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Neck Pain and Headaches

Treating Cervicogenic Headaches

Question: I hurt my neck in a car accident about a year ago. Nothing was fractured, but I did get a bulging disc in my neck as a result. My pain began only in my neck at first, but I soon started getting bad headaches at the back of my head and toward the top. Sometimes, the pain moves behind my eyes, too. These headaches have been occurring regularly since my accident. Why am I still in pain, and what can I do to relieve my headaches?
— New Bern, NC

Answer: I'm sorry to hear about your pain. It sounds like you have cervicogenic headaches, which are caused by referred neck pain. Referred pain is pain that moves away from where it originates. In your case, the pain source is in your neck, and the pain radiates to the back of your head, into one or both temples, and one or both of your eyes.

Cervicogenic headaches are sometimes misdiagnosed as either migraine or cluster headache (cluster headaches are extremely painful and come and go periodically, which is where the "cluster" name comes from). Both migraines and cluster headaches arise within the sensitive membrane coverings of the blood vessels within the skull. In other words, they originate in your head.

[Editor's note: you can learn more about headaches and migraines on Practical Pain Management, our sister site. We have a Migraine and Headache Center full of information about chronic headaches and migraines.]

However, cervicogenic headaches—while felt in the back of the head, and sometimes in the temples or behind the eyes—arise from a problem in the upper cervical spine. Because the upper 3 cervical spinal segments share nerve tracts with cranium itself, pain is misunderstood and thus "felt" by the brain as being located in the head. Sadly, many patients are misdiagnosed and treated each year as suffering from migraine or cluster headache, and do not receive a proper diagnosis or treatment for their cervicogenic headache disorder.

How Neck Pain Can Cause Headaches
Anatomically and physiologically, the upper 3 cervical spinal roots (located at C1, C2, and C3) share a pain nucleus (which routes pain signals to the brain) with the trigeminal nerve. This nerve is the main sensory nerve that carries messages from your face to your brain.

The upper 3 cervical spine nerve roots send fibers toward the head that converge on the trigeminal nuclei, which are located at the very top of the spinal cord. These nuclei relay pain messages through the the trigemino-cervical tract.

Think of the trigemino-cervical tract as a relay station where pain signals are sent via nerve tracts first to the thalamus in the midbrain, and then to the higher cortical region of the brain. It is at these thalamic and cortical centers that pain acquires its defining qualities, including severity, meaning, how the body should respond to it, and where it originated.

The brain is not good at defining the precise location of pain that comes from the neck. This is why the brain usually mistakes upper cervical spine pain as a headache.

Treating Cervicogenic Headaches
As a general rule, treatment begins once the diagnosis of cervicogenic headache has been made. A proper diagnosis should include:

  • your detailed medical history and physical examination
  • a series of plain cervical spine x-rays, including flexion/extension views of the facet joints and other joints in the upper 3 cervical spinal segments
  • an open-mouth view of the skull and a lateral skull x-ray may be necessary

Although it may be of interest, a CT or MRI of the cervical spine is not mandatory.

Pain drugs may be considered, including non-steroidal anti-inflammatory drugs (NSAIDs), anti-seizure agents such as gabapentin, tricyclic anti-depressants, and/or migraine drugs such as Fiorinal. Many patients coming to a pain management specialist will have tried one or more of these agents, though most will have proven less than spectacularly helpful.

If pain medications prove unsuccessful, then specific interventional pain procedures should be considered. These include the simple, yet frequently helpful, occipital nerve blocks, atlantoaxial joint block administered at C1-C2, and/or facet joint blocks administered at C2-C3. These injections can be done in the doctor's office setting.

It's important that both you and your doctor realize that at first, one or more diagnostic nerve blocks in your neck will need to be performed. This will demand patience from you and your doctor. Doing one diagnostic block at a time to see whether it reduces your pain will help narrow down the origin of your headache within the cervical spine. Frequently, it will take several (possibly half a dozen) diagnostic blocks, carefully performed and evaluated by both you and your doctor, to arrive at the understanding of the precise source of your cervicogenic headache disorder. But be patient—finding the source of your pain will greatly improve the success of the treatment. And that is worth the wait!

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