In cervicogenic headache (CGH) cases where a specific source of pain is identified from a diagnostic nerve block or diagnostic imaging test, treatment methods involving injections or surgery may be considered. The treatment method can depend on many factors, including the location of the pain source and the corresponding nerve involved.
Injection Procedures for Cervicogenic Headache
Injection techniques involving the use of anti-inflammatory or pain reducing medications can often provide enough pain relief and are minimally invasive. These procedures also allow for other forms of manual and non-invasive therapeutic treatments to take place in a comfortable and patient compliant manner. A few injection techniques for pain-relief from CGH are discussed below.
- Radiofrequency neurotomy. If the source of pain has been confirmed, such as by a cervical facet injection or medial branch block aided contrast-enhanced fluoroscopy (x-ray guidance), radiofrequency neurotomy may be considered. The most common nerve treated by this procedure is the third occipital nerve that innervates the C2-C3 joint and the C3 and C4 medial branches of the dorsal rami that innervates the C3-C4 joint. A radiofrequency needle is guided via fluoroscopy alongside the nerve. To assure proximity to the target nerve, a small amount of electric current may be passed to momentarily recreate the usual pain. Once successfully identified, the tip of the needle is heated, and a heat lesion is created on the target nerve. This resulting lesion prevents the treated nerve from sending pain signals up to the brain. While the nerves do eventually grow back or regenerate after about a year, the pain may or may not recur.
- Cervical epidural steroid injection. The procedure involves the use of fluoroscopically guided, contrast enhanced needle placement into the epidural space (space around the nerve root containing cerebrospinal fluid and nerves). The injection delivers steroid medication to coat the nerves in this region. The goal is to reduce local inflammation and decrease nerve pain.
- Cervical intra-articular steroid injection. Steroid injections may be administered to relieve pain and inflammation stemming from the facet joints. The lateral atlanto-axial joint is a common source identified for this type of procedure. A fluoroscopically guided, contrast enhanced technique is used to direct the needle to the target facet joint. The medication is then deposited within the joint.
Injection techniques for pain relief from CGH have not been well studied in controlled clinical trials. Also, there have been inconsistent reports of effective pain-relief from these procedures. The effectiveness and safety of epidural steroid injections for CGH have not been approved by the FDA, and there is always a small risk of serious side effects, such as stroke or paralysis. Other risks and complications include bleeding, infections, and allergic reactions following injection of medications.
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Surgical Options for Cervicogenic Headache
In rare cases where nonsurgical treatments, including injections, have clearly identified the source of pain but have not provided long-term relief of CGH pain, surgery may be considered. Surgical examples of CGH treatment may include:
- Decompression and microsurgical neurolysis of the nerve. This procedure involves relieving pressure on the nerve by removing adhesive tissues such as ligaments, blood vessels, or other fibrous tissues that may be compressing the nerve. Neurolysis is not a well-accepted surgical technique as there is little evidence that scar tissue causes pain.9
- Neurectomy. The nerve is partially or completely removed to relieve nerve pain. This procedure is generally performed on the greater occipital nerve.
- Arthrodesis of atlanto-axial joint. Arthrodesis or surgical fusing of the atlanto-axial joint is used to treat lateral atlanto-axial joint pain. This procedure limits movement, increases stability, and reduces pain.
- Anterior cervical discectomy and fusion (ACDF). This surgery involves removing a damaged intervertebral disc from the cervical spine and setting up a bone graft to allow the two adjacent vertebrae to fuse together. This procedure can eliminate materials that may have been causing inflammation and pain, such as a damaged disc, and give more room for the spinal nerves and spinal cord to function.
- Cervical disc arthroplasty (CDA). CDA’s goals are similar to ACDF. However, instead of a fusion, the damaged disc is replaced by an artificial disc in an attempt to maintain motion between the adjacent vertebrae. Long-term data is still being collected on this newer procedure.
More studies are needed to determine the long-term effectiveness of these surgical options for treating CGH. As with all surgeries, there is a small risk for serious complications, such as excessive bleeding, allergic reaction, infection, and others.
- Bovim G, Fredriksen TA, Stolt-nielsen A, Sjaastad O. Neurolysis of the greater occipital nerve in cervicogenic headache. A follow up study. Headache. 1992;32(4):175-9.