How do you diagnose and treat patients with cervicogenic headache?

I struggle with cervicogenic headaches. Conceptually, it is a secondary headache disorder with headache attributed to a disorder of the cervical spine and its component bony, disc, and/or soft tissue elements.

The ICHD-3 criteria help make this causal attribution. If a headache begins in relation to the onset of neck disease, if it is relieved when the neck disorder is relieved or by cervical nerve block then the diagnosis can be clear. Most patients I see with neck pain and headache have migrai...

I see a lot of cervicogenic headache in my TBI clinic. Diagnosis is based off of symptoms and physical exam. Patients will typically complain of neck pain/tightness and/or occipital pain. This pain will frequently radiate to the forehead. Patients frequently wake up with these headaches and also limits their ability to fall asleep (can't get comfortable).

On exam, they will always have tenderness in the paraspinal muscles and frequently in the occiput. Palpation typically will reproduce their he...

Totally agree with all management. A unilateral or bilateral occipital block with possible 1-2 trigger point injection usually gives 80-90 % relief in pain and is diagnostic and therapeutic. Then you can educate the patient about better neck posture and stretching neck exercises along with traditional medicines. Many migraine headaches are starting as cervicogenic headaches so if you take care of the root cause then you have great luck to treat your headache patients.

If the patient is in severe pain and palpation over the greater occipital nerve exit area produces or exacerbates the head pain, I will perform a greater occipital nerve block and put the patient on an NSAID, if no contraindication, as well as starting the patient on a course of manual neck PT treatments. Patients want the severe headache gone quickly and the med and PT will hopefully markedly reduce recurrence.

There is a significant overlap of post-TBI headaches with migraine headaches. In those patients who you feel have migraine, valproate can certainly help, although I do not use it very often. I typically start with propranolol or nortriptyline. The latter is nice if insomnia is a problem. I stay away from topiramate, unless the patient has no cognitive deficits. Valproate would be reasonable to try next vs CRP inhibitors and/or botox.

With regard to trigger point injections, I tend to inject wher...