Dr. Awss Zidan on Cervicogenic Headache

By Dr. Awss Zidan

What are the causes of headaches?

Headaches can happen for many different reasons. They are generally classified in one of two types: 1) Primary, meaning they are diseases on their own, without being a symptom of another disease. These primary headaches include migraines, tension headaches and clusters. they are the most common reason for headaches. 2) Secondary, meaning they arise in setting of other illnesses or conditions, such as meningitis or brain tumors. While it may appear the differentiation is clear-cut and dry, Dr. Awss Zidan, a board-certified neurologist and a pain management specialist believes the line is blurred more often than not.

The gray area between primary and secondary

Headache, just like any other pain, can be and often is a reflection of musculoskeletal derangement. Meaning that just like back pain and knee pain, the reason behind headache can be irritated joints, or stretched ligaments. The key is that for the musculoskeletal structure to cause headache, it has to be innervated by the nerves that also travel to the head. The most prominent of these nerves are the trigeminal nerve, and the nerves arising from the top cervical spine.

Only if you look at headache from this perspective that you will start to understand some simple links that you have noted before, such as why toothache results in a headache on the same side of the head (hint: teeth are innervated by the trigeminal nerve), why sleeping wrong gives some people a strained neck and a headache on the back of the head in the morning, or why strained eye muscles from wearing the wrong glasses can give a headache in the front.

But wait, all these headaches happen because of a "reason", so they must be secondary

That is true, but only for a minority of patients. In clinical practice, Dr. Awss Zidan, and other headache physicians, frequently encounter patients who have a primary headache that is worsened by one of these musculoskeletal issues. Meaning that in a normal individual, a strained neck may cause some mild headache in the back of the head that disappears with massage or a hot bath, but in a patient with migraines (or with genetic predisposition for migraines), a strained neck may result in a vicious cycle of breakthrough migraines that can become incapacitating and chronic.

What is cervicogenic headache?

Out of the "local" issues exacerbating migraines, Dr. Awss Zidan has frequently identified the neck as a common contributing factor in headache. The term "cervicogenic headache" means a headache originating from the neck (or cervical spine to be more accurate). Classically, cervicogenic headache is thought of as a "tension headache" occurring on the back of the head and strongly related to some neck pathology such as injury or arthritis. In reality, cervicogenic headache is often camouflaged as a typical migraine with its usual features of the throbbing pain with light and noise sensitivity. The exacerbation may happen immediately or after years of the neck injury, the same exact way that hip arthritis may happen years after a hip injury.

How to tell that cervicogenic headache is playing a role in your migraines

It all comes to a good history and clinical examination. This is where Dr. Awss Zidan's experience in both pain management (which treats mostly musculoskeletal pain) and headache medicine can be of great use in identifying the culprit.

However being aware of some simple clues can direct you in the right direction in identifying if the neck has a role in your headaches; these clues include a migraine that always occurs on the same side (as opposed to a typical migraine which may occur on one side, but usually switches between right and left), a history of neck injury such as an accident with neck whiplash (like being rear-ended at a stop sign), extreme tenderness on the back of your head, or finding that certain neck positions can immediately worsen or improve your headache.

How to treat cervicogenic headache

A collaboration between a headache specialist or pain management can yield the best results. Unfortunately, we rarely see a coordination of care between these two specialties. Rather, the neurologist and the pain management physician each treats the headache and the neck pain as if they were separate issues.

Dr. Awss Zidan believes a good treatment plan for migraines exacerbatedby cervicogenic headache has all the elements of typical migraine treatment,with the addition of neck-specific therapies, such as counseling on good neckergonomics at work and home, physical therapy to strengthen neck muscles, and certainpain procedures to reduce the pain and improve the range of motion. It isimperative that these procedures be done as a part of a good therapy plan (andnot be the only treatment provided), and be directed to the pain generators inthe neck that can cause headache as well.