Cervicogenic Headache

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Cervicogenic Headache
Definition Pain that is perceived in the head but whose source is actually in the cervical spine or which is innervated by cervical nerves (a form of cervical referred pain)

Cervicogenic headache is headache arising from the cervical region. It is treated by four main groups of health professionals: neurologists, headache specialists, pain medicine, and manual therapists. Each group has their own view.


There are sensory axons in C1, C2, and C2 spinal nerves that converse on dorsal horn neurons that also receive trigeminal afferents largely from the ophthalmic division. The convergence allows pain mediated in the C1, C2, or C3 nerves to be perceived in regions innervated by the trigeminal nerve (cervical - trigeminal referral). Can also have cervical - cervical referral.


The origin of the pain in cervicogenic headache can be

  • Nociceptive - irritation of nerve endings in damaged or diseased structures
  • Neuropathic - intrinsic disorder of a peripheral nerve
  • Central - disturbance of pain pathways within the central nervous system.
Possible sources of cervicogenic headache, classified by structure
C1 Nerve Root C2 Nerve Root C3 Nerve Root C4 Nerve Root
Joints Median C1-2
Lateral C1-2 joint (7%)[1] C2-3 ZA joint (62%)[1]
C2-3 disc
C3/4 ZA joint (6%)[1]
Ligaments Transverse C1-2
Muscles Prevertebral
Dura Upper spinal cord
Posterior cranial fossa
Arteries Vertebral
Internal carotid

Causes of cervicogenic headache classified by prevalence and validity.

  • Detectable but rare
    • Aneurysms - vertebral and internal carotid artery
    • Tumours and infection of the posterior cranial fossa
    • Neck tongue syndrome - sudden onset of occipital headache with turning of the head, associated with numbness of the ipsilateral half of the tongue. Subluxation of lateral C1-2 joint and stretching of C2 spinal nerve
    • C2 neuralgia - paroxysmal lancinating pain in occiput. C2 spinal nerve irritation by periarticular fibrosis, nerve tumours, or vascular malformations. Confirmation with C2 spinal nerve block.
  • Common
    • Third occipital nerve headache - arises from C2-3 zygapophyseal joint, mediated by the third occipital nerve. 53% of patients with headache after whiplash. 62% in a general group of patients with cervicogenic headache.[1]
  • Uncommon
    • Lateral atlanto-axial (C1-2) joint - 7%.[1]
    • C3/4 - 6%.[1]
  • Putative
    • Osteoarthrosis of upper cervical spine joints (Median C1-2 joint and C0-C1 joints).
  • Refused
    • Occipital neuralgia - dated entity
    • Barre syndrome, or migraine cervale - dated entity
    • Trigger points - not confirmed by formal studies.

Clinical Assessment


Getsoian et al used diagnostic blocks of C2-3 and C3-4 as a gold standard to evaluate clinical assessment against (C0-1 and C1-2 not blocked due to increased risk). There are no major distinguishing characteristics on history between cervicogenic headache (positive diagnostic blocks) and non-responders to blocks. Responders more frequently have headache onset related to trauma and neck pain (50% vs 14.3%), and symptoms are more often brought on by pressure to the back of the head or neck (100% vs 43%). Non-responders more often have pain that changes sides (57% vs 20%) and more often have premonitory symptoms (85% vs 50%).[2]


Getsoian et al found that cervical dysfunction cannot be defined based on any one single examination sign such as isolated tenderness or isolated reduced cervical extension. They found that dysfunction was characterised by, at least, the simultaneous presentation of reduced cervical extension, painful upper cervical joint dysfunction (segmental restriction plus pain), and impaired muscle function (craniocervical flexion test). They assessed cervical extension, craniocervical flexion test, and symptomatic joint dysfunction (segmental restriction plus pain). The C1-2 flexion rotation test was also used to assess for C1-2 cervicogenic headache because they did not do diagnostic blocks at this level. They found that greater flexion-rotation test values (i.e. less likely to have C1-2 dysfunction) was associated with a greater chance of relief with C2-3 and C3-4 blocks.[2]

In effect, the evidence thus far for useful examination features

  • C1/2 - Reduced flexion-rotation test
  • C2/3 and C3/4 - Simultaneous reduced cervical extension, segmental restriction plus pain, and reduced craniocervical flexion test values.


Diagnostic criteria ICHD-3(2018)[3]

A. Any headache fulfilling criterion C

B. Clinical and/or imaging evidence[Notes 1] of a disorder or lesion within the cervical spine or soft tissues of the neck, known to be able to cause headache[Notes 2][Notes 3]

C. Evidence of causation demonstrated by at least two of the following:

1. headache has developed in temporal relation to the onset of the cervical disorder or appearance of the lesion
2. headache has significantly improved or resolved in parallel with improvement in or resolution of the cervical disorder or lesion
3. cervical range of motion is reduced and headache is made significantly worse by provocative manล“uvres
4. headache is abolished following diagnostic blockade of a cervical structure or its nerve supply[Notes 4]

D. Not better accounted for by another ICHD-3 diagnosis.[Notes 5][Notes 6][Notes 7]


  1. โ†‘ ICDH Note: Imaging findings in the upper cervical spine are common in patients without headache; they are suggestive but not firm evidence of causation.
  2. โ†‘ ICDH Note: Tumours, fractures, infections and rheumatoid arthritis of the upper cervical spine have not been formally validated as causes of headache, but are accepted to fulfil criterion B in individual cases. Cervical spondylosis and osteochondritis may or may not be valid causes fulfilling criterion B, again depending on the individual case.
  3. โ†‘ Clinical sign must be reliable and valid, but none is established at present. Neck pain, focal neck tenderness, history of neck trauma, mechanical exacerbation of pain, unilaterality, coexisting shoulder pain, reduced range of motion in the neck, nausea, vomiting, photophobia, etc are not unique to cervicogenic headache. Maybe features of cervicogenic headache, but they do not define relationship between the disorder and the source of the headache.
    Editor's note: Not technically true that no valid clinical sign see Clinical Assessment.
  4. โ†‘ Abolition of headache means VAS 0/100. But >90% reduction in pain is accepted, or pain <5/100 on VAS.
  5. โ†‘ ICDH Note: When cervical myofascial pain is the cause, the headache should probably be coded under 2. Tension-type headache; however, awaiting further evidence, an alternative diagnosis of A11.2.5 Headache attributed to cervical myofascial pain is in the Appendix.
  6. โ†‘ ICDH Note: Headache caused by upper cervical radiculopathy has been postulated and, considering the now well-understood convergence between upper cervical and trigeminal nociception, this is a logical cause of headache. Pending further evidence, this diagnosis is in the Appendix as A11.2.4 Headache attributed to upper cervical radiculopathy.
  7. โ†‘ ICDH Note: Features that tend to distinguish 11.2.1 Cervicogenic headache from 1. Migraine and 2. Tension-type headache include side-locked pain, provocation of typical headache by digital pressure on neck muscles and by head movement, and posterior-to-anterior radiation of pain. However, while these may be features of 11.2.1 Cervicogenic headache, they are not unique to it and they do not necessarily define causal relationships. Migrainous features such as nausea, vomiting and photo/phonophobia may be present with 11.2.1 Cervicogenic headache, although to a generally lesser degree than in 1. Migraine, and may differentiate some cases from 2. Tension-type headache.


File:Cervicogenic Headache - Lancet Bogduk 2009.pdf


  1. โ†‘ 1.0 1.1 1.2 1.3 1.4 1.5 Govind & Bogduk. Sources of Cervicogenic Headache Among the Upper Cervical Synovial Joints. Pain medicine (Malden, Mass.) 2021. . PMID: 33484154. DOI.
  2. โ†‘ 2.0 2.1 Getsoian et al.. Validation of a clinical examination to differentiate a cervicogenic source of headache: a diagnostic prediction model using controlled diagnostic blocks. BMJ open 2020. 10:e035245. PMID: 32376753. DOI. Full Text.
  3. โ†‘ ICHD-3. Full Text

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