By: Christy Jackson, MD and Andrew Blumenfeld, MD
Numerous pain sensitive structures exist in the cervical and occipital regions. The junction of the skull and cervical vertebrae have regions that are pain generating, including the lining of the cervical spine, the joints, ligaments, cervical nerve roots and vertebral arteries passing through the cervical vertebral bodies. Unilateral headaches may emanate from this region and are often misdiagnosed leading to numerous costly examinations and frustration for the patient and physician.
In the following 2 cases, a form of occipital headache known as cervicogenic headache will be described.
A 52 year old white female with past history of intractable migraine was referred to me for a third opinion of intractable headache.
The patient had suffered from lifelong migraine without aura and migraine with aura. She had been under the treatment of headache specialists and over the years had significant success with decreased headache frequency and severity, although headaches persisted. Multiple prophylactic medications had been employed as well as most of the known abortive medications.
Upon history, the patient stated that the pain was daily and started in the morning with pain from the occipital region spreading to the angle of the jaw on the right side. She also experienced retro-orbital pain. MRI and CT of the brain had been found to be normal.
The exam revealed a thin female with a long and thin neck. She had tenderness over the suboccipital region on the right, diminished range of motion of her neck and a significant amount of spasm in the neck and shoulder musculature. Otherwise, the neurologic exam was normal.
An occipital nerve block using a steroid and local analgesic was performed on the right occipital region while the patient was in my office. The patient noted a decrease in the amount of pain after about 5 minutes. The pain at the angle of the jaw also resolved. The next course of treatment employed a physical therapist who identified postural issues which contributed to her muscular spasm and with a home exercise program the headache have resolved.
A 61 year old male with a remote history of migraine came to see me for complaints of pain above his left eye, ongoing for several years. This headache he stated was different from his migraine as it was only occurring on the left side and occurred mostly above his left eye. Upon detailed questioning, he stated the headache would begin at the left occipital ridge and spread up over the top of his head to the region above his left eye. No inciting event could be discovered. He had been evaluated and actually treated for cluster headache without success. The headache would last all day, every day and was often worse in the morning when he arose from sleep. He had occasional phonophobia with the headache, but no other migrainous features. His evaluation had included MRI of the Brain with normal results. On exam he had a normal neurological exam. Exam of his spine revealed mild curvature of the thoracic spine and an elevated shoulder on his right. Point tenderness was found at the left occipital ridge which reproduced a portion of his pain.
An occipital nerve block was delivered to the left occipital nerve and the patient was pain free for over one month. He returned for a second nerve block two months later, which again resolved the pain. Spinal Xray has revealed a very mild scoliosis of his thoracic spine. Evaluation by Orthopedics recommended physical therapy and no surgical intervention. He is currently in a physical therapy program to strengthen the shoulder and neck musculature. He has remained headache free for over 4 months.
Unilateral headaches originating in the cervical and occipital regions coupled with limited range of motion, reproduction of the pain with positional maneuvers and relief of the pain from a diagnostic occipital nerve block may point to a form of headache known as cervicogenic headache. The concept of cervicogenic headache is somewhat controversial with different criteria for diagnosis among the International Headache Society and the Cervicogenic Headache International Study Group. Both societies agree that headaches can result from pathology in the neck region from many of the pain sensitive structures. As many patients suffering from migraine also have unilateral pain which often begins in the occipital region, this headache subtype may be overdiagnosed.
A local anesthetic block may help in the diagnosis of cervicogenic headache. In the cases presented, the patient’s headaches resolved with the office procedure. Diagnostic studies then revealed significant arthritic degeneration in the upper cervical spine. A course of aggressive physical therapy along with postural changes and medications to reduce cervical spasm and inflammation provided the patients with significant relief.
In some cases, a series of occipital nerve blocks is required, and if the conservative treatment plan does not relieve the pain, trials of occipital nerve radiofrequency ablation or even occipital nerve stimulator placements have been successful.
In case #1, the features of the headache occurring always on one side of the occipital region, coupled with pain radiating to the angle of the jaw led to suspicion for a headache originating among the pain sensitive structures of the neck. The original migraine headaches had been well treated by prior headache specialists, and the current headache was somewhat different and did not meet normal diagnostic criteria for migraine. In case #2, the headaches also had a few migrainous qualities, but did not meet the criteria for migraine any longer. In patients with a long history of migraine, a fresh look at the origin of the pain may be warranted. In these 2 cases, the unilateral and side locked headache stemmed from pain sensitive structures in the neck which ultimately were revealed to be degenerative in nature and amenable to physical therapy to strengthen and mobilize the neck and shoulder region.
Christy Jackson, MD, Scripps Clinic Torrey Pines, La Jolla, CA.; Andrew Blumenfeld, MD, The Headache Center of Southern California, Del Mar, CA.