Cervicogenic Headache Revisited

This section is compiled by Frank M. Painter, D.C.
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Thanks to The Chiropractic Report   for permission
to reproduce this article, exclusively at Chiro.Org!

September 2010 Vol. 24 No. 5

Editor:   David Chapman-Smith LL.B. (Hons.)

“In my experience, cervical migraine is the type of headache most frequently seen in general practice and also the type most frequently misinterpreted. It is usually erroneously diagnosed as classical migraine, tension headache, vascular headache. Such patients have usually received an inadequate treatment and have often become neurotic and drug-dependent”

Frykholm, neurosurgeon, Sweden (1972) [1]

Manipulation is effective in patients with cervicogenic headache”.

Duke University Evidence-Based Practice Center, USA (2001) [2]


Headache is one of the most frequent reasons people seek medical advice and is the primary complaint of about 10% of chiropractic patients. [3, 4] Headaches may have a ‘sinister’ cause, such as accidental injury, a space-occupying lesion in the brain or other disease process. In that case they are secondary headaches. However the great majority of headaches are ‘benign’, not linked to any specific injury or disease, and are known as primary headaches.

Benign does not mean mild – symptoms may be frequent and severe. The three most common types of primary headaches are migraine, tension-type headache (TT H) and cervicogenic headache (CGH). [5] Back in the 1960s the various categories of primary headache were thought to be distinct. That thinking still influences much clinical practice and public perception. However by 1988, when the International Headache Society (IHS) published a new classification of headacheS [6] it was known:

  • The diagnosis and classification of primary headaches were extremely confusing and difficult areas. A headache may have various causes – genetic, neurological, biomechanical, vascular, physiological, environmental (e.g. certain foods and drink). New findings were casting doubt on the peripheral nervous system as the main source of pain. The “most fundamental problem”, noted the IHS, was that there was “a complete absence of laboratory tests which can be used as diagnostic criteria for any of the primary headache forms”.

  • There was a continuum between what had been thought to be separate types of headache – migraine could convert to chronic TT H, episodic TT H could convert to chronic headache.

  • Movement abnormalities or dysfunctions in the cervical spine were a significant contributing factor to primary headaches. Where patients met the diagnostic criteria for migraine or TT H they might also have cervicogenic headache (CGH – headache born in the cervical spine).

Figure 1 gives the IHS criteria for CGH.

Figure 1. IHS Classification – Cervicogenic Headache (1988)

11.2.1 Cervical spine

Diagnostic criteria:

  1. Pain localized to neck and occipital region. May project to forehead, orbital region, temples, vertex or ears.

  2. Pain is precipitated or aggravated by neck movements or sustained neck posture.

  3. At least one of the following:

    1. Resistance to or limitation of passive neck movements

    2. Changes in neck muscle contour, texture, tone or response to active and passive stretching and contraction

    3. Abnormal tenderness of neck muscles
  1. Radiological examination reveals at least one of the following:

    1. Movement abnormalities in flexion/extension

    2. Abnormal posture

    3. Fractures, congenital abnormalities, bone tumours, rheumatoid arthritis or other distinct pathology (not spondylosis or osteochondrosis)

Comment:   Cervical headaches are associated with movement abnormalities in cervical intervertebral segments. The disorder may be located in the joints or ligaments. The abnormal movement may occur in any component of intervertebral movement, and is manifest during either active or passive examination of the movement.

The 1972 quote from Frykholm that opens this article speaks to this diagnostic confusion and unfortunately remains valid in general practice today. [2]. While there is still much to learn there has been a wealth of new research since the early 1990s. With respect to CGH:

(a)   Anatomical Basis.   In 1995 Hack et al., dental researchers at the University of Maryland in Baltimore, presented new evidence of bridges of connective tissue between the posterior muscles and the pain-sensitive dura (myodural bridges) in the upper cervical spine that gave a much stronger anatomical basis for CGH [7]. See Figure 2 for details. These and other connective tissue and ligamentous bridges were confirmed by subsequent studies and surgeries.

(b)   Definition.   CGH, rather narrowly defined by the IHS as in Figure 1, received a wider definition from the North American Cervicogenic Headache Society (NAC HS), a multidisciplinary society promoting the study of CGH:

“Referred pain perceived in any region of the head caused by a primary noceceptive source in the musculoskeletal tissues innervated by cervical nerves”.

(c)   Research.   A systematic review from the respected Duke University Evidence-Based Practice Center in 2001 summarized the research evidence to that time concerning the safety and effectiveness of various physical and behavioral treatments for CGH and TT H. It found that, even on the narrow definition given by the IHS, CGH was one of the most common forms of headache, similar in prevalence to migraine, and that the one physical or behavioral treatment with proven effectiveness was manipulation. Manipulation had two distinct advantages over use of medication – first it targeted the source of pain rather than control of symptoms, and second it was safe with fewer side effects. With respect to TT H, the effectiveness of manipulation was “less clear” because there were only three randomized controlled trials (RCTs), none with a placebo or non-treatment group.

However the trials suggested effectiveness. The largest, by Boline et al. in the US, reported that chiropractic manipulation was superior to amitriptyline in terms of reduced headache frequency and severity [8]. How can manipulation be effective for patients with TT H? That question highlights the diagnostic and classification difficulties. Some patients diagnosed as having TT H, because they do not fall within the IHS definition of CGH – perhaps because they have no neck pain or headache provoked by neck movements, nonetheless have spinal joint dysfunctions – also known as subluxation in chiropractic practice.

When these mechanical restrictions are corrected with manipulation, associated muscle tension is resolved. In 2002, the year following the Duke University review, Spine published the first physiotherapy trial of manipulative therapy for patients with CGH. This also reported effectiveness.


  1. Frykholm R. (1972)
    Cervical Migraine: The Clinical Picture.
    In: Hirsch C, Zotterman Y, eds. Cervical Pain.
    Oxford England: Pergammon Press,13-16.

  2. McCrory DC , Penzien DB et al. (2001)
    Evidence Report: Behavioral and Physical Treatments for Tension-Type
    and Cervicogenic Headache

    Des Moines, Iowa, Foundation for Chiropractic Education and Research.

  3. Kelner M, Hall O, Coulter I (1980)
    Chiropractors, Do They Help. Fitzhenry and Whiteside, Toronto (Canada).

  4. Straton RG, Sweeney J, Grandage J (1990).
    Review of the Relationship of Chiropractic Services to the Public Health System
    in Western Australia.
    Health Department of Western Australia, Perth, Australia.

  5. Nilsson-Grunnet N (2002)
    Epidemiology of Headache.
    Eur J Chiropr (49):33-5.

  6. Classification and Diagnostic Criteria for Headache Disorder, Cranial Neuralgias
    and Facial Pain. (1988)
    IHS Classification Committee, Cephalalgia 8 Suppl 7:1-93.

  7. Hack GD, Koritzer RT et al. (1995)
    Anatomic Relation Between the Rectus Capitis Posterior Minor Muscle
    and the Dura Mater

    Spine 20(23):2482-2486.

  8. Boline PD, Kassak K, Bronfort G, Nelson C, Anderson AV.
    Spinal Manipulation vs. Amitriptyline for the Treatment of Chronic Tension-type Headaches:
    A Randomized Clinical Trial

    J Manipulative Physiol Ther 1995 (Mar);   18 (3):   148–154

  9. Jull G, Trott P et al. (2002)
    A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache
    Spine (Phila Pa 1976) 2002 (Sep 1); 27 (17): 1835—1843.

  10. Sjaastad O, Fredriksson TA (2000)
    Cervicogenic Headache; Criteria, Classificatin and Epidemiology
    Clin Exp Rheumatol 18(Suppl 19):S3-6.

  11. Haas M, Spegman A et al. (2010)
    Dose Response and Efficacy of Spinal Manipulation for Chronic
    Cervicogenic Headache: A Pilot Randomized Controlled Trial

    Spine J. 2010 (Feb); 10 (2): 117–128

  12. Astin JA (1998)
    Why Patients Use Alternative Medicine: Results of a National Study.
    JAMA 279:1548-53.

  13. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RC.
    Trends in Alternative Medicine Use in the United States, 1990 to 1997:
    Results of a Follow-up National Survey

    JAMA 1998 (Nov 11); 280 (18): 1569–1575

  14. Peterson DH, Bergmann TF (2002)
    Chiropractic Technique: Principles and Practice. 2nd ed St. Louis, MO: Mosby

  15. Weingarten S, Kleinman M, Elperin L, Larson E (1992)
    The Effectiveness of Cerebral Imaging in the Diagnosis of Chronic Headaches.
    Arch Intern Med 152:2457-2462

  16. Granella F et al. (1987)
    Drug Abuse In Chronic Headache: A Clinico-epidemiologic Study.
    Cephalalgia 7:15-19

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