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Author: Tinyel This article is published by the author with the authorization of Yimaitong, please do not reprint without authorization
.
Let's look at a case first
.
A young female patient complained of pain in the left shoulder, neck, and posterior occiput for 1 week
.
Oral painkillers were ineffective
.
The patient complained that he had a headache 2-3 months ago, which occurred before menstruation, was pulsatile, accompanied by photophobia and phonophobia, nausea, and no vomiting, but he could continue to work and improved after rest
.
The headache has lasted for 1 week and has not been relieved.
Standing for a long time can aggravate the headache, and it improves after lying down.
There is no obvious photophobia and phonophobia
.
Brain CT showed no obvious abnormality, and cervical MRI showed mild herniation of cervical 3/4 and cervical 5/6 intervertebral discs, and dural sac compression
.
After more than 10 days of treatment with acupuncture and traditional Chinese medicine, the patient's pain was significantly relieved, but there was still a slight head discomfort, mainly on the left side, and complained of headache at home, but not obvious at work
.
(You can look back on the previous post and do you think you will see headaches? Headache consultation process, and "cheats" Oh, this is the same case) Neck pain and headache are both common clinical phenomena, but the same phenomenon can be different diseases The same patient can suffer from different diseases at the same time
.
Just like the patient in the case, he has neck pain, headache, photophobia, and nausea.
Is it a migraine? Or cervical spondylosis? Or cervicogenic headache? This article introduces the connection and difference between these three diseases, and puts forward some personal views
.
Migraine According to the International Classification of Headache, Third Edition (ICHD-3), migraine includes migraine without aura, migraine with aura, chronic migraine, migraine complications, probable migraine, and migraine with possible migraine.
associated cycle syndrome
.
Migraine without aura is the most common, followed by migraine with aura
.
In ICHD-3, it is clearly pointed out that prodromal symptoms, such as neck stiffness, nausea, fatigue, etc.
, may appear before the onset of migraine without aura, and similar manifestations will appear after the headache, which is the late symptom of migraine
.
Here's a reminder, don't confuse "prodromal symptoms" with "aura", the former can appear in migraine without aura and migraine with aura, while the latter only appears in migraine with aura, and the two behave differently , auras are generally visual manifestations (eg, flashes of light, fence-like streaks), sensory manifestations (eg, numbness), verbal/verbal manifestations,
etc.
At the same time, don't think that the pain stage is the whole process of migraine onset.
The onset process of migraine includes prodromal phase - aura phase (if any) - headache phase - remission phase - recovery phase
.
Figure 1 Classification of migraine cervicogenic headache Nearly 20 years ago, scholars introduced the origin, evolution history, pathophysiological mechanism and treatment of the name "cervicogenic headache"
.
The generalized cervicogenic headache refers to all headaches related to structural or functional abnormalities of the neck; the narrowly defined cervicogenic headache can be diagnosed according to the diagnostic criteria of ICDH-2
.
Among patients with cervical spondylosis, about 80% of patients have recurrent neck pain every year, but few patients have headache attacks; the incidence of headache is lower in patients with cervical spondylosis with cervical disc herniation; in patients with cervical radiculopathy Among the patients, most patients will have obvious radicular symptoms, and the proportion of headache is significantly lower than that of any kind of radicular symptoms, which suggests that positive imaging results do not necessarily provide objective evidence for the diagnosis of cervicogenic headache.
Pain and headache patients are not necessarily cervicogenic headache
.
At the same time, cervicogenic headaches caused by cervical disc herniation are generally located in the neck and occiput, no more than the top of the skull.
The pain rarely radiates to the limbs, and imaging shows are concentrated in the upper cervical spine
.
Headache may occur in the herniated disc of the upper cervical vertebra, which may be related to the presence of the C1-C4 nerve roots and the communicating branch of the trigeminal nerve
.
Cervicogenic headache is classified in ICHD-3 under Headache or facial pain attributed to head, neck, eye, ear, nose, sinus, dental, oral, or other facial or neck structure disorders, and migraine Same as primary headache
.
Cervicogenic headaches include headaches caused by nontraumatic disorders of any structure in the neck, including bones, muscles, and other soft tissues
.
It's important to point out, however, that cervicogenic headaches are not always accompanied by neck pain
.
"Headache" is repeatedly mentioned in the diagnostic criteria, indicating that although it is "cervicogenic", "headache" is the core symptom, which also complies with the special reminder that "neck pain is not always present"
.
Figure 2 Classification of cervicogenic headache in ICDH Cervical spondylosis Cervical spondylosis is one of the most common diseases in outpatient clinics
.
With the rapid development of imaging technology, it is not too laborious to do a neck or head MRI, so more and more cervical disc herniation, bone spurs, straightening of physiological curvature, calcification of ligamentum flavum, etc.
Prompt with nerve root compression
.
Clinicians often match the test results with the symptoms of the patient.
If they can be matched, the diagnosis of "cervical spondylosis" is marked; if they cannot be matched, they will write another diagnosis.
The "trash can" of dizziness/vertigo is also the "trash can" of headache diagnosis
.
Patients with cervical spondylosis (specifically cervical spondylosis and radiculopathy) generally have neck and back pain, numbness and weakness of the upper limbs, generally no headache (may also be accompanied by headache), do not affect daily activities, related nervous system Physical examination may be positive and imaging may or may not be positive
.
Table 1 Comparison of the three diseases Summary Generally speaking, there is a relationship between cervicogenic headache, migraine, and cervical spondylosis, and there are also certain differences, which should be distinguished in clinical practice
.
Cervicogenic headache is included in the ICDH, and the "vascular neuropathic headache" we usually use does not exist in ICDH, that is to say, there is no diagnosis of "vascular neuropathic headache"
.
It's like the vertigo community is phasing out the diagnosis of "cervical vertigo" and replacing it with other, more precise diagnoses
.
Some of our "accustomed" diagnoses are not necessarily correct, which should arouse the high attention of clinicians
.
These three diseases have overlapping parts and independent parts, which need to be comprehensively considered and diagnosed with caution in clinical diagnosis
.
At the same time, the possibility of patients suffering from two or three diseases (or other diseases) at the same time cannot be ignored.
After all, patients with migraine can also suffer from cervical spondylosis at the same time, and neck pain in patients with cervicogenic headache may also be a migraine attack.
The prodromal or post-symptoms, other primary or secondary headaches combined with pathological changes of the cervical spine or neck pain are not necessarily or only cervicogenic headaches
.
As for cervicogenic headache and cervical spondylosis, it can be seen literally that the main symptom of the former is "headache", and "cervicogenic" indicates the nature, or the cause of the disease; cervical spondylosis focuses on "cervical vertebra" This diseased part (including muscles, bones, etc.
) leads to the appearance of some symptoms.
Headache is one of the symptoms, but it does not necessarily appear
.
Therefore, I personally think that the two need to be differentiated
.
As for the stiff neck pain of migraine, it is a prodrome or/and a later symptom, and there are some special accompanying symptoms, which are not difficult to distinguish from the other two diseases
.
In general, cervical spondylosis + headache ≠ cervicogenic headache, neck pain ≠ cervical spondylosis, no neck pain + headache ≠ no cervicogenic headache
.
Only by clearly grasping the basic concepts and relationships can be targeted in clinical practice
.
So, what diagnosis should the patient in this case give? References: [1] Yu Shengyuan.
Neck and Headache [J].
Chinese Journal of Pain Medicine, 2005, 11(6): 323.
[2] Yu Shengyuan, et al.
International Headache Classification Third Edition [J].
[3] Zhang Yinan, Tan Ge, Zhou Zefang, et al.
Research progress on diagnostic criteria for cervicogenic headache ICHD [J].
Chinese Journal of Practical Neurological Diseases, 2019, 22(23): 2665-2668.
[4] Zhu Shourong, Yu Sheng Yuan, Hou Kedong, et al.
Clinical diagnosis and treatment of cervicogenic headache caused by cervical spondylosis [J].
Chinese Journal of Pain Medicine, 2005, 11(6): 330.
.
Let's look at a case first
.
A young female patient complained of pain in the left shoulder, neck, and posterior occiput for 1 week
.
Oral painkillers were ineffective
.
The patient complained that he had a headache 2-3 months ago, which occurred before menstruation, was pulsatile, accompanied by photophobia and phonophobia, nausea, and no vomiting, but he could continue to work and improved after rest
.
The headache has lasted for 1 week and has not been relieved.
Standing for a long time can aggravate the headache, and it improves after lying down.
There is no obvious photophobia and phonophobia
.
Brain CT showed no obvious abnormality, and cervical MRI showed mild herniation of cervical 3/4 and cervical 5/6 intervertebral discs, and dural sac compression
.
After more than 10 days of treatment with acupuncture and traditional Chinese medicine, the patient's pain was significantly relieved, but there was still a slight head discomfort, mainly on the left side, and complained of headache at home, but not obvious at work
.
(You can look back on the previous post and do you think you will see headaches? Headache consultation process, and "cheats" Oh, this is the same case) Neck pain and headache are both common clinical phenomena, but the same phenomenon can be different diseases The same patient can suffer from different diseases at the same time
.
Just like the patient in the case, he has neck pain, headache, photophobia, and nausea.
Is it a migraine? Or cervical spondylosis? Or cervicogenic headache? This article introduces the connection and difference between these three diseases, and puts forward some personal views
.
Migraine According to the International Classification of Headache, Third Edition (ICHD-3), migraine includes migraine without aura, migraine with aura, chronic migraine, migraine complications, probable migraine, and migraine with possible migraine.
associated cycle syndrome
.
Migraine without aura is the most common, followed by migraine with aura
.
In ICHD-3, it is clearly pointed out that prodromal symptoms, such as neck stiffness, nausea, fatigue, etc.
, may appear before the onset of migraine without aura, and similar manifestations will appear after the headache, which is the late symptom of migraine
.
Here's a reminder, don't confuse "prodromal symptoms" with "aura", the former can appear in migraine without aura and migraine with aura, while the latter only appears in migraine with aura, and the two behave differently , auras are generally visual manifestations (eg, flashes of light, fence-like streaks), sensory manifestations (eg, numbness), verbal/verbal manifestations,
etc.
At the same time, don't think that the pain stage is the whole process of migraine onset.
The onset process of migraine includes prodromal phase - aura phase (if any) - headache phase - remission phase - recovery phase
.
Figure 1 Classification of migraine cervicogenic headache Nearly 20 years ago, scholars introduced the origin, evolution history, pathophysiological mechanism and treatment of the name "cervicogenic headache"
.
The generalized cervicogenic headache refers to all headaches related to structural or functional abnormalities of the neck; the narrowly defined cervicogenic headache can be diagnosed according to the diagnostic criteria of ICDH-2
.
Among patients with cervical spondylosis, about 80% of patients have recurrent neck pain every year, but few patients have headache attacks; the incidence of headache is lower in patients with cervical spondylosis with cervical disc herniation; in patients with cervical radiculopathy Among the patients, most patients will have obvious radicular symptoms, and the proportion of headache is significantly lower than that of any kind of radicular symptoms, which suggests that positive imaging results do not necessarily provide objective evidence for the diagnosis of cervicogenic headache.
Pain and headache patients are not necessarily cervicogenic headache
.
At the same time, cervicogenic headaches caused by cervical disc herniation are generally located in the neck and occiput, no more than the top of the skull.
The pain rarely radiates to the limbs, and imaging shows are concentrated in the upper cervical spine
.
Headache may occur in the herniated disc of the upper cervical vertebra, which may be related to the presence of the C1-C4 nerve roots and the communicating branch of the trigeminal nerve
.
Cervicogenic headache is classified in ICHD-3 under Headache or facial pain attributed to head, neck, eye, ear, nose, sinus, dental, oral, or other facial or neck structure disorders, and migraine Same as primary headache
.
Cervicogenic headaches include headaches caused by nontraumatic disorders of any structure in the neck, including bones, muscles, and other soft tissues
.
It's important to point out, however, that cervicogenic headaches are not always accompanied by neck pain
.
"Headache" is repeatedly mentioned in the diagnostic criteria, indicating that although it is "cervicogenic", "headache" is the core symptom, which also complies with the special reminder that "neck pain is not always present"
.
Figure 2 Classification of cervicogenic headache in ICDH Cervical spondylosis Cervical spondylosis is one of the most common diseases in outpatient clinics
.
With the rapid development of imaging technology, it is not too laborious to do a neck or head MRI, so more and more cervical disc herniation, bone spurs, straightening of physiological curvature, calcification of ligamentum flavum, etc.
Prompt with nerve root compression
.
Clinicians often match the test results with the symptoms of the patient.
If they can be matched, the diagnosis of "cervical spondylosis" is marked; if they cannot be matched, they will write another diagnosis.
The "trash can" of dizziness/vertigo is also the "trash can" of headache diagnosis
.
Patients with cervical spondylosis (specifically cervical spondylosis and radiculopathy) generally have neck and back pain, numbness and weakness of the upper limbs, generally no headache (may also be accompanied by headache), do not affect daily activities, related nervous system Physical examination may be positive and imaging may or may not be positive
.
Table 1 Comparison of the three diseases Summary Generally speaking, there is a relationship between cervicogenic headache, migraine, and cervical spondylosis, and there are also certain differences, which should be distinguished in clinical practice
.
Cervicogenic headache is included in the ICDH, and the "vascular neuropathic headache" we usually use does not exist in ICDH, that is to say, there is no diagnosis of "vascular neuropathic headache"
.
It's like the vertigo community is phasing out the diagnosis of "cervical vertigo" and replacing it with other, more precise diagnoses
.
Some of our "accustomed" diagnoses are not necessarily correct, which should arouse the high attention of clinicians
.
These three diseases have overlapping parts and independent parts, which need to be comprehensively considered and diagnosed with caution in clinical diagnosis
.
At the same time, the possibility of patients suffering from two or three diseases (or other diseases) at the same time cannot be ignored.
After all, patients with migraine can also suffer from cervical spondylosis at the same time, and neck pain in patients with cervicogenic headache may also be a migraine attack.
The prodromal or post-symptoms, other primary or secondary headaches combined with pathological changes of the cervical spine or neck pain are not necessarily or only cervicogenic headaches
.
As for cervicogenic headache and cervical spondylosis, it can be seen literally that the main symptom of the former is "headache", and "cervicogenic" indicates the nature, or the cause of the disease; cervical spondylosis focuses on "cervical vertebra" This diseased part (including muscles, bones, etc.
) leads to the appearance of some symptoms.
Headache is one of the symptoms, but it does not necessarily appear
.
Therefore, I personally think that the two need to be differentiated
.
As for the stiff neck pain of migraine, it is a prodrome or/and a later symptom, and there are some special accompanying symptoms, which are not difficult to distinguish from the other two diseases
.
In general, cervical spondylosis + headache ≠ cervicogenic headache, neck pain ≠ cervical spondylosis, no neck pain + headache ≠ no cervicogenic headache
.
Only by clearly grasping the basic concepts and relationships can be targeted in clinical practice
.
So, what diagnosis should the patient in this case give? References: [1] Yu Shengyuan.
Neck and Headache [J].
Chinese Journal of Pain Medicine, 2005, 11(6): 323.
[2] Yu Shengyuan, et al.
International Headache Classification Third Edition [J].
[3] Zhang Yinan, Tan Ge, Zhou Zefang, et al.
Research progress on diagnostic criteria for cervicogenic headache ICHD [J].
Chinese Journal of Practical Neurological Diseases, 2019, 22(23): 2665-2668.
[4] Zhu Shourong, Yu Sheng Yuan, Hou Kedong, et al.
Clinical diagnosis and treatment of cervicogenic headache caused by cervical spondylosis [J].
Chinese Journal of Pain Medicine, 2005, 11(6): 330.
