Cervicogenic headaches: a critical review
Scott Haldeman, DC, MD, PhDa*, Simon Dagenais, DCb
aDepartment of Neurology, University of California, Irvine, Medical Center, 101 The City Drive South, Orange, CA 92868, USA
bResearch Division, Southern California University of Health Sciences, 16200 East Amber Valley Drive, Whittier, CA 90609-1166
Received December 22, 2000; revised January 8, 2001; accepted January 28, 2001
Abstract Background context: The notion that headaches may originate from disorders of the cervical spine and can be relieved by treatments directed at the neck is gaining recognition among headache clini- cians but is often neglected in the spine literature. Purpose: To review and summarize the literature on cervicogenic headaches in the following ar- eas: historical perspective, diagnostic criteria, epidemiology, pathogenesis, differential diagnosis, and treatment. Study design/setting: A systematic literature review of cervicogenic headache was performed. Methods: Three computerized medical databases (Medline, Cumulative Index to Nursing and Al- lied Health Literature [CINAHL], Mantis) were searched for the terms “cervicogenic” and “headache.” After cross-referencing, we retrieved 164 unique citations; 48 citations were added from other sources, for a total of 212 citations, although all were not used. Results: Hilton described the concept of headaches originating from the cervical spine in 1860. In 1983 Sjaastad introduced the term “cervicogenic headache” (CGH). Diagnostic criteria have been established by several expert groups, with agreement that these headaches start in the neck or oc- cipital region and are associated with tenderness of cervical paraspinal tissues. Prevalence esti- mates range from 0.4% to 2.5% of the general population to 15% to 20% of patients with chronic headaches. CGH affects patients with a mean age of 42.9 years, has a 4:1 female disposition, and tends to be chronic. Almost any pathology affecting the cervical spine has been implicated in the genesis of CGH as a result of convergence of sensory input from the cervical structures within the spinal nucleus of the trigeminal nerve. The main differential diagnoses are tension type headache and migraine headache, with considerable overlap in symptoms and findings between these condi- tions. No specific pathology has been noted on imaging or diagnostic studies which correlates with CGH. CGH seems unresponsive to common headache medication. Small, noncontrolled case se- ries have reported moderate success with surgery and injections. A few randomized controlled tri- als and a number of case series support the use of cervical manipulation, transcutaneous electrical nerve stimulation, and botulinum toxin injection. Conclusions: There remains considerable controversy and confusion on all matters pertaining to the topic of CGH. However, the amount of interest in the topic is growing, and it is anticipated that further research will help to clarify the theory, diagnosis, and treatment options for patients with CGH. Until then, it is essential that clinicians maintain an open, cautious, and critical ap- proach to the literature on cervicogenic headaches.
2001 Elsevier Science Inc. All rights re-
I hereby certify that, to the best of my knowledge, no aspect of my cur-
It is common in clinical practice to encounter conditions
rent personal or professional circumstances places me in the position of
that are widespread and routinely treated but that suffer
having a conflict of interest with any interest of NASS relating to themanuscript. I further hereby certify that, to the best of my knowledge, nei-ther I (including any member of my immediate family) nor any individualor entity with whom or with which I have a significant working knowledge
* Corresponding author. 1125 East 17th Street, W-127, Santa Ana, CA
have (has) received something of value from a commercial party related
92701, USA. Tel.: ϩ1-714-547-2536; fax: ϩ1-714-547-4822.
directly or indirectly to the subject of this manuscript. E-mail address: HaldemanMD@aol.com (S. Haldeman).
1529-9430/01/$ – see front matter 2001 Elsevier Science Inc. All rights reserved. PII: S 1 5 2 9 - 9 4 3 0 ( 0 1 ) 0 0 0 2 4 - 9
Haldeman and Dagenais / The Spine Journal 1 (2001) 31–46
from limited research and lack of consensus among experts.
duplicates were eliminated. The reference section of each
Cervicogenic headache (CGH) is one of these conditions.
article was then searched for relevant articles not uncovered
Although the idea that headaches can originate from struc-
by the computerized databases. Although no formal search
tures in the neck and can be treated by interventions di-
strategy was attempted for books, theses, and presentation
rected at the cervical spine is long-standing, it is only in the
abstracts, these were included when articles uncovered by
past two decades that the topic has gained attention in the
our search made reference to them. This strategy yielded
mainstream headache and pain literature. There are now
212 papers, some of which were not relevant to our review.
several associations dedicated solely to studying CGH, in-
These results encouraged us to pursue our original goal of
cluding the Cervicogenic Headache International Study Group
reviewing the literature pertaining specifically to CGH
and the World Cervicogenic Headache Society (WCHS).
rather than attempt to cover the much broader topic of head-
These societies are comprised mainly of neurologists and
aches and neck pain. Because the term CGH was introduced
pain management and headache specialists. Journals and
in 1983, this search was mainly limited to papers published
professional associations devoted to studying the spine,
within the last two decades, although additional papers were
however, have not participated in this development. This is
added when relevant and important to the discussion. Al-
unfortunate, because the majority of spinal pain syndromes
though this may seem too restrictive, we thought that this
are managed by clinicians who treat the spine rather than
type of review could reduce some of the confusion sur-
rounding this topic by excluding older literature where it is
This problem of headaches related to the cervical spine
impossible to determine if the authors are in fact describing
cannot be underestimated. Up to 80% of patients with cervi-
cal acceleration-deceleration injuries report headaches
The information gleaned from our literature review was
within 2 months of injury . Almost 25% of patients with
divided into the following six categories for analysis: histor-
this form of injury continue to have significant neck pain 2
ical perspective; definition and diagnostic criteria; epidemi-
years later, with the majority also complaining of headaches
ology; pathogenesis; differential diagnosis; and treatment.
. These figures do not by themselves confirm that theheadaches noted in these studies originate from the cervical
spine. Many patients with whiplash injuries to the neck arealso under financial and litigation stresses, and their head-
Table 1 highlights some of the historical milestones in
aches may be the result of muscle tension. Furthermore,
the evolution of the concept of CGH. The earliest reference
these patients commonly take medications with the poten-
we uncovered was a series of lectures given by Hilton in the
tial of causing headaches. To make the issue more compli-
period 1860–1862, as reported by Pearce . In those lec-
cated, many of these patients have also had head injuries
tures, Hilton proposed that pain in the anterior or lateral part
that may be the primary cause of their headaches. It is there-
of the head may come from the great or small occipital
fore not sufficient to assume that patients with complaints
nerve, most likely from disease between the first and second
of both neck pain and headaches after injury have head-
vertebrae. Sixty years later, in 1926, Barré  hypothesized
aches that are being caused by the same pathology that is
a relationship between the cervical spine and neurological
causing the neck pain. It is up to the clinician to be aware of
symptoms, including headache and vertigo. His collabora-
the current literature in order to be able to make a reason-
tor, Lieou , stated in 1928 that cervical arthritis should be
able diagnostic effort to differentiate between the various
considered a common cause of these symptoms. Twenty
types of headache that may accompany neck pain.
years later, Raney and Raney  reported that headache
This article is an attempt to assist the spine specialist in
may be a common symptom of cervical disk lesions. The
understanding the current literature on CGH. With this re-
following year, a case series published by Hunter and May-
view it is hoped that a clinician will be able to discuss the
field  reported that occipital neuralgia, where pain radi-
current state of knowledge and be aware of the controversies
ated from the occiput to the periorbital and jaw areas, could
concerning CGH, as well as place the multiple theories and
be an important cause of headaches. This theory, in turn,
treatment approaches for this condition in some perspective.
was used to justify the injection of analgesics into the occip-ital nerves in an attempt to relieve these headaches. Also in1949, Bärtschi-Rochaix  used the term “cervical mi-graine” to describe headaches presumed to come from the
The literature search
neck, while Josey  published a case series on patients
A search was performed with three computerized medi-
with headaches associated with pathologic changes in the
cal databases (Medline, CINAHL, Mantis) for the terms
cervical spine. In 1955 Kovacs  wrote that motion re-
“cervicogenic” and “headache” for the periods covered by
striction in the cervical spine could lead to muscle spasm
each database (1966 for Medline, 1982 for CINAHL, 1880
and compromise of the vertebral artery and nerves, causing
for Mantis). The search was limited to articles in English,
headaches. This helped popularize osteopathic, chiropractic,
French, and German. Search results from the different data-
and manual treatment of the cervical spine to relieve head-
bases were merged using reference-managing software, and
aches. Maigne  was a prominent advocate of using ma-
Haldeman and Dagenais / The Spine Journal 1 (2001) 31–46
Table 1Historical milestones in cervicogenic headaches
Hilton mentions that pain in the anterior or lateral part of the head may come from the great or small occipitalnerve, most likely from disease between the first and second vertebrae.
French neurologist Barré describes a relation between the cervical spine and neurological symptoms, includingheadache and vertigo.
French neurologist Lieou reports that cervical arthritis is a common cause of headache and vertigo.
Raney describes patients with headaches caused by cervical disk lesions.
Hunter and Mayfield publish a series of case reports on occipital neuralgia.
Bärtschi-Rochaix coins the term “cervical migraine.”
Josey publishes a case series where headaches are associated with pathologic changes in the cervical spine.
Kovaks postulates that motion restriction in the cervical spine can lead to muscle spasm and compromise of thevertebral artery and nerves causing headaches.
Grillo, a chiropractor, discusses vertebragenous headaches very similar to CGH.
Bogduk discusses third occipital headache with a presentation very similar to CGH.
French physiatrist Maigne reports success in treating headaches with manual medicine.
Sjaastad publishes an article introducing the term cervicogenic headache.
Fredriksen presents a detailed description of the clinical presentation of patients with CGH.
The International Headaches Society introduces a category for headaches associated with disorders of the neck.
Sjaastad publishes diagnostic criteria for CGH.
The International Association for the Study of Pain publishes diagnostic criteria for CGH.
The multidisciplinary World Cervicogenic Headache Society is created.
The Quebec Headache Study Group publishes diagnostic criteria for CGH.
The first randomized controlled clinical trial for CGH is published by Nilsson.
Sjaastad publishes revision of diagnostic criteria for CGH.
nipulation to treat headaches, while Bogduk and Marsland
least in their connotation. Such terms as neuralgia, espe-
 advocated surgical intervention to treat what they
cially those referring to a specific nerve, assume, with little
termed “3rd occipital headache”.
evidence, that the origin of the headache is known [12,22].
The term “cervicogenic headache” was first introduced
Other terms are more vague, referring simply to a syndrome
to the medical literature in 1983 by Sjaastad et al. , who
or a specific location of the headache [23–26].
described patients with a headache not classified by diag-
The confusion seen in CGH terminology is also apparent
nostic criteria at that time. In 1987 Fredriksen et al. 
when examining the diagnostic criteria for CGH. Table 3
gave a more detailed description of patients they had diag-
summarizes the prominent features of the diagnostic criteria
nosed with CGH. In 1988 the International Headache Soci-
published by various expert groups. The most widely used
ety (IHS)  amended its diagnostic classification system
diagnostic criteria for many years were those proposed by
to include a category for headaches associated with disor-
Sjaastad  in 1990 and subsequently updated in 1998
ders of the neck. In 1990 Sjaastad et al.  published very
. Although the publication of these criteria brought fo-
specific and detailed diagnostic criteria for CGH. This was
cus to the field of CGH research, certain aspects have
followed by the publication of less stringent diagnostic cri-
proved difficult to embrace. For example, Sjaastad vigor-
teria for CGH by the International Association for the Studyof Pain (IASP) in 1994, and by the Quebec Headache Study
Group in 1995 [11,17]. In 1998, Sjaastad et al.  revised
Conditions similar to cervicogenic headache
their diagnostic criteria for CGH based on more extensive
Definition and diagnostic criteria
The term CGH, although adopted by a number of organi-
zations, is not universally accepted, and there remains a
great deal of variation in the terminology used to discuss
headaches associated with disorders of the cervical spine.
This is especially true of literature before 1983, when a
number of terms (Table 2) appear to have referred to the
same clinical entity. Many of these terms, such as verte-
bragenous , vertebrogenic , or spondylotic 
headaches, can be considered synonymous with CGH, at
Haldeman and Dagenais / The Spine Journal 1 (2001) 31–46
Table 3The characteristics and definitions of cervicogenic headache
Awkward headpositioningPressure over ipsilateralcervical/occipital area
Edema/flushingDizzinessPhono/photophobiaBlurred visionDysphagiaNo effect withindomethacin,ergotamine, orsumatriptan
ously advocated the position that these headaches should be
cluded radiological abnormalities in their diagnostic crite-
strictly unilateral, whereas others have accepted that these
ria, despite a failure to identify radiographic abnormalities
headaches may be unilateral or bilateral. Sjaastad also in-
specific to CGH [15,27]. The IASP and WCHS focused
cluded a number of accompanying symptoms, such as nau-
their attention on the relief of pain by the injection of anal-
sea, vomiting, flushing, dizziness, phono- and photophobia,
gesics into cervical structures with no convincing clinical
blurred vision, and dysphagia, making his criteria too spe-
trials to support this position and no consensus regarding
cific and detailed for general practice.
the various injection techniques [17,28].
Lack of consensus is also evident in the criteria of the
Despite these differences, certain features are common to
three other main expert groups. For example, the IHS in-
the majority of the diagnostic criteria for CGH. There is
Haldeman and Dagenais / The Spine Journal 1 (2001) 31–46
agreement that these headaches start in the neck or occipital
ferent diagnostic criteria used to define CGH. Several stud-
area and can then spread to other areas of the head, includ-
ies did not specify the criteria used to define CGH, making
ing the frontal, temporal, and periorbital regions. The pain
direct comparisons impossible; even studies using the same
tends to be dull, nonthrobbing, and nonlancinating, and can
criteria varied in the stringency with which these were ap-
become moderate to severe in intensity. Examination re-
plied (i.e., patient must fulfill a minimum of x criteria to be
veals tenderness and abnormal palpatory findings in the cer-
included). The study reporting the highest prevalence for
vical paraspinal tissues, as well as possible decreased cervi-
CGH was by Rothbart , a clinician from a pain manage-
cal range of motion. The other reported findings and
ment center, who estimated that 80% of the patients with
characteristics of CGH appear to be less well defined.
headache in his clinic had CGH. As founder of the WCHS,he may have spent considerably more time than other physi-cians in seeking patients with this syndrome. An incidental
finding in a study by Loh et al.  reported that 10% of pa-
There is a great deal of variation in the perceived preva-
tients with obstructive sleep apnea were diagnosed with
lence of CGH. The published prevalence rate estimates un-
CGH, although no explanation was offered as to the mecha-
covered through our literature search are presented in Table
4. These ranged from 0% of patients with migraine head-
Analysis of patient descriptive data (age, gender, etc.)
ache (MH)  to 80% of patients with headache .
from studies where such information was given reveals that
There are several reasons for this wide range of published
patients with CGH appear to form a fairly homogeneous
estimates, including vastly different populations of subjects.
population, with a mean age of 42.9 years, a gender distri-
In the general population, for example, prevalence rates
bution that is 79.1% female and 20.9% male, and a mean
ranged from 0.4% to 2.5% [31,32], whereas studies looking
duration of symptoms of 6.8 years. More detailed demo-
at all patients with a complaint of headache reported esti-
graphic data were found in a study by Shah and Nafee 
mates of 15% to 20% [15,32–34]. The highest variation was
in India, where patients with CGH were described as 43%
among headache center patients, with prevalence estimates
urban and 57% rural, with 55.7% employed as handicraft
of 0.4% to 80%. Part of this variation can be attributed to
workers, 28.3% as laborers, 10.0% as clerks, 4.9% as busi-
the different methodology used in these studies (i.e., pro-
ness executives, and 1.6% as doctors. Shah and Nafee spec-
spective cohort, retrospective analysis, etc.), as well the dif-
ulated that the poor ergonomics associated with the handi-
Table 4Prevalence estimates for cervicogenic headache
Frequent headache patients (Ͼ5/month) ages 20–59 years
Patients with degenerative cervical spine disease
Unilateral headaches without sideshift starting in neck and spreading to frontal area
Side-locked unilateral headaches or headaches starting in the neck
IHS ϭ International Headache Society. Haldeman and Dagenais / The Spine Journal 1 (2001) 31–46
craft occupations may account for the higher prevalence in
tients with MH, he and Bovim  reported on four patients
that group. They also reported that the population in his
where both MH and CGH co-existed. These patients were
study had a mean age of onset of 62.5 years for CGH, which
able to distinguish between episodes of each headache, re-
is considerably older than the mean age of typical patients
porting improvement of MH but not CGH with sumatriptan
and ergotamine, and relief of CGH but not MH with greater
Another factor influencing prevalence rates in headache
occipital nerve anesthetic blockade.
centers is the apparent overlap between the diagnosis ofCGH, tension-type headache (TTH), and common migraine
headache. Bono et al.  report that 75% of patients ful-filling IHS criteria for MH also meet most of the criteria for
One of the most controversial areas within the CGH liter-
CGH. Furthermore, the CGH diagnostic criteria by Sjaastad
ature is the discussion of its cause. Almost every structure
et al.  include many of the systemic symptoms, such as
and pathology within the cervical spine has been implicated
nausea, vomiting, phonophobia, and photophobia commonly
as a cause of these headaches. Table 5 summarizes the
seen in MH. CGH also appears to frequently co-exist with
structures suggested as the origin of CGH and the types of
primary headache disorders such as MH and TTH. One
pathology associated with these headaches. The rationale
study of headache center patients reported that whereas only
for most of the theories is the observation, usually in a small
16.1% were diagnosed with CGH, an additional 20.1% were
number of cases, of either a reproducible finding on clinical
diagnosed with both MH and CGH, for a total prevalence of
examination, a response to stimulation of the structure, or
36.2% . A recent study of patients with neck injuries re-
relief of symptoms after treatment directed at the structure.
ported that 34.3% had CGH, whereas an additional 11.4%
Examples include the response of patients to surgery for
had both CGH and MH, and an additional 8.6% had CGH in
disk disease , injections of posterior facets with anesthe-
combination with headaches associated with the neck, for a
sia , and injections of cervical muscles with botulinum
total prevalence of 54.3% . The reason for distinguish-
ing CGH from headaches associated with the neck was un-
One theory of CGH etiology comes from anatomical
clear. When narrowing the field among patients with head-
studies showing an attachment of the suboccipital tissues to
ache to those with unilateral pain without sideshift and pain
the dura mater at the cervical–cranial junction, and the ob-
starting from the neck and spreading to the oculofrontal
servation that mechanical traction on these tissues can cause
area, Bono et al.  diagnosed 47% of such patients with
movement of the dura [48–51]. The rectus capitus posterior
CGH, including 15% where there was overlap between MH
minor muscle  and ligamentum nuchae  have been
and headaches associated with the neck, although again the
shown to have direct connections to the suboccipital dura
distinction of the latter from CGH was unclear. Another
on very delicate dissection in a small number of cadavers.
study reported that 56.4% of CGH diagnoses occur in com-
This suggests a role for the dura as a nociceptive structure
bination with other headaches, including MH, TTH, and
drug-induced headache . Although Sjaastad has tended
Structures implicated in the genesis of CGH all have
to disagree that CGH symptoms are commonly found in pa-
their sensory innervations through the upper cervical and
Table 5Theories of pathogenesis for cervicogenic headache
Trauma or immobility stimulates the C1–C3 nerves
Restrict joint motion. Referred symptoms from muscles
Disk herniation, spondylosis, or scar tissue
Apophyseal exostoses impacting vertebral artery
Nerve roots producing sternocleidomastoid and trapezius
Tension on the dura or vertebrobasilar artery compression
Haldeman and Dagenais / The Spine Journal 1 (2001) 31–46
Fig. 1. Convergence of sensory input from the upper cervical nerve roots into the trigeminal nucleus. Haldeman and Dagenais / The Spine Journal 1 (2001) 31–46
midcervical nerve roots, which lead to the cervical cord and
ache are rarely confused with CGH, because each possesses
converge within the spinal tract of the trigeminal nucleus
unique distinguishing characteristics. To aid the task of dif-
 (Fig. 1). This allows nociceptive input from cervical
ferential diagnosis, several studies have reported the results
structures to be perceived as head pain, including pain to the
of various radiographic, neurologic, and physiologic testing
temporal, frontal, and orbital regions. This convergence
may also help to explain the systemic and sympathetic ner-
The significance of radiological findings in CGH has
vous system features accompanying CGH. Studies showing
been difficult to establish (Table 6). Only one of these stud-
relief of headache after lower nerve root blocks have cast a
ies used a control group , and most had a small number
doubt on whether only the upper nerve roots are significant
of subjects. These shortcomings make it difficult to draw
conclusions regarding the relationship of radiological find-
Martelletti has reported increased levels of pro-inflamma-
ings and CGH. Although degenerative changes have been
tory cytokines interleukin-I ␤ and tumor necrosis factor-␣
found in patients with CGH on plain film radiography and
during mechanically induced attacks of CGH; these were sig-
magnetic resonance imaging scans of the cervical spine,
nificantly higher than in patients with MH [45,46]. He postu-
these changes cannot be considered specific and unique to
lated that this could represent a specific signal from the im-
CGH [27,36,54,55]. A study by Jansen  in 1998 found
mune system to activate such pain-producing agents as
that 100% of patients with CGH had radiographic evidence
substance P and calcitonin-gene–related peptide. This may
of retrospondylosis and osteochondrosis. With multiple spi-
help define CGH as an inflammatory consequence of cervical
nal levels involved (42.9% at C5–C6, 22.7% at C4–C5,
trauma, explaining the wide variety of pathological processes
21.4% at C6–C7, 11.0% at C3–C4, 0.6% at C7–T1, and
in different structures that can cause similar headaches.
only 1.3% at C2–C3), it is difficult to assess the importance
The inability to find a definitive structure or pathology as
of this finding. The description of Chiari type 1 malforma-
the cause of CGH has lead some to believe that CGH does
tions and spinal cord compression in small numbers of pa-
not represent a single pathological entity but rather a pain
tients with characteristics of CGH may simply represent pa-
syndrome resulting from the nociceptive stimulation of al-
thology that causes headaches by stimulating cervical
most any structure in the cervical spine .
structures rather than a finding specific to CGH.
Table 7 summarizes the results of various diagnostic
tests on patients with CGH. Although many of these studies
report statistically significant findings, the number of sub-
The differential diagnosis stressed in most of the litera-
jects is too small to reach any conclusion. Many of the phys-
ture on this topic is between CGH, MH, and TTH. It is gen-
iological tests, such as sweating patterns  and electro-
erally assumed that intracranial pathology from infection,
nystagmography , are so esoteric that it is difficult to
neoplasm, trauma, and so forth has been ruled out. Head-
determine their significance or relevance in clinical prac-
aches associated with sinusitis, temporomandibular joint
tice. The finding of various forms of muscle dysfunction,
syndrome, visual or auditory disturbances, and cluster head-
such as myofascial trigger points , responses of differ-
Table 6Diagnostic imaging studies for CGH
Disk protrusionVentral dura compressionNarrowed subarachnoid space
CS ϭ cervical spine; CT ϭ computed tomography; MRI ϭ magnetic resonance imaging. Haldeman and Dagenais / The Spine Journal 1 (2001) 31–46
Table 7Neurological and other diagnostic studies for CGH
Romberg quotient 3.1 for anterior posterior sway
Significant ↓ amplitude on painful side
Significant ↑ upper trapezius passive stretching response vs. controls 30
Significant more on symptomatic (70) vs. asymptomatic (22) side
C2–C4 instantaneous axis of rotation PϾ.05
No relation between abnormality and headache
Asymmetry in rotatory nystagmusCongenital cranial nerve VI palsyCaloric hyporesponsiveness
Significant ↓ shoulder maximum conduction velocity in CGH
Significant ↑ pretest activity in frontalis on symptomatic sideSignificant ↑ electromyography response in trapezius onsymptomatic side
Significant ↓ response in CGH for all medications vs.
ent muscle groups to mental stress , and cervical muscle
they compared CGH with MH and reported that CGH ful-
strength and endurance , seems to confirm the involve-
filled seven of eight common MH criteria (the exception be-
ment of cervical and paraspinal muscles in CGH. The lack
ing aggravation by physical activity). Nausea and/or vomit-
of response to common vasoactive medications used in MH
ing was reported in 55% of patients with CGH versus 70%
 argues against arterial involvement in CGH and can be
to 85% for MH. Photophobia was reported in 45% of pa-
one of the clues that a patient may have a CGH.
tients with CGH versus 88% of patients with MH. Patients
Attempts to differentiate CGH from MH and TTH on the
with MH, however, did not fulfill the most important crite-
basis of some clinical or experimental measure are pre-
ria for CGH, that is, precipitation of headaches with neck
sented in Tables 8 and 9. It does not appear that any specific
movements and/or external pressure on the neck. A second
test or clinical finding can be used to define patients with
study by Sjaastad et al.  in 1992 compared pain patterns
CGH. A detailed clinical history is therefore imperative in
in CGH and MH and reported that whereas typical MH at-
order to diagnose CGH. The difficulties of diagnosing CGH
tacks were unilateral without side shift (the typical CGH
were stressed by Sjaastad and Bovim in 1991 , when
pattern) in only 16% of patients, 75% of nontypical MH at-
Table 8Comparison of CGH with tension-type headache
Response to greater occipital nerve blockade
Both groups had lower thresholds than controls
Significant ↓ flexion/extension and rotation in CGH
Haldeman and Dagenais / The Spine Journal 1 (2001) 31–46
Table 9Comparison of CGH with migraine headache
Significant ↑ thermal thresholds on both sides
Response to greater occipital nerve blockade
Significant ↑ pain reduction in CGH (54.5%) vs. MH (6%)
Significant ↓ flexion/extension and rotation in CGH
CGH ϭ cervicogenic headache; MH ϭ migraine headache.
tacks presented in this fashion. Their group of patients with
with CGH could not be classified according to IHS criteria
CGH fulfilled only 3.79 of 7 IHS criteria for common MH
as having either MH or TTH. D’Amico et al.  similarly
criteria, compared with 6.78 for patients with MH.
examined the characteristics of patients with headache and
A study by Vincent and Luna in 1999  examined the
reported that in patients with long-lasting, side-locked, uni-
number of patients with CGH, TTH, and MH who could
lateral pain, the diagnosis was MH in 85.1%, TTH in
fulfill Sjaastad’s criteria for CGH. Patients with CGH met
10.8%, and CGH in 4.1%. The percentage of patients with
10.51 of 18 criteria versus 3.85 for patients with MH and
headache in whom the pain was localized in the occipito-
4.89 for patients with TTH, a statistically significant differ-
nuchal region was 100% in CGH, 12.5% in MH, and 20.0%
ence. One third (33.3%) of patients with CGH met the IHS
in TTH. Conversely, the percentage of patients in whom the
criteria for MH, whereas only 3.3% of patients with CGH
initial pain was nonoccipital was 0% in CGH, 76.6% in MH,
met IHS criteria for TTH. In other words, 63.4% of patients
and 30.0% in TTH. CGH may then be differentiated from
Table 10Surgical treatment of cervicogenic headache
CS ϭ cervical spine; RCPM ϭ rectus capitis posterior minor. Haldeman and Dagenais / The Spine Journal 1 (2001) 31–46
Table 11Manual treatment for cervicogenic headache
Significant ↓ drug consumption indexSignificant ↓ total pain index
Significant ↓ headache hours/day (group 1, 59%; group 2,
Significant ↓ VAS, group 1 only (36%)Significant ↓ NSAIDs/day, group 1 only (47%)
Significant difference in ↓ headache hours/day in favor of
Significant difference for analgesics/day between 2 groups
Significant ↓ headache severity (59%)Significant ↓ headache frequency (62%)Significant ↓ headache duration (77%)
Significant ↓ headache duration (43%)Significant ↓ headache intensity (53%)
Complete relief of headaches Restoration of full CS ROM
10% had 50–75% reduction in symptoms3% had 50% reduction in symptoms2% had no change5% had aggravation in symptoms
Manual therapy is better than Maitland concept
Both are better than no-treatment control
Patient was headache free for 6–7 months until involved in
A single manipulation added to NSAIDs was superior to
NSAIDs only immediately after treatment but not at 3
Manipulation was more effective than mobilization and
wait list but without statistical significance
CS ROM = cervical spine range of motion; NSAID = nonsteroidal anti-inflammatory drug; RCT = randomized controlled trial; VAS ϭ visual analog
MH and TTH by a pattern of unilateral pain without sideshift,
poor documentation of the criteria used for diagnosing
with the initial pain located in the occipital area, and failure to
CGH, and the lack of standardized outcome measures in the
be classified by diagnostic criteria for other headaches.
majority of these studies. For example, a number of papers onradiofrequency neurotomy report some improvement of
symptoms in 71% to 83% of patients and complete relief in
The type of treatment recommended to patients with
7% to 43% of patients [65–69]. The authors, however, re-
CGH appears more dependent on the specialty of the treat-
ported the ablation of different nerves in these studies, mak-
ing physician than the science or research supporting it. The
ing it difficult to reach conclusions or compare the results.
four treatment options generally recommended are surgery
A number of papers on various decompression procedures
for a number of pathological entities; cervical spine manip-
report relief of headaches in a substantial number of patients
ulation; injections of various cervical structures with a vari-
but again have not used a standardized protocol [55,70].
ety of agents; and medication. The published literature in
The remaining papers on surgery consist mainly of isolated
support of surgical intervention for CGH is listed in Table
case reports. There are no controlled studies to support the
10. The main criticisms of this literature are the small sam-
use of any surgical procedure for the management of CGH,
ple sizes, the marked variation in the surgical procedures
and current justification for surgery appears to be based
used, the difference in the structures being operated on, the
solely on the anecdotal experience of the surgeon. Haldeman and Dagenais / The Spine Journal 1 (2001) 31–46
As mentioned above, the prevalence of CGH ranges from
reducing the frequency and severity of headaches and the
3.3% to 22.5% of chiropractic patients, indicating the fre-
amount of analgesic use by patients. A study by Howe et al.
quency with which these headaches are treated with manipu-
 indicated that the addition of one cervical manipulation
lation [48,72,73]. A survey of primary care physicians in Aus-
to nonsteroidal anti-inflammatory drug (NSAID) therapy was
tralia reported that 69% of them agreed that referral to a
superior to NSAID therapy alone immediately after treatment,
chiropractor was appropriate for headache provoked by head/
but this difference was lost at 3 weeks posttreatment. Bitterli
neck postures . The results of studies on cervical manipu-
et al.  found an advantage for cervical manipulation com-
lation for CGH are listed in Table 11. The results from the
pared with mobilization and controls after 3 weeks of treat-
case series are similar to those reported after surgery but suf-
ment, but the differences did not reach statistical significance.
fer from the same shortcomings. However, there are more
In an effect size analysis of randomized controlled trials on
randomized controlled trials on manipulation than any other
manipulation, Bronfort  concluded that there is moderate
treatment for CGH. The studies by Nilsson et al. [74,75] have
evidence of efficacy of cervical manipulation in the manage-
been the most rigorous and demonstrated that spinal manipu-
ment of CGH. Similar conclusions have been reached in qual-
lation was more effective, in the short term, than massage in
itative analyses by Hurwitz et al.  and Coulter et al. .
Table 12Treatment with injections for cervicogenic headache
Group 1: 90.6% had significant relief (mean 23.5 days)
54.4% reduction in number of days with VAS
56% had VAS ↓ Ͼ50% (only 16 patients for facet)
13.8% painfree for days8.0% painfree for weeks
Epidural corticosteroid Epidural space of C6–T1 Case series
Significant ↓ pain numeric intensity scale
Group 1:Significant ↓ pain and ↑ range of
Group 2: no changeNo between-group analysis
Headache frequency ↓ Ͼ50%Autonomic symptoms disappearedFull range of motion was restored in neck
No significant benefit for either treatment
GON ϭ greater occipital nerve; LON ϭ lesser occipital nerve; RCT ϭ randomized controlled trial; VAS ϭ visual analog scale. Haldeman and Dagenais / The Spine Journal 1 (2001) 31–46
Another common treatment approach for CGH is thera-
headaches, including TTH, no studies were found on their
peutic injections. The results of injection of various agents
and anesthetics on CGH are listed in Table 12. There are anumber of small case series on the injection of the occipital
nerves where short-term improvement of was noted in 50%to 90% of patients [34,43,54]. Again, these studies suffer
Despite a growing body of literature on CGH and an in-
from the same shortcomings as those on surgery and manip-
creasing acceptance that headaches can originate from the
ulation, and many reported only immediate postinjection re-
cervical spine, there remains considerable controversy and
sults with no follow-up period. One study  compared li-
confusion concerning all aspects of this topic. However, a
gnocaine, lignocaine with methylprednisolone, and
number of comments on CGH appear quite reasonable. The
methylprednisolone alone in a nonrandomized case series
concept that headaches can originate from the neck is not
and found that methylprednisolone was less effective than
new. The pain appears to be generated by irritation of noci-
lignocaine and did not add anything to the injection of li-
ceptors from structures in the cervical spine and may ac-
gnocaine alone. This finding does not support Martelletti’s
company injury and pathology in the neck. These headaches
theory about the role of inflammation in CGH [45,46]. Two
are difficult to differentiate from MH and TTH, although
relatively good cohort studies on the injection of sterile wa-
they possess the distinguishing characteristics of being trig-
ter and saline into tender points in cervical muscles failed to
gered by neck movements, pain spreading to the occipital
show any improvement of symptoms . A small case se-
region, tenderness in the suboccipital tissues, decreased cer-
ries on epidural corticosteroid injection reported some de-
vical range of motion, and unresponsiveness to typical
gree of relief . One intriguing study was a randomized
headache medication. The significance of radiological find-
controlled trial comparing botulinum toxin with saline in-
ings and advanced diagnostic testing is unclear. Evidence to
jection into the cervical paraspinal muscles, which found a
support treatment with surgery and injections consists
significant decrease in pain and increased cervical spine
mainly of case series without controls or standardized fol-
range of motion in the botulinum group .
low-up. The only treatment approach supported by a reason-
Among other treatments for CGH (Table 13) we found
able body of controlled trials is cervical manipulation, but
one randomized controlled trial on the use of transcutaneous
electrical nerve stimulation  suggesting slight tempo-
Until additional research and improved consensus on the
rary relief of symptoms. There were no significant studies
topic of CGH becomes available, it is essential that any cli-
that we could find on the use of medication for CGH. Where
nician maintain an open, cautious, and critical approach to
medications have been discussed, there has been the sugges-
the literature. At this point, the clinician must be wary of en-
tion that CGH is relatively unresponsive to most medica-
thusiastic and dogmatic claims concerning CGH. As the lit-
tions commonly used to treat other forms of headache. Al-
erature on this topic grows in volume and quality, the debate
though other treatments, including massage, biofeedback,
will intensify and hopefully result in the clarification of the
exercise, or nutrition, are commonly used to treat other
cause, diagnosis, and treatment of CGH.
Table 13Other treatment for cervicogenic headache
80% had Ͼ60% improvement20% has 40–60% improvement
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One Hundred Years Ago in Spine
on January 7, 1896 . Sometimes things moved quickly,even without the Internet.
In 1901 Wilhelm Conrad Röntgen received the Nobel
Prize. On November 8, 1895, he had noticed that dischargefrom an induction coil passed through a Crookes vacuumtube caused fluorescence on a shielded paper coated with
barium platinocyanide. Straightaway, he reported his newray to the Würzburg Physico-Medical Society and submit-
 Röntgen W. Uber eine neue Art von Strahlen. Nature 1896;53:274.
ted a paper to Nature . He took a radiograph of his wife’s
 Underwood EA. WC Röntgen and the early development of radiology.
hand on December 22, 1895. Robert Jones sent immediatelyfor the apparatus and used it to take the first clinical x-ray
LETRA DE CÂMBIO E NOTA PROMISSÓRIA - X I - Letra de Câmbio: a) Aspectos gerais e históricos: - Muito pouco se utiliza neste país a letra de câmbio, porque com a criação da duplicata mercantil, largamente utilizada nas operações mercantis, por ser mais operacional, aquele título praticamente caiu em desuso junto aos comerciantes, mesmo porque é proibida a sua emissão, na co
PREAMBULE La phase I du programme d’étude de l’écologie et de l’HAbitat de deux espèces de Requins Côtiers sur la côte Ouest de la Réunion (CHARC) a fait l’objet d’une convention entre la Direction de l'Environnement, de l'Aménagement et du Logement de la Réunion (DEAL) et l’Institut de Recherche pour le Développement (IRD). Il a été convenu que cette phase I qui s'