What are Cervicogenic Headaches?
Cervicogenic headaches are a type of head pain that involves referral from structures in the upper cervical spine. They are among the most common neurological disorders, with millions of people experiencing headaches on a frequent basis.
How Common are Cervicogenic Headaches?
Approximately 0.4-2.5% of the general population is estimated to live with cervicogenic headaches, although it has been found that those living with and being treated for chronic pain can experience these at a higher rate (1).
What Causes Cervicogenic Headaches?
Cervicogenic headaches are rooted in the muscles and deep structures of the neck. The cervical spinal area is loaded with potential pain-generating tissues that can cause intense localized discomfort. Cervicogenic headaches can be caused by whiplash injuries, sports injuries, inflammation the muscles and joints, or irritation of nerves. The pain is usually associated with a reduced range of neck motion, which can lead to fibrotic tissue formation that reduces the range of motion even further. When this happens pain usually radiates from the neck to the back and sides of the head, as well as to the forehead and around or behind the eyes. By this point your perception of neck pain usually fades behind your awareness of the headache. Most people focus on their headache and tend to ignore the pain generators in their cervical spine.
What are the Symptoms of Cervicogenic Headaches?
Beyond the head and face pain, common symptoms of a cervicogenic headache include neck tension, limited range of motion, pain and headache triggered by neck movement or neck position. It is also common to experience sudden head pain with coughing or sneezing, nausea, vomiting, light sensitivity, sound sensitivity, dizziness, arm pain, neck pain, shoulder pain, and vision changes (2).
What are the Consequences of Cervicogenic Headaches?
Headaches are an enormous source of disability and lost productivity. Approximately 157 million days of work are lost each year due to headaches, costing approximately $50 billion in work absenteeism and medical benefits (3).
Headaches can have profound impacts on your mental health. There are well-established links between chronic headaches and conditions such as depression and anxiety (4). Chronic sleep disruption has been associated with cervicogenic headaches, which reinforces a cycle of depression, further sleep disturbance, and further headache (5).
What Happens in the Brain with Cervicogenic Headaches?
People usually think of their pain system as a series of on-off switches, in that either something hurts and there is something wrong, or it doesn’t hurt and everything is fine. That’s not really the way your pain system works.
A better analogy is that the experience of pain is more like trying to ring the bell at the amusement park. You hit the hammer on the striker, the puck goes up, and if you hit it hard enough, the puck goes all the way up and rings the bell. Your pain receptors are the hammer, and your pain threshold is the height of the bell. We want as little firing of pain receptors as possible, so the hammer does not hit the striker hard. We also want the bell to be as high as possible, so that the hammer needs to hit really hard to send the puck up to ring the bell.
The pain receptors for head and face pain fire through your Trigeminal Nerve (6). This nerve also carries pain inputs from the brain’s blood vessels and meninges. When pain receptors are compressed or irritated by inflammation, they fire inputs into the spinal trigeminal nucleus (7). This collection of neurons functions as the striker for your headache pain. It is always being hit with pain inputs from the trigeminal nerve, from pain receptors being compressed through movement, from chemical waste products, and so on.
The only pain receptors in this system that are not constantly firing are the dead ones. All neurons need to be constantly firing to stay healthy, including pain neurons. The firing rates of these will increase with tissue damage and so on, but even if there is nothing stimulating them they will still have an inherent rate of activity. Because of this, your pain system needs the ability to modulate these inputs, otherwise we would be in pain 24/7.
In order to keep pain under control we have a series of pathways from the brain that fire down to inhibit the trigeminal nucleus. These make sure that normal background firing rates of your pain receptors are not enough for you to experience pain. When this system is working effectively, the “bell” in your pain system is very high, and the striker needs to be hit very hard for you to experience pain.
Your trigeminal nerve doesn’t just map your head, face, and brain. It also receives pain input from the top three segments of your neck. The sub-occipital spine at the base of your skull sends input into your spinal trigeminal nucleus. If there is enough pain input from your upper cervical spine, the bell can start to ring and you experience a headache.
If this pain input is bad enough to ring the bell hard, pain can start to refer throughout the trigeminal system. This means that you will experience pain not just at the base of your skull, but behind your eyes, in your forehead, in your jaw, and potentially everywhere else that receives input from this nerve. This pain referral is basically crosstalk within your trigeminal system. In the same way that during a heart attack you can have pain go down your left arm even through there is nothing wrong with your arm, if the pain inputs from your neck are high enough you can experience pain throughout your trigeminal system. Most of the pain receptors in your brain surround blood vessels, and if the trigeminal system is stimulated hard enough, you can start to experience throbbing pain every time blood is pumped through your brain’s arteries.
Your pain system works just like everything else in your system, in that if you use it over and over, it gets better at what it does. Unfortunately, that means that if you keep ringing the bell for an extended period of time, the bell gets lower, and it takes less pain input to trigger a headache. Your pain threshold can become low enough that even background noise from normal compression of pain fibers can start to trigger headaches.
There are many ways that your cervical spine can promote firing of pain receptors. In many cases, the causes of pain can be hard to detect without the use of advanced diagnostics. Increased tone of sub occipital muscles can be from injured tissue, but it may also be from something as subtle as impaired eye movements, inappropriate inputs from the inner ear, inability to hold the eyes still on targets, or failure to synchronize eye and head movements properly to follow moving targets. There are a host of ways that your nervous system can poorly adapt to the environment, with the result being increased tone of upper neck muscles resulting in headaches (8).
How are Cervicogenic Headaches Usually Treated?
There are many different types of treatment for cervicogenic headaches. These range from physical therapy (24), to commonly prescribed pain medications, and even to surgical destruction of pain nerves (25).
Most traditional therapies for cervicogenic headaches have limited success. We regularly see patients that have been chasing a solution for their cervicogenic headaches for years, often seeing dozens of providers and having attempted both conservative and invasive forms of therapies.
How is the NeuroRescue Program Different?
We design your unique NeuroRescue program to address every structural and neurological factor involved in your headaches. We also evaluate the influences of metabolism, inflammation, and other chemical factors that may be promoting your pain. We evaluate the function of all of the muscles, joints, ligaments, and nerves in your cervical spine and jaw, the neurological mechanisms that control their function, and the central brain and brainstem systems that normally function to shut off pain.
We combine all of this information into a comprehensive protocol that does not just help you mask your headache symptoms. Instead, we get to the unique root of your problem, address it at a foundational level, and help you rebuild the functional integration necessary for your headaches to finally be resolved.
Research shows that individuals with cervicogenic headache have impaired balance during standing, which indicates the presence of impairment of the vestibular system and integration with proprioception (9). Studies also suggest that computerized balance assessment is critically necessary for assessing spinal muscle control following a cervical proprioceptive injury such as whiplash. Direct injuries to the vestibular system can be demonstrated in many whiplash injuries, however these are more likely to exist in concussions. Assessing these functions can be important in determining if a concussion took place during a cervical injury, with significant ramifications for treatment (10).
Additional research has shown impairment in vestibular function to be common in whiplash injuries. After whiplash trauma, vertigo was shown to be more common in elderly patients with evidence of bilateral vestibular hypofunction after caloric stimulation. Neck pain after the trauma was reported significantly more by young adults, who also showed more frequently bilateral vestibular hypofunction. These findings seem to support the hypothesis of a functional lesion to the brainstem regions after a whiplash injury (11). Vestibular rehabilitation is usually a critically important component of your NeuroRescue Program.
We pay a great deal of attention to the assessment and rehabilitation of eye movements in cervicogenic headache cases. Impaired eye movement is common after cervical whiplash injuries. Given the tight integration between eye movement and neck muscles, proper rehabilitation of neck injuries that promote cervicogenic headaches requires proper analysis of eye movement and rehabilitation of any abnormalities. Research comparing eye movement to cervical dysfunction shows that these exist together in many cases, and that rehabilitation of eye movement in conjunction with cervical rehabilitation is effective in decreasing both cervical and oculomotor dysfunction after whiplash injury (12).
The abnormalities seen in eye movement after cervical whiplash injuries is often a consequence of subclinical brain injury. It is very common that we see chronic cervicogenic headache patients that are unaware that they have suffered a concussion. Eye tracking studies of specific fast eye movements called saccades have shown significant impairment on chronic whiplash patients. The pattern of performance, with normal performance in reflexive saccade tasks and impaired performance in the intentional saccade tasks, especially impaired inhibitory function, suggests dysfunction of prefrontal and frontal cortical structures in chronic whiplash cases (13).
Neck due to whiplash can cause distortion of the posture control system as a result of disorganized neck proprioceptive activity (14). The ability to drive the neurological reflexes that control deep muscles that stabilize the neck can become impaired. Coordination between neck muscle activity and eye movements at different speeds has been shown to be disrupted in whiplash injuries, and this lack of appropriate control and integration of the eyes and neck has many implications for common whiplash symptoms (15).
Gaze stability has also been shown to be an important feature of cervicogenic headaches after whiplash injuries. Deficits in gaze stability and head eye co-ordination have been shown to be related to disturbed reflex activity associated with decreased head range of motion and/or neck pain (16).
The main concern with whiplash is that a large proportion of whiplash patients experience disabling symptoms or whiplash-associated disorders (or WADs) for months if not years following the accident. Abnormalities in head or trunk kinematics, abnormal test of the otolithic function, and abnormal balance tests appear to be the main factors that will determine if cervicogenic headaches will become chronic after a whiplash injury (17). We thoroughly address all of these factors in your NeuroRescue Program.
We employ a host of additional therapies in your NeuroRescue Program, tailored to your diagnostic testing data and the realities of your case. All of our therapies are well supported by cutting-edge neuroscience research.
We may engage in various forms of electrical stimulation, such as trigeminal nerve stimulation (18), transcutaneous vagal nerve stimulation (19), or transcutaneous occipital nerve stimulation (20) to help get your pain under control.
We may employ laser photobiomodulation devices (21), or hyperbaric oxygen therapy to reduce pain and improve endurance (22). We may even use transcranial magnetic stimulation to reduce your symptoms (23).
Upper cervical injuries frequently respond well to manual therapies (26), and all of our providers are highly skilled in these techniques. Joint manipulation in particular has been shown to be a very effective therapy for resolving cervicogenic headaches (27).
Your therapies will be dictated by your unique presentation. No two brains are alike, and every NeuroRescue Program is different.
How Does the NeuroRescue Program Work?
We design your unique NeuroRescue Program to be among the most comprehensive diagnostic and therapeutic protocols available today. We create individual NeuroRescue Programs based on a comprehensive analysis of every relevant neurological system and pathway, using gold-standard, cutting edge neurodiagnostic technologies and examination procedures and state-of-the-art therapies.
We begin with your Discovery Day, wherein we perform a comprehensive history of not only your condition, but your life on a timeline. This allows us to dive deeply into your case and see all of the factors that led to where you are now. It helps us uncover hidden problems and associated conditions that may be making it difficult for you to move your recovery forward.
Our examination allows us to identify the areas and pathways of your brain that have been impacted by your condition. We begin by precisely quantifying the function of your visual, vestibular, and proprioceptive systems through computerized analysis of your eye movements, your inner ear reflexes, and your ability to balance in a host of different sensory conditions.
We employ technologies including Videooculography and Saccadometry to measure several classes of eye movements. We use Video Head Impulse Testing to measure the function of your inner ear, and Computerized Dynamic Posturography to assess your balance in different sensory conditions.
We use NeuroSensoryMotor Integration testing to evaluate hand-eye coordination and cognition, and Virtualis testing to assess dynamic eye tracking and perception of vertical in a virtual reality environment.
We combine all of this with a comprehensive physical and neurological examination of your sensory, motor, autonomic, and cognitive systems. We review any relevant laboratory testing, radiological imaging, and prior neurodiagnostic testing, and integrate that information with our findings.
We use this information to identify which parts of your brain are working properly, which systems are struggling, and the precise point at which your systems fatigue.
We can then design a NeuroRescue Program that is unique and specific to your brain, and yours alone. Your NeuroRescue Program works to rejuvenate and reintegrate the damaged neurons and pathways in your brain. It works to improve energy, endurance, and functional capacity within your fragile systems.
We use our technologies and procedures to not only see what we need to address, but also when it is time to stop and let you rest. We address your impaired neurological function from multiple angles of therapy, and provide metabolic support to improve neurological recovery.
While we cannot bring back neurons that have been lost, your NeuroRescue Program allows us to take the pathways that remain and maximize their efficiency and endurance. And by focusing on the integration of systems, we can do more than just get pathways working better, we can get them working together again. This gives us our best opportunity to get your headaches under control, reduce their frequency and intensity, and return you to living a healthy, vibrant, and fulfilling life.
Your Next Best Step:
Living with cervicogenic headaches can be challenging, but there is hope for recovery and remission. To see if the NeuroRescue Program is right for you, contact one of our patient care coordinators to schedule your Discovery Day.
And remember, it’s never too late to start getting better.
References:
3. https://chiromt.biomedcentral.com/articles/10.1186/s12998-016-0105-z
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4887397/
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5957363/
6. https://en.wikipedia.org/wiki/Trigeminal_nerve
7. https://en.wikipedia.org/wiki/Spinal_trigeminal_nucleus
8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3821111
9. https://pubmed.ncbi.nlm.nih.gov/29767651/
10. https://pubmed.ncbi.nlm.nih.gov/22323849/
11. https://pubmed.ncbi.nlm.nih.gov/32345445/
12. https://pubmed.ncbi.nlm.nih.gov/32963912/
13. https://pubmed.ncbi.nlm.nih.gov/10734013/
14. https://pubmed.ncbi.nlm.nih.gov/8780953/
15. https://pubmed.ncbi.nlm.nih.gov/30609281/
16. https://pubmed.ncbi.nlm.nih.gov/21185219/
17. https://pubmed.ncbi.nlm.nih.gov/27812348/
18. https://pubmed.ncbi.nlm.nih.gov/33364541/
19. https://pubmed.ncbi.nlm.nih.gov/26156114/
20. https://pubmed.ncbi.nlm.nih.gov/30888540/
21. https://pubmed.ncbi.nlm.nih.gov/33636371/
22. https://pubmed.ncbi.nlm.nih.gov/32189664/
23. https://pubmed.ncbi.nlm.nih.gov/28557049/
24. https://pubmed.ncbi.nlm.nih.gov/24421621/
25. https://pubmed.ncbi.nlm.nih.gov/24421621/
