Headaches can have multiple underlying causes. A cervicogenic headache is a headache which is caused by underlying cervical spinal pathology. This is a secondary type of headache, which means that it is caused by another illness or physical issue. Cervicogenic headaches are chronic and recurrent headaches that may be brought on with cervical spinal movement, and may be associated with cervical related pain. This headache is often confused with a migraine, tension headache, or other primary headache syndromes.

People with cervicogenic headaches may have a reduced range of motion of their neck and worsening of their headache with certain movements or activities or pressure applied to certain spots on their neck. The headaches may be only on one side of the head, and the pain may radiate from the neck/back of the head up to the front of the head or behind the eye. While many patients experience cervical related pain or symptoms, patient with cervicogenic headaches do not have to have neck pain.

The common features of CGH include

• Pain originating at the back of the neck and radiating along the forehead, area around the eye, temple, and ear
• Pain along the shoulder and arm on the same side
• Reduced flexibility of the neck
• Eye swelling and blurriness of vision may occur on the affected side in some cases
• Pain almost always affects the same side of the neck and head, but in uncommon cases both sides may be affected

Diagnostic criteria must include all the following points

1. The cause of the pain must be from the neck and perceived in head or face.

2. Evidence that the pain is stemming from the cervical spine. The role of diagnostic injections such as a cervical medial branch block can help with the diagnosis.

3. Pain resolves within three months after successful treatment of the causative disorder or lesion.

Medication specifically for ilioinguinal nerve pain is the first line of therapy. These medications are similar to other drugs prescribed to treat neuropathic pain. Neuropathic pain can be caused when the nerve fibers become damaged, injured, or cannot properly function. If medications do not provide good pain relief, the ilioinguinal nerve can be blocked using an injection therapy. This treatment is both diagnostic and therapeutic. Depending on injection results, future treatment can be considered, including nerve ablation (disables the nerve) and neuromodulation (pain control using spinal stimulation).

Diagnostic imaging such as X-rays, MRI and CT scans cannot confirm the diagnosis of cervicogenic headache but can lend support to its diagnosis. These exams also help rule out other potential causes of the pain.

Trigeminal Neuralgia, Supraorbital, Infraorbital & Mandibular Neuralgia

The supraorbital (SON) and infraorbital nerves (ION) are branches of the trigeminal nerve; the main nerve that provides sensation to facial skin. The trigeminal nerve is the fifth cranial nerve, and the three major branches are called the V1, or ophthalmic, V2, or maxillary, or V3, or mandibular. The SON provides superficial sensation from the forehead into the scalp line. The ION supplies sensory innervations to the mid-face; from the cheek to the nose, along the V2 distribution. The mandibular branch travels in the back of our jaw bone to cover our lower face and teeth.

Supraorbital, infraorbital, and mandibular neuralgia (nerve pain) may be caused by trauma, plastic surgery, dental work, shingles or other infections that can lead to nerve irritation. Symptoms range from sharp, shooting, and tingling to dull and aching pain and are usually limited to the effected dermatome.

Causes or Symptoms

Supraorbital, infraorbital, and mandibular neuralgia (nerve pain) may be caused by trauma, plastic surgery, dental work, shingles or other infections that can lead to nerve irritation. Symptoms range from sharp, shooting, and tingling to dull and aching pain and are usually limited to the effected dermatome.

Areas of the face may become very sensitive to touch and when severe, disabling. Often, these nerves may heal with time. However, if pain is intolerable or becomes prolonged, there are several options from interventional pain management which may help.

Treatment Options

Your initial evaluation would begin with a thorough history and physical assessment to confirm the diagnosis and rule out other potential causes of pain. Initial therapies would potentially start with additional testing, conservative options such as neuropathic pain medications, topical medication, referrals to other specialists, and other relevant therapies.

Often, injuries leading to pain from the supraorbital and infraorbital nerves may heal with time and conservative care. However, if pain is intolerable or becomes prolonged, a minimally invasive supraorbital, infraorbital nerve block, or trigeminal nerve block may help relieve pain. These injections are diagnostic and therapeutic. By placing a small amount of local anesthetic with or without a very small amount of steroid on the nerves and having a significant improvement of pain for the duration of the local anesthetic, it diagnostically indicates that the pain is coming from that nerve. Therapeutically, the small amount of steroid can decrease inflammation that is related to the pain.

Peripheral nerve stimulation (PNS) may be considered if trigeminal neuralgia (SON or ION) cannot be otherwise controlled or managed. PNS involves implanting a small low-level electrical stimulator beneath the skin to block transmission of pain signals to the brain. This is first performed with a trial of the treatment before insertion of the device. During the trial period, a temporary device is placed under the skin, with the generator externalized and taped to an area like the chest or the back. There are typically no incisions made during the 7-day trial period, after which it is removed. At that point, it is the determination of the patient and the physician on whether the device is to be implanted.

Occipital neuralgia is a type of headache that presents on the posterior aspect of the head in the distribution of the greater occipital nerve (GON), lesser occipital nerve (LON), third occipital nerve (TON), or a combination of the three. The reported pain originates in the suboccipital region up to the vertex and radiates to the frontotemporal region. Radiation to the orbital region is also common. Pain from occipital neuralgia can be paroxysmal, lasting from seconds to minutes, and often consists of lancinating pain that directly results from the pathology of one of these nerves. There may be associated with posterior scalp dysesthesia and/or hyperalgesia.

Sensory triggers to the face or skull can initiate a painful episode. One may complain of worsening of pain when putting their head on a pillow. Prolonged abnormal fixed postures that occur in reading or sleeping positions and hyperextension or rotation of the head to the involved side may provoke the pain. The pain may be bilateral, although the unilateral pattern is more common. Often, a previous history of cervical or occipital trauma or arthritic disease of the cervical spine is obtained. Occasionally, patients may report other autonomic symptoms concurrently such as nausea, vomiting, photophobia, diplopia, ocular and nasal congestion, tinnitus, and vertigo. Severe ocular pain has also been described, as well as symptoms in other distributions of the trigeminal nerve. Convergence of sensory input from the upper cervical nerve roots into the trigeminal nucleus may explain this phenomenon

Occipital pain is sometimes reproduced by palpation of the greater and/or lesser occipital nerves. Hypersensitivity to normal touch may be present in the nerve distribution. Myofascial pain may be present in the neck or shoulder, and cervical range of motion may be decreased. Neurologic examination of the head, neck, and upper extremities is generally normal. Occasionally, patients may report other autonomic symptoms concurrently such as nausea, vomiting, photophobia, diplopia, ocular and nasal congestion, tinnitus, and vertigo. Ocular pain may also be present, as well as symptoms in other distributions of the trigeminal nerve

Anatomy

The greater occipital nerve innervates the posterior skull from the suboccipital area to the vertex. It is formed from the medial (sensory) branch of the posterior division of the second cervical nerve. It emerges between the atlas and lamina of the axis below the oblique inferior muscle and then ascends obliquely on the latter muscle between it and the semispinalis muscle.

The lesser occipital nerve forms from the medial (sensory) branch of the posterior division of the third cervical nerve, ascends similar to the greater occipital nerve, and pierces the splenius capitis and trapezius muscles just medial to the greater occipital nerve. It ascends along the scalp to reach the vertex, where it provides sensory fibers to the area of the scalp lateral to the greater occipital nerve.

The diagnostic criteria include the following:

• Paroxysmal stabbing pain, with or without persistent aching between paroxysms, in the distribution(s) of the greater, lesser, and/or third occipital nerves
• Tenderness over the affected nerve
• Pain is eased temporarily by local anesthetic block of the nerve

Occipital neuralgia must be distinguished from occipital referral of pain from the atlanto-axial or upper zygapophyseal joints or from tender trigger points in neck muscles or their insertions.

The greater occipital nerve is the terminal branch of the dorsal ramus of C2 with contribution from C3, while the lesser occipital nerve is a branch of the dorsal ramus of C3 with contributions from C2. Segmental nerve blocks at C2 and C3 may be necessary to make the diagnosis in some cases.

Treatments

Interventional pain management options are available for the treatment of occipital neuralgia. Occipital nerve blocks involve placing a local anesthetic and a small amount of steroid along the nuchal line in the posterior scalp. This procedure can be repeated should the symptoms return. If the pain continues to return, longer term options such as cryoablation of the occipital nerves, C 3 nerve block and potential ablation, or finally, neuromodulatory techniques.

The premise of cervicogenic headache results from the functional and anatomical intersection between the sensory fibers supplying the face and the neck. The neck consists of seven cervical vertebrae (C1-C7) and facet joints on either side. Like many joints in the body, facet joints and surrounding soft tissues can become sprained or strained. C2-3 facet joint pain is also known as occipital headache due to the occipital nerve supplying the C2-3 facet joint. Therefore, it is well established that upper cervical spine disorders and injuries can cause headaches in the back of the skull. Roughly 1 in 3 patients develop cervicogenic headaches after a whiplash injury. Symptom reproduction or tenderness with palpation over the upper neck and C2–C3 joint tenderness is a common finding on physical exam. However, a diagnostic third occipital nerve block is critical to confirm the diagnosis of occipital headache or cervicogenic headache from inflamed neck joints.

The terminal upper cervical vertebra (C1 and C2 )form the atlantoaxial (AA) joints. AA joints are located immediately below the base of the head. Therefore, AA joint pathology could manifest as headache (see C2-3 FACET JOINT AND 3RD OCCIPITAL HEADACHE), pain in the back of the head or bottom of the skull. AA joint pain is typically aggravated by rotating the head from side to side like shake one’s head as in saying “No.” Commonly, AA joint pain or injury is related to an accident, such as head trauma or whiplash-type injury, or arthritis. AA joint pain can be challenging to diagnose with radiological testing alone, including routine x-ray, open-mouth view neck x-ray, CT, or MRI. A thorough history and clinical exams are paramount; however, diagnostic AA joint block(s) is the gold standard to confirm if your headache stems from AA joint(s).

Medical acupuncture involves the insertion of tiny needles in key locations of the body — or acupressure. It is a valid medical tool that can change a person’s energy, or “chi,” from within. It does not involve the injection of any medication. It’s not a therapy that necessarily means a lifetime commitment. Everything depends on the patient’s response and the doctor’s ability to understand the patient and his or her history. It has been established that neurotransmitters in the body, called endorphins, decrease a patient’s perception of pain. Endorphins are produced by the pituitary gland and the hypothalamus in vertebrates, in response not only to pain, but to exercise, excitement, consumption of spicy food and love. Endorphins resemble opiates in their ability to produce a feeling of well-being. In fact, the word “endorphins” comes from shortened versions of the words “endogenous” and “morphine,” which when put together mean “a morphine-like substance originating from within the body.

Acupuncture in and of itself may not be enough for many patients, but when combined with other therapies — many that have nothing to do with opioid pharmaceuticals that are great in certain situations, but sometimes abused — a patient’s quality of life can usually be significantly improved.

To expand the breadth of treatment options offered to her patients, Dr. Kiran V. Patel completed training in medical acupuncture at Harvard Medical School and Brigham Women’s Hospital. She is certified by the State Medical board of New York to practice Medical Acupuncture and performs it in both our Manhattan and New Hyde Park (Long Island) offices. Currently, Dr. Patel is the only physician in our Practice to perform medical acupuncture to treat chronic pain.

The spine’s joints are called facet joints or zygapophyseal joints. Facet joints are found in the cervical (neck), thoracic (mid back), and lumbar (low back) spine. These joints allow the spine to flex, extend, and rotate. The medial branch nerve innervates (stimulates) the facet joint. As we age, or secondary to trauma (such as whiplash), the facet joints can be damaged and develop arthritis similar to other body joints. Facet joint pain can be secondary to neck pain and may radiate (travel) into the posterior (back) aspect of your head, shoulders and upper back where the rhomboid muscles attach your shoulder blades to your spine. While arthritis is commonly detected by x-ray or MRI, the presence of arthritis/facet hypertrophy (increased joint size) does not always mean it is the cause of neck pain.

The medial branch nerve innervates the facet joint and may cause nerve root irritation and pain. A medial branch nerve root block is performed to confirm that a facet joint is the source of your pain. While the nerve block is diagnostic, it may be therapeutic providing pain relief.

Before the cervical medial nerve block, you may be given medication to relax you (optional). Most patients do not need anesthesia (twilight) because the needles are very small (25 or 27 gauge). The skin area is numbed using a local anesthetic. Using fluoroscopy (real-time x-ray), the physician guides the needle into the proper area of your cervical spine. Once the needle is positioned near the median nerve, a combination of anesthetics (less than half of 1 cc) is injected into the medial region. The entire facet block procedure takes less than 10 minutes.

BOTOX® is the first and only FDA-approved preventive treatment for chronic migraines. It’s also the only treatment for people with chronic migraine that can help prevent headaches and migraines before they even start. What makes BOTOX® a different type of treatment? Unlike acute treatments, which are taken to treat a headache or migraine once it’s already begun, BOTOX® prevents headaches and migraines before they even start. BOTOX® prevents on average 8 to 9 headache days and migraine/probable migraine days a month (vs 6 to 7 for placebo). And for people with Chronic Migraine—people who live with 15 or more headache days a month—that can make a big difference.

5 quick things you should know about BOTOX® treatment

• It prevents headaches and migraines before they even start. BOTOX® prevents on average 8 or 9 headache days and migraine/probable migraine days a month (vs 6 to 7 for placebo) at 24 weeks.
• It’s given every 12 weeks. It will take 2 treatments, 12 weeks apart to determine how well BOTOX® is working for you. If you don’t get treated every 12 weeks, you may not get the full benefit of BOTOX®.
• It’s a small needle. People say that the injections feel like tiny pinpricks.
• It’s injected by a BOTOX®specialist. Our doctors are experienced in treating with BOTOX®.
• It takes about 15 minutes. The injections take about 15 minutes, and are done right in our office.