Dr. Awss Zidan discusses cervicogenic headaches, emphasizing that headaches can be either primary or secondary, with a significant gray area involving musculoskeletal issues. He highlights how neck problems often exacerbate primary headaches, particularly migraines, and suggests that effective treatment requires a collaborative approach between headache specialists and pain management experts. The diagnosis of cervicogenic headaches involves a careful clinical history and examination, with treatment plans tailored to include both typical migraine therapies and neck-specific interventions.

1. Dr. Awss Zidan on Cervicogenic Headache;
when the Headache is not all in your
Head!
What are the causes of headaches?
Headaches can happen for many different reasons. They are generally classified in
one of two types: 1) Primary, meaning they are diseases on their own, without
being a symptom of another disease. These primary headaches include migraines,
tension headaches and clusters. they are the most common reason for headaches.
2) Secondary, meaning they arise in setting of other illnesses or conditions, such
as meningitis or brain tumors. While it may appear the differentiation is clear-cut
and dry, Dr. Awss Zidan, a board-certified neurologist and a pain management
specialist believes the line is blurred more often than not.

2. The gray area between primary and secondary
Headache, just like any other pain, can be and often is a reflection of
musculoskeletal derangement. Meaning that just like back pain and knee pain, the
reason behind headache can be irritated joints, or stretched ligaments. The key is
that for the musculoskeletal structure to cause headache, it has to be innervated
by the nerves that also travel to the head. The most prominent of these nerves are
the trigeminal nerve, and the nerves arising from the top cervical spine.
Only if you look at headache from this perspective that you will start to
understand some simple links that you have noted before, such as why toothache
results in a headache on the same side of the head (hint: teeth are innervated by
the trigeminal nerve), why sleeping wrong gives some people a strained neck and
a headache on the back of the head in the morning, or why strained eye muscles
from wearing the wrong glasses can give a headache in the front.
But wait, all these headaches happen because of a
“reason”, so they must be secondary
That is true, but only for a minority of patients. In clinical practice, Awss Zidan,
and other headache physicians, frequently encounter patients who have a primary
headache that is worsened by one of these musculoskeletal issues. Meaning that
in a normal individual, a strained neck may cause some mild headache in the back
of the head that disappears with massage or a hot bath, but in a patient with
migraines (or with genetic predisposition for migraines), a strained neck may
result in a vicious cycle of breakthrough migraines that can become incapacitating
and chronic.
What is cervicogenic headache?

3. Out of the “local” issues exacerbating migraines, Dr. Awss Zidan has frequently
identified the neck as a common contributing factor in headache. The term
“cervicogenic headache” means a headache originating from the neck (or cervical
spine to be more accurate). Classically, cervicogenic headache is thought of as a
“tension headache” occurring on the back of the head and strongly related to some
neck pathology such as injury or arthritis. In reality, cervicogenic headache is
often camouflaged as a typical migraine with its usual features of the throbbing
pain with light and noise sensitivity. The exacerbation may happen immediately or
after years of the neck injury, the same exact way that hip arthritis may happen
years after a hip injury.
How to tell that cervicogenic headache is playing a
role in your migraines
It all comes to a good history and clinical examination. This is where Awss Zidan’s
experience in both pain management (which treats mostly musculoskeletal pain)
and headache medicine can be of great use in identifying the culprit.

4. However being aware of some simple clues can direct you in the right direction in
identifying if the neck has a role in your headaches; these clues include a migraine
that always occurs on the same side (as opposed to a typical migraine which may
occur on one side, but usually switches between right and left), a history of neck
injury such as an accident with neck whiplash (like being rear-ended at a stop
sign), extreme tenderness on the back of your head, or finding that certain neck
positions can immediately worsen or improve your headache.
How to treat cervicogenic headache
A collaboration between a headache specialist or pain management can yield the
best results. Unfortunately, we rarely see a coordination of care between these
two specialties. Rather, the neurologist and the pain management physician each
treats the headache and the neck pain as if they were separate issues.
Awss Zidan believes a good treatment plan for migraines exacerbated by
cervicogenic headache has all the elements of typical migraine treatment, with the
addition of neck-specific therapies, such as counseling on good neck ergonomics
at work and home, physical therapy to strengthen neck muscles, and certain pain
procedures to reduce the pain and improve the range of motion. It is imperative
that these procedures be done as a part of a good therapy plan (and not be the
only treatment provided), and be directed to the pain generators in the neck that
can cause headache as well.