What is CH?
Believe it or not, a cervicogenic headache (CH) is a type of referred pain. The real cause is in the upper part of your neck. This means that treatment of the neck is required to alleviate the headache. Fortunately manual therapy treatment often provides rapid relief, and addressing any ergonomic, postural or weakness concerns to prevent recurrence is usually straight forward, providing the patient does their “homework”.
The traditional Physiotherapy view (circa 1970!) on CH is that it is caused by joint issues in the first three cervical (neck) vertebrae. However, any structure in the upper 3 cervical levels can cause referred pain into the head, since the upper three sensory neurons also innervate the dura in the posterior fossa (ie the covering of the back half of the brain), the spinal cord dura, muscles, ligaments, and the disc between C2 and C3. There is well recognised physiological basis for the referred pain, which is the convergence of the upper three cervical nerves (which supply sensation to the back half of the head) and the Trigeminal nerve (which supplies the front half of the head) on the same nucleus in the brainstem. This means that neck issues can cause referred headache (as in cervicogenic headache) or headache conditions such as migraine can cause referred neck pain. And for some both things are going on all at the same timer!
Of further interest is that there is quite a bit of communication (think of this as “cross talk”) between the upper three cervical nerves and other cranial nerves. For example, the posterior cranial fossa (back half of the inside of the head) is also supplied by branches of the Vagus and Hypoglossal nerves, with the Hypoglossal nerve communicating with the sensory nerve arising from C2. The sinuvertebral nerves (which are well known for supplying the discs in the spine) also receive a sympathetic component. The sympathetic nerves begin as far away as the upper back (hence many people with headaches may also feel pain or stiffness lower down in the spine).
In recent years there has been an explosion of knowledge and development in manual therapy treatment. We now have specific manual therapy techniques to address each one of the structures: nerves, discs, vertebrae, ligaments, muscles, lymphatic-venous and arterial vessels which supply the region. Addressing this more complete picture, in my experience, produces better results.
Is this a common type of Headache?
Absolutely – CH often accompanies a neck injury of some sort, for example whiplash, a fall or head knock, even “tweaking” you neck in the gym can result in this type of headache. It may also accompany more chronic neck conditions. Cervicogenic headache is always associated with upper neck pain, whereas other types of headaches may not necessarily have neck symptoms. CH is regarded as a musculoskeletal condition that Physiotherapists are ideally suited to manage.
Myofascial Headaches
It is difficult not to mention headaches resulting from muscle or myofascial pain when talking about CH, since many of the muscles that can cause headache are innervated by the upper cervical or trigeminal nerves. Myofascial headaches are extremely common, arising from dysfunction in the muscles in the neck and jaw regions which cause referred pain that is felt as a headache. This is another musculoskeletal cause of headache but can differ from CH in that the clinical findings and triggering events are often different, with muscle overload from various causes (including stress) being a key factor. Thus, myofascial or “tension” headaches often co-exist with cervicogenic headaches (and jaw pain!) since overload of muscles is likely accompanied by overload of other neck structures.
If you are experiencing recurrent or chronic headaches without other symptoms, CH may just be the type of headache you have. Alternatively, it is very common for people with headaches to have a more complex picture in which the central nervous system is more chronically irritated, which is often (but not always) associated with more widespread symptoms. In this case treating the neck may only form part of what is required to alleviate pain, with multiple other areas also likely requiring treatment for great results.
References:
Noseda R, Melo-Carrillo A, Nir RR, et al. Non-Trigeminal nociceptive innervation of the posterior dura: implications to occipital headache. J Neurosci. 2019; 39(10): 1867–1880.
Rennie C et al (2013): The sinuvertebral nerves at the craniovertebral junction: A microdissection
Study. Clinical Anatomy 26:357-366.
Schmidt-Hansen PT et al (2005): Patterns of experimentally induced pain in pericranial muscles. Cephalalgia, 2006, 26, 568–577.
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