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• Pharmacologic management of cervicogenic headache is still widely considered first line. |
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• The anatomical etiology of cervicogenic headache should guide the appropriate treatment modality. |
When evaluating treatment options for cervicogenic headache, it is essential to consider the underlying etiology. As noted earlier, cervicogenic headache arises from pathology directly involving the cervical or occipital musculature, high cervical facet joints, intervertebral discs, and surrounding tissues. Thus, understanding the specific origin of the headache will guide appropriate treatment strategies.
Pharmacologic treatment is recommended as first-line intervention for cervicogenic headache. Muscle relaxers, nonsteroidal anti-inflammatories (NSAIDs), antiepileptics, and antidepressants are indicated (17).
Cervical and occipital musculature hypertonicity and myofascial pain as the source of cervicogenic headache can be managed with conservative treatments, such as heat or ice application, massage, traction therapy, or transcutaneous electrical nerve stimulation (TENS) (08). Additionally, trigger point injections, employing a needling technique with or without an injectate, may provide relief, particularly when targeting muscles, such as the trapezius, sternocleidomastoid, and splenius capitis. However, it is possible for patients to experience minimal response from trigger point injections if the facet joints are the actual pain generators as these may be difficult to distinguish on physical exam (15). Chemodenervation with botulinum toxin for focal cervical dystonia has shown over 80% satisfactory symptom relief, although it is not indicated for the treatment of cervicogenic headache as the mechanism of action is not fully understood (04). Instead, this intervention is more commonly used to treat migraine headache disorders (14).
Cervical facet pain is another potential cause of cervicogenic headache. Facet pain is quite common, with a reported prevalence of 70% by the age of 40 (13). Intra-articular facet injections may benefit patients whose pain can be reproduced with provocative neck maneuvers, although focal tenderness over the C2–3 facet joint is commonly the only presenting symptom (15). For more prolonged pain relief from high cervical facet joints, radiofrequency ablation is a viable consideration. A systematic review analyzed the treatment of cervicogenic headache with radiofrequency ablation (RFA) of cervical facet joints and found level II evidence supporting this treatment modality (13). Additionally, a single-center retrospective study evaluating RFA of the C2 dorsal root ganglion showed that the majority of subjects experienced over 50% pain relief, with sustained relief at 6 months (09).
If a patient experiences suboptimal relief following cervical RFA for the treatment of cervicogenic headache, the reason may lie in the potential variability of facet joint innervation. Cervical facet joints typically receive innervation from the medial branches of the adjacent levels, which are targeted during the RFA procedure. However, if a facet joint is innervated by nerves from a more distant level, the RFA may not adequately ablate all the nerves supplying the joint, leading to insufficient pain relief (13). There is also potential for unilateral cervical paraspinal muscular weakness.
Discogenic pain, especially stemming from degenerative disc disease at the C2–3 level, is another possible cause of cervicogenic headache. Although an identifiable anatomical pain generator is present, interventions for discogenic pain in the high cervical region are often avoided due to the risk of serious complications, such as vascular injury or discitis (15).
Regarding the use of cervical epidural steroid injections for treating cervicogenic headache, evidence suggests short-term benefits, particularly for radicular pain associated with cervicogenic headache, lasting approximately 4 weeks. Moreover, a retrospective study demonstrated that a continuous infusion of corticosteroid and anesthetic into the cervical epidural space over several weeks provided sustained relief at a 6-month interval and reduced the need for oral pain medication. Overall, cervical epidural steroid injections are relatively safe when performed by a skilled practitioner adhering to necessary safety protocols (15). In the aforementioned study, one patient with cervicogenic headache experienced transient post-injection flushing, and no patients who underwent continuous infusion reported any endocrine or gastrointestinal side effects. Notably, all patients who experienced pain relief from the continuous infusion had some degree of radiographic evidence of C2–6 disc pathology. This suggests that epidural steroids may be particularly effective for patients with cervicogenic headache who also have corresponding imaging findings.
