fatigue, postural malalignment, injuries, disc problems, joint degeneration, muscular stress and even prior neck surgeries all can compound the wear and tear on this critical region of the human skeletal anatomy. One may also develop a narrowing of the spinal canal itself, through which runs the spinal cord and all of its exiting nerve roots, leading to a condition termed spinal stenosis, also a possible source of headaches, among other symptoms.

Cervicogenic Headache Treatment

Treatment requires a thorough evaluation of the possible contributing factors, several of which often exist together. Physical therapy, provided by an expert spine therapist, is critical to the success of most other treatment modalities, whether those include pain injections or surgery or relaxation and posture techniques. Injections can take the form of muscle (or myofascial) trigger point blocks, nerve blocks or epidural spinal injections. The most effective injections for cervicogenic headaches usually end up being x-ray guided facet joint blocks, especially of the upper facet levels. These should only be performed by a physician trained, skilled and experienced in such procedures, as the area in the neck where they are given is quite complex. If investigation leads to discovery of significant enough disc or joint disease in the cervical spine, leading to altered load bearing in that area and pain, surgery is sometimes the best answer. Any particular treatment, however, is provided in the context of a comprehensive program addressing all of the issues and possible contributing factors noted above.

Chiropractic adjustments, acupuncture and massage are all excellent therapeutic options to assist in managing chronic pain problems or in arresting acute flare-ups of headache pain emanating from the neck area. A word of caution about such modalities, though, is that they are passive. A critical component of any long-term effective pain-management regimen is a committed, active participation of the patient. Triggering activities need to be recognized. Early pain-building warning signs must be learned and counter-acted. Posture and exercise need to be attended to, while stress must be diffused out of the body. Medications are very effective for cervicogenic headaches, to the degree that they can be tolerated while an individual goes on living a functional life. Certainly in severe pain crises, the paramount goal is to maximally relieve pain as quickly as possible. The balance is to work toward minimizing the number of crises one has to experience, whether through corrective treatment or proactive effective management.

Severe headaches are almost universally described as “oh this was a migraine,” but true migraine variant headaches are thought to comprise only 8% of all headache episodes. The much more common, but just as severe, pounding, throbbing, stabbing and nauseating headaches originate from tension, absorbed most frequently in the body in the neck and shoulder region. The majority of these can fall into the category of cervicogenic headache. TMJ and sinus sources are in actuality small fractions of the primary etiologies of headaches. They certainly can be secondary contributors, which set off a smoldering major complex headache. But beware of sinus or major dental surgical procedures without at least a thorough evaluation of all diagnostic possibilities.

Remember, pain is invisible. Very few headaches “show up”on brain MRI scans. There is much to be seen and found in the high stress zone of the neck, however, and this area should be evaluated in detail and treated aggressively in anyone with chronic or recurrent headaches. Even patients with true migraines or cluster headaches will eventually also often end up with compounding cervicogenic headaches, because of the severe stress of the original headache in the first place. One headache is bad enough. No one needs two types to suffer under.

Causes, Symptoms, Diagnosis and Treatment of Cluster Headaches

Cluster headaches are a relatively uncommon form of headache. They are characterized by sudden sharp pain that involves one side of the head, usually the forehead and eye. The headaches last for anywhere from a few minutes to an hour and a half. There are two types of cluster headaches, episodic and chronic. The episodic type is much more common, occurring in about 90 percent of cases. Cluster headaches occur much more frequently in men.

Cluster Headache Causes

The cause of cluster headache is unknown. There are a number of possible precipitating factors but the exact physiology (as with most headaches) is unknown.

Cluster Headache Symptoms

The symptoms of the two types of cluster headaches, episodic and chronic are similar in a number of ways. They both exhibit sudden, sharp, stabbing pain in the forehead and eye. There is one or more of the following: stuffy or runny nose, redness of the eye, tearing, flushed appearance of the face, small pupil or drooping eyelid. These symptoms all occur on the same side as the headache. The headaches tend to occur at the same time of day, and last for a standard amount of time.

Cluster Headache Diagnosis

As always, a careful history and physical examination are the first steps in diagnosis. In the case of episodic cluster headaches, the headache tends to go away for many months. In the case of chronic cluster headache, the headaches do not go away or if they do, it is for a short period of time. Imaging studies such as CT scans and MRI scans are usually not needed if the diagnosis is straightforward. However, if there are unusual aspects to the diagnosis or presentation, then scanning may be warranted. Some things that may lead to scanning include increasing headache frequency, dizziness or coordination changes, numbness or tingling, weakness, headaches that wake the patient from sleep and new onset of headaches in older patients.

Cluster Headache Treatment

The most common treatments for cluster headaches are various medications. These include lithium, methysergide, prednisone and calcium channel blockers. Inhaled oxygen may be used to abort an attack. In certain cases that fail medical treatment, surgical options may be tried. These include radiofrequency lesioning of the trigeminal nerve and stereotactic radiosurgery with the gamma knife.

Migraine headaches are a group of headaches that are also known as vascular headaches. They include migraine without aura (formerly known as common migraine) and migraine with aura (formerly known as classic migraine). The cluster headache is described separately. These are fairly common headaches that affect up to 28 million people in the United States, almost three-fourths women. They cause significant economic loss as measured in time away from work.

Migraine Headache Causes

The specific cause of migraine headache is unknown. It used to be thought that the problem was primarily a vascular problem involving the blood vessels of the head. One current theory is that certain cells — neurons — in the brainstem are somehow responsible for causing the vascular problems.

Migraine headaches may be triggered by such things as stress, change in sleep patterns (too little or too much), alcohol consumption (red wine), menstruation, various foods. Much research still remains to be done.

Migraine Headache Symptoms

The symptoms of a migraine depend on the type of migraine. Although there is variability in the symptoms, the two types are quite distinct.

Migraine without aura is characterized by a recurring headache that is located on one side of the head and lasts between 4 and 72 hours. The headache is usually throbbing and may be moderate to severe. Activity usually makes the headache worse. There may also be nausea, vomiting and sensitivity to light (photophobia).

Migraine with aura is a recurring headache with neurological symptoms. These neurologic symptoms usually develop over the first 5 to 20 minutes of the headache and last for less than 60 minutes. Visual symptoms are the most common followed by sensory changes in the hands or face, weakness or trouble with speech. The headache usually starts after the aura and is similar to the headache in a migraine without aura.

Migraine Headache Diagnosis

As always, a careful history and physical examination are the first steps in diagnosis. Imaging studies such as CT scans and MRI scans are usually not needed if the diagnosis is straightforward. However, if there are unusual aspects to the diagnosis or presentation, then scanning may be warranted. Some things that may lead to scanning include increasing headache frequency, dizziness or coordination changes, numbness or tingling, weakness, headaches that wake the patient from sleep and new onset of headaches in older patients.

Migraine Headache Treatment

There are a number of different concepts in the treatment of migraine headaches including avoidance of triggering events, abortive treatments taken as soon as the headache starts, acute treatments used once the headache has established itself and prophylactic treatment used to prevent headache.

Tension headaches or muscle contraction headaches are very common. They probably represent 80 percent of all of the headaches seen by primary care doctors. These headaches are seen in up to 70 percent of men and as many as 90 percent of women.

Tension Headache Cause

Tension headaches are related to a number of factors. Some common causative factors include tension, stress, anxiety, depression, fatigue and eye strain. There may be an association with cervical spine degenerative disease.

Tension Headache Symptoms

The most obvious symptom is a headache that is described as a steady ache, pressure, tightness and a band-like sensation. There may be pain in the back of the neck. The headache is described as mild to moderate and may last from a few hours to a few days. They may become chronic. Tension headaches may be seen in association with migraine headache.

Tension Headache Diagnosis

As always, a careful history and physical examination are the first steps in diagnosis. Imaging studies such as CT scans and MRI scans are usually not needed if the diagnosis is straightforward. However, if there are unusual aspects to the diagnosis or presentation, then scanning may be warranted. Some things that may lead to scanning include increasing headache frequency, dizziness or coordination changes, numbness or tingling, weakness, headaches that wake the patient from sleep and new onset of headaches in older patients.

Tension Headache Treatment

Lifestyle adjustments may help with tension headaches. Most respond to over-the-counter pain relievers. In some cases, short term use of prescription medications may be tried. Some patients respond to antidepressants or beta-blockers. The treatment is individual and most patients do not seek treatment with a doctor until after usual medications have failed.