Цервикогенная головная боль

[Dr.]

TREATMENT*—*There is no proven effective treatment for cervicogenic headache. However, a number of different treatment modalities are available. Physical therapy is the preferred initial treatment because it is noninvasive.

Physical therapy*—*Physical therapy may provide long-term improvement for cervicogenic headache. In a randomized controlled trial with unblinded treatment and blinded assessment of 200 patients with cervicogenic headache, those assigned to six weeks of treatment with either manipulative therapy, exercise therapy, or a combination of both therapies had a significant reduction in headache frequency at 12 months, the primary outcome measure, compared with controls who received no treatment [38]. The effect size was reported as moderate and clinically relevant. Combined treatment was not significantly better than either treatment alone.

An earlier randomized controlled trial with unblinded treatment and blinded assessment found that manipulative therapy was beneficial for cervicogenic headache at five weeks [39].

Given these data, we suggest physical therapy as the initial treatment option for patients with cervicogenic headache.

Anesthetic blockade*—*Anesthetic injections can temporarily reduce or relieve pain and may allow greater participation in physical treatments. Although the concept has not been adequately confirmed in clinical trials, complete relief of pain by diagnostic blockade of the cervical spinal nerve, medial branch, or zygapophyseal joint is likely to predict response to radiofrequency neurotomy [40]. It seems intuitive that patients who have incomplete response to anesthetic blocks should not undergo radiofrequency neurotomy or surgical procedures. (See "Radiofrequency neurotomy" below).

Greater and lesser occipital nerve blockade may provide temporary but substantial pain relief in some cases, although the benefit of this treatment does not appear to be specific for cervicogenic headache [41].

Radiofrequency neurotomy*—*Percutaneous radiofrequency neurotomy can be considered for cervicogenic headache if diagnostic anesthetic blockade of cervical nerve, medial branch, or zygapophyseal joint blockade is temporarily successful in providing complete pain relief [40,42,43]. However, the benefit of this procedure for cervicogenic headache is not established by adequate randomized controlled trials.

In the setting of neck pain, radiofrequency neurotomy appears to be beneficial in patients selected on the basis of complete pain relief with diagnostic blockade. This point is illustrated by a randomized controlled trial involving 24 patients with chronic cervical zygapophyseal joint pain (but NOT cervicogenic headache) confirmed with double-blind, placebo-controlled local anesthesia [43]. Patients assigned to active treatment (n=12) had a significantly longer pain relief compared with those assigned to controls.

In contrast, radiofrequency neurotomy compared with sham treatment was not beneficial in patients with cervicogenic headache selected on the basis of purely clinical criteria, as shown in a randomized controlled trial of 12 patients [44]. A major limitation of this study is that all included patients had an incomplete response to diagnostic anesthetic blockade and, thus, might not be expected to respond to radiofrequency denervation [45].

For patients with third occipital headache selected on the basis of controlled diagnostic blocks of the third occipital nerve (see "Third occipital headache" above), one series of 49 patients reported that treatment with radiofrequency neurotomy was successful with complete relief of pain in 43 patients (88 percent) [46]. The median duration of relief was 297 days. After recurrence, headache relief could be reestablished by repeating the procedure. Side effects of the procedure were consistent with denervation of the third occipital nerve and included mild ataxia, numbness, and temporary dysesthesia; none of these side effects required intervention.

Given these data, we suggest radiofrequency neurotomy for patients with third occipital headache or cervicogenic headache who have the diagnosis confirmed by complete pain relief in response to controlled anesthetic block and who are refractory to noninvasive therapy.

Steroid injection*—*Small uncontrolled retrospective studies suggest that some patients may obtain relief from intraarticular steroid injections at the C2-3 zygapophyseal joint [47]. Cervical epidural steroid injections may give short-term pain relief in cases of multilevel disc or spine degeneration [48].

Pharmacologic treatment*—*Pharmacologic treatment options for chronic cervicogenic headache include medications that are used for the preventive or palliative management of neuropathic pain, such as tricyclic antidepressants, anticonvulsants, and others. However, these medications have not been evaluated in controlled clinical trials for the treatment of cervicogenic headache.

Available evidence suggests that pharmacologic therapy does not provide substantial pain relief for cervicogenic headache in most cases [9]. In addition, patients with chronic cervicogenic headache may overuse or become dependent on analgesics. Despite these observations, the judicious short-term use of analgesic medication may provide enough pain relief to allow greater patient participation in a physical therapy and rehabilitation program.

Surgery*—*A variety of surgical interventions, such as neurectomy, dorsal rhizotomy, and microvascular decompression of nerve roots or peripheral nerves, have been performed for presumed cases of cervicogenic headache [3]. However, the available data are limited to small observational studies, and these have generally reported that surgery is associated with only incomplete or temporary benefit for pain relief.

As an example, in a series of 31 patients who met clinical criteria for cervicogenic headache, including headache relief from diagnostic block of the C2 spinal nerve, surgical decompression and microsurgical neurolysis of the C2 spinal nerve was associated with complete pain relief in 14 patients (45 percent) and "adequate improvement" in 16 (52 percent) [15]. Another study found that surgical liberation of the occipital nerve from entrapment in the trapezius muscle or surrounding connective tissues provided immediate but temporary pain relief for most patients [49]. Similarly, only temporary pain relief was observed after surgical transection of the greater occipital nerve [49].

Case reports have suggested benefit of surgical decompression for patients with C2 neuralgia who have entrapment of the C2 root by a hypertrophied atlantoepistrophic ligament [50] or meningioma [17].

Intensification of pain or anesthesia dolorosa are potential adverse outcomes that must be considered when contemplating the use of surgical interventions.

Given the uncertain and temporary benefit, surgical procedures for cervicogenic headache are not recommended unless there is compelling radiologic evidence for a surgically correctable pathology in patients who are refractory to all reasonable nonsurgical treatments.

SUMMARY AND RECOMMENDATIONS The underlying pathophysiology and source of pain in cervicogenic headache are controversial. The leading explanation is that cervicogenic headache is caused by referred pain from the upper cervical joints. The first three cervical spinal nerves and their rami are the primary peripheral nerve structures that can refer pain to the head. (See "Etiology and anatomy" above). There is no consensus regarding the definition of cervicogenic headache, but two conflicting viewpoints are widely recognized. One relies on clinical features, while the other ignores clinical features and relies on the demonstration of a distinct anatomic source in the neck that can cause head pain. The definitive criterion for the latter definition is complete relief of pain after controlled anesthetic blocks of cervical structures or their nerve supply. Conflicting diagnostic criteria have also been proposed. (See "Definition and clinical features" above, see "Diagnosis" above and see "Diagnostic criteria" above). C2 neuralgia and third occipital headache are subtypes of cervicogenic headache. (See "C2 neuralgia" above and see "Third occipital headache" above). Since accurate diagnosis of cervicogenic headache is a prerequisite to treatment, we suggest that the diagnosis should be confirmed by controlled anesthetic blocks of cervical structures or their nerve supply. Other headache etiologies should be pursued if the response to diagnostic blockade is incomplete. (See "Diagnosis" above and see "Diagnostic anesthetic blockade" above). The main differential diagnoses in cases of suspected cervicogenic headache, particularly when chronic, include migraine and tension-type headache. Aneurysm of the internal carotid or vertebral artery is an important consideration in cases of suspected acute cervicogenic headache. (See "Differential diagnosis" above). There is no proven treatment for cervicogenic headache. For patients with cervicogenic headache that is confirmed by complete pain relief with controlled anesthetic block of a relevant cervical structure or its nerve supply, we suggest physical therapy as the initial treatment option (Grade 2B). (See "Treatment" above and see "Physical therapy" above) For patients with third occipital headache, confirmed by complete pain relief with diagnostic blockade of the third occipital nerve, who are refractory to physical therapy, we suggest radiofrequency neurotomy (Grade 2B). For patients with other etiologies of cervicogenic headache (confirmed by controlled anesthetic block) who are refractory to physical therapy, we suggest radiofrequency neurotomy as the next treatment option (Grade 2C).