Headache is a common disease encountered in clinical treatment and has many causes, among which there is a type of headache accompanied by neck pressure pain and related to the stimulation of cervical nerve, which has a high incidence, complex clinical manifestations, long duration of headache, and difficult treatment. This kind of headache was once called “neurogenic headache”, “neurovascular headache”, “occipital neuralgia”, “auricular neuralgia “etc. The main treatments for these headaches are oral NSAIDs, head acupuncture, physiotherapy, massage, head pain injections and head nerve trunk blocks (including occipital major nerve or auricular major neuralgia blocks). However, a significant number of patients do not improve or the treatment does not last. The situation of “headache for patients and headache for doctors” was created.
In 1983, Sjaastad first proposed the concept of cervicogenic headache, and in 1990, the International Headache Society (HIS) promulgated the classification criteria for cervicogenic headache, and cervicogenic headache became clinically accepted.
In recent years, research on the anatomy of the cervical nerve and the central afferent mechanisms of its endings, as well as the progress of research on the mechanisms of cervical degenerative disc degeneration triggering aseptic radiculitis, have continued to deepen the understanding of cervicogenic headache and guided the improvement of clinical diagnosis and treatment. 1995 Bogduk pointed out that cervical degeneration and muscle spasm are the direct causes of cervicogenic headache. Cervicogenic headache can also be referred to as posterior cervical nerve branch origin headache. More recently, cervicogenic headache has also been referred to as high neurogenic cervical spondylosis.
Definition of cervicogenic headache
The International Cervicogenic Headache Society describes cervicogenic headache as a dull or aching pain in the occipital, top, temporal, or orbital regions of the head or both of these regions. This definition lacks specificity because it encompasses almost the entire head. For this reason, the International Cervicogenic Headache Society has added the characteristics of cervicogenic headache, which is headache accompanied by upper neck pain, neck pressure, neck stiffness or pain in the upper neck with movement, limited movement, and most often a history of head and neck injury.
Relationship between cervicogenic headache and age and gender
Most patients with cervicogenic headache are between 20 and 60 years old, but in recent years, there is a trend of younger age. Cervicogenic headache is more common in women, at least twice as often as in men, which may be related to the fact that women take more medications while suffering from various diseases, which are not necessarily analgesics, but may be contraceptives, glucocorticoids or other drugs that can cause headache.
Pathogenesis of cervicogenic headache
1. Anatomical basis of cervicogenic headache Since all surface and deep structures of the head and face are innervated by the trigeminal nerve and C2-3 spinal nerve distribution, most headaches may be related to pathological changes of the cervical spine. Recent neuroanatomical studies have revealed a strong connection between the upper cervical nerve and the nucleus pulposus of the trigeminal nerve, further confirming the role of the cervical nerve in the pathogenesis of headache. Cervicogenic headache can be divided into neurogenic pain and myogenic pain according to the different parts of the nerve roots involved. Stimulation of the sensory nerve fibers of the nerve root causes neurogenic pain, while stimulation of its ventral motor nerve fibers causes myogenic pain.
The C2 spinal nerve emanates from the intervertebral space and its posterior branches are divided into medial, lateral, superior, inferior, and inferior cephalic oblique branches. The medial branch, together with fibers from the C3 spinal nerve, forms the greater occipital nerve, the lesser occipital nerve, and the greater auricular nerve, which are the main nerves that conduct cervicogenic headaches. The lateral branch distributes to the longest cephalic muscle, the cephalic splinters, and the cephalic semispinalis muscle. The posterior branch of the C2 spinal nerve connects with the posterior branch of the C1 spinal nerve in the interungual sulcus of the transverse process, and the inferior branch of the C2 spinal nerve connects with the posterior branch of the C3 spinal nerve by entering the joint of the 2nd and 3rd cervical vertebrae.
2, cervical spine and cervical intervertebral disc degeneration caused by intervertebral foraminal stenosis cervical intervertebral disc degeneration or protrusion, after “fibrosis” and become “hard”, later with tissue repair calcification can form osteophytes. The vertebrae with osteophytes are in close proximity to each other, and the lateral hook vertebral joints are also in close proximity to each other, losing the normal relationship of the articular surfaces and deforming the intervertebral foramen. Erosion of the intervertebral foramen space can cause pain and neurological dysfunction. The size and shape of the intervertebral foramen depends largely on the integrity of the intervertebral disc.
3, cervical disc degeneration and herniation caused by non-bacterial inflammation cervical disc degeneration, herniation, release of disc material can directly cause non-bacterial inflammation, edema; because the disc in adults under normal conditions is non-vascular, is immune immune immune immune area, the immune system sees the disc material as a foreign body and produces immune rejection inflammation, causing discogenic radiculitis. In addition to the direct production of radicular pain, the release of inflammatory mediators at the end causing inflammation of soft tissues in the distribution area can also produce pain, which is the mechanism by which intractable cervicogenic headaches occur in some patients.
4. Cervical spine synovial arthritis Cervical spine synovial arthropathy is one of the important causes of cervicogenic headache. Trauma and degeneration are two sure factors that cause arthrogryposis. Chronic injury to the synovial joints and degenerative degeneration of the cervical discs are the causes of accelerated synovial joint degeneration.
On the one hand, the nerve roots, especially the motor nerve roots on its ventral side, can cause reflex cervical muscle spasm when they are compressed or inflamed; on the other hand, chronic muscle spasm can cause tissue ischemia, metabolites gather in muscle tissue, and the end products of metabolism cause myofasciitis and pain, and can directly stimulate the nerve trunks and nerve endings that travel through the soft tissue. The nerve trunks and nerve endings in the soft tissues can be directly stimulated to produce pain.
Long hours of head-down work and continuous muscle contraction to maintain posture reduce muscle blood supply and cause muscle spasm, and make ligaments and myofascia prone to injury; long and tedious mental activities or physical labor are the most likely to cause cervical nerve-muscle tension among all parts of the body.
Clinical features of cervicogenic headache
1.The nature of pain Early cervicogenic headache patients mostly have discomfort in the occipital region, behind the ear, and the lower part of the ear, which later turns into stuffiness or soreness, and pain gradually appears. The site of pain may extend to the forehead, temporal region, top, and neck. In some cases, ipsilateral shoulder, back and upper limb pain may occur at the same time. The pain may have a remission period. As the disease progresses, the pain becomes progressively more severe, persistent, with shorter periods of remission and worse episodes. Cold, exertion, alcohol consumption and emotional excitement can trigger the pain to worsen.
2. Site of pain Cervicogenic headache is often not manifested in its pathological changes not for, the site of pain is often blurred, diffuse in distribution and involved to the distant, may appear involved pain, similar to the performance of sinus or eye diseases. In some patients, the pain is accompanied by tinnitus, ear swelling, eye stuffiness, and stiffness in the neck. Oral nonsteroidal anti-inflammatory drugs may reduce the severity of the headache. The incidence of cervicogenic headache is higher among ambulatory workers. Those with long duration of the disease have decreased work efficiency, reduced concentration and memory, depressed mood, irritability, easy fatigue, and significantly reduced quality of life and work.
3. Neck pain Patients often have chronic pain in the neck at the same time, mostly persistent dull pain, which can be triggered or aggravated by activities. The lesions in different segments can cause pain in different areas, and the distribution has certain characteristics: ① 2nd to 3rd cervical segment: the pain is located in the upper cervical region and can extend to the occipital region. In severe cases, the pain may extend to the ear, top of the head, forehead or eyes. ② 3rd to 4th cervical vertebral segment: the posterior region of the lateral neck, also extending to the suboccipital region, but not beyond the occipital region, and downward not beyond the scapular band, and its distribution shape is similar to that of the scapular muscle. (3) 5th to 6th cervical segment: it can cause shoulder pain and is easily confused with frozen shoulder. In addition, there may be chest pain and upper limb pain.
4. Local signs ① Pressure pain: In patients with traumatic degenerative arthritis of small joints, there is often obvious pressure pain in the upper cervical paraspinal fixation, and the pressure pain increases after neck activity. In patients with longer disease duration, there may be pressure pain points in the posterior cervical region, temporal region, top, and occipital region. (ii) Restriction of neck movement: Patients mostly have tension and stiffness in the upper cervical soft tissues. ③Sensory impairment: some patients have reduced local tactile and pinprick sensation, and some patients have reduced sensation of smell, taste and tongue and cheek on the affected side. ④Some patients have positive pressure top test and head rest test.
5.History of neck injury Sometimes people cannot recall all neck injuries. Violent forward or backward head flinging in traffic accidents called whip-like injury is a common cause of underlying cervical spine injury, which increases the incidence of cervicogenic headache.
6.The triggering factors of cervicogenic headache ①Strong light and noise: When there are strong light and noise in the surrounding environment, the muscles of the neck are under tension, and the muscles of the neck pull the base of the skull and the muscle attachment points of the temporal and frontal parts, which can directly cause temporal and frontal headache. ②Tension and stress: Social, life or work stress is an important trigger in the onset and aggravation of cervicogenic headache. (iii) Wearing glasses and smoking: Cervicogenic headache has a higher incidence in people who wear glasses and smoke.
Treatment of cervicogenic headache
1. General treatment For patients with cervicogenic headache with short duration and mild pain, rest, head and neck acupuncture, traction and physiotherapy can be taken, together with oral non-steroidal anti-inflammatory drugs, and some patients can be improved. Caution should be exercised on massage, as many patients are aggravated by massage, and some have serious injuries. In the patient’s acute exacerbation period, treatment should be rest, heat therapy and analgesia. Rest is very important, can reduce the patient’s work stress and mental tension, improve the mood.
2. Health education ① Pay attention to maintaining a good sleeping position and working position: it is generally believed that it is better to keep the head in a natural posterior extension position, and the pillow should not be too high. Change the position frequently at work, avoid the same position for too long, adhere to the combination of work and rest and do interval exercises, if necessary, you need to change the type of work. ②Pay attention to self-protection and prevention of head and neck trauma: In life and work, especially when traveling by car and airplane, the use of seat belts can reduce the degree of head and neck trauma and slow down the development of head and neck diseases. ③Acute injury should be treated in time: In the acute injury period, attention should be paid to maintaining bed rest, using neck brace and other neck braking protection, and if necessary, oral non-steroidal anti-inflammatory analgesic drugs can also be taken. Try to minimize the traumatic reaction of the injured cervical intervertebral joint.
3. Injection therapy Injecting anti-inflammatory and analgesic drugs into the corresponding focal area of patients with cervicogenic headache can play a diagnostic role as well as a therapeutic role such as analgesia and relief of local muscle spasm. Commonly used injection treatment methods: ① Injection of cervical paravertebral lesions: Puncture injection of anti-inflammatory and analgesic drugs in the transverse process of the second cervical vertebra has good therapeutic effect on most patients with cervicogenic headache. The drug solution can flow into the cervical 1 to 3 spinal nerves and surrounding soft tissues by spreading in the intertransverse process groove, exerting the therapeutic effects of anti-inflammation, analgesia and promoting the recovery of nerve function. ②Cervical joint injection: For cervical intervertebral joint-derived headache, puncture of the responsible joint can be performed under the guidance of X first, and anti-inflammatory and analgesic drugs can be injected after confirmation by imaging, which can lead to rapid relief of cervical-derived headache. ③Atlantoaxial intervertebral joint injection: used for the treatment of headache caused by atlantoaxial joint lesions, puncture is performed under X-ray imaging guidance to avoid entering the vertebral artery and subarachnoid space. ④Atlanto-occipital joint injection: for the treatment of headache of atlanto-occipital origin, puncture is performed under X-ray imaging guidance to avoid entering the artery, epidural and subarachnoid space. ⑤ Cervical epidural space injection: If the treatment effect is not good by cervical paravertebral injection, the lesion is mostly located in the spinal canal, and discogenic radiculitis caused by disc herniation is the most common, and the drug of paravertebral injection cannot reach the lesion, so cervical epidural space injection can be used.