What Can We Do About It?
Watson and his colleague sit at their usual table in the corner of the wine bar, a bottle of 2012 Albert Bichot Côte de Nuits Villages Burgundy breathing beside them as they settle into another one of their monthly philosophical unravellings of clinical complexity.
“I’ve been thinking a lot about cervicogenic headache (CGH) lately,” Watson’s colleague begins, swirling the wine thoughtfully. “It still amazes me how underrepresented it is in headache diagnosis. It’s like CGH is the elephant in the consultation room – but the medical model of headache is not looking at it.”
Watson gives a knowing nod, “Yes. And I suspect the problem isn’t just ignorance – it’s structural. It’s diagnostic frameworks, research focus, and even clinical training; CGH is hiding in plain sight.”
The Diagnostic Dilemma
“But isn’t it classified as a secondary headache?” his colleague asks. “Shouldn’t that attract more attention, not less?”
Watson raises an eyebrow. “In theory, yes. However, in practice, the International Classification of Headache Disorders-3 requires a visible lesion to confirm CGH. And therein lies the problem – what happens when the lesion is functional or microstructural, something we can’t easily image?”
“Ah, so you’re saying that if it doesn’t show up on a scan, it’s as if it doesn’t exist?”
“Precisely. The diagnostic system relies on visibility, and CGH often doesn’t adhere to these rules. As I’ve said before, the term CGH is an intellectual straight-jacket; we’re trying to understand pain with a lens that’s correlated with the pathology we can see. Invisibility is not absence of evidence[1].”
Training the Clinician’s Eye
His colleague pauses. “But surely clinicians can do better than that. Shouldn’t more emphasis be placed on clinical examination, especially skilled assessment of the upper cervical spine?”
“Absolutely,” Watson replies. “But how many undergraduate or postgraduate programs teach thorough manual assessment of the C1-C3 segment in any depth? And how many emphasise its importance in headache presentations?”
So the under-recognition of CGH isn’t just a diagnostic issue, but also an educational one.
Watson nods. “Yes. If we don’t equip clinicians with the skills—or even the mindset—to consider the cervical spine, we limit their capacity to detect its involvement. Cervicogenic headache becomes an ‘afterthought’ diagnosis rather than something you assess for with intent and method.”
A Matter of Research Priorities
“And then there’s the research,” Watson’s colleague adds, leaning back. “It seems like CGH has always suffered from a lack of rigorous (manual therapy) inquiry compared to migraine or tension-type headache.”
“Exactly,” Watson agrees. “The funding tends to follow pharmaceutical interventions. Cervicogenic headache, being more mechanically and neurologically nuanced, doesn’t lend itself as easily to medication trials. So it’s underfunded, under-researched, and therefore, under-acknowledged.”
“So, the data gap maintains the diagnostic gap.”
“Correct. And let’s not forget the extensive translational and human research demonstrating that noxious cervical afferent input can sensitise the trigemino-cervical complex. These are not vague notions – they are reproducible findings. Yet, some still consider them fringe.”
The Narrative Reframed
Watson’s colleague refills their glasses. “So, what’s the solution?” he asks.
“To begin,” Watson responds, “we need a fundamental shift in perspective from both clinicians and academics. We must not underestimate the importance of cervical afferents. They play a vital role in the headache matrix, contributing not only to cervicogenic headache (CGH) but also influencing primary headache syndromes through central sensitisation.”
“And that would mean what – more training? Updated diagnostic criteria?”
“Both,” says Watson. “Plus, interdisciplinary collaboration. Neurologists and musculoskeletal physiotherapists or manual therapists need to speak the same language. At the moment, CGH too often falls between the cracks of scope and specialisation.”
A Better Future for Cervicogenic Headache
“So,” reflects Watson’s colleague, “addressing the underrepresentation of CGH requires rethinking how we define, teach, and approach headache. It means legitimising functional dysfunctions, not just visible lesions. It means recognising that not all causes of pain are detectable on a scan.”
“Well said,” Watson smiles, lifting his glass. “It also means being brave enough to acknowledge that our current systems – diagnostic, educational, and research – are overdue for an update.”
“To that, I’ll drink,” says his colleague, raising a glass of Burgundy. “Here’s to not letting CGH remain the forgotten headache.”
“Yes, CGH is usually the bridesmaid, never the bride.”
They clink glasses, quietly contemplating the many patients whose headache may finally be recognised and treated for what they truly are.
Reference:
1. Bogduk, N. and N. Yoganandan, Biomechanics of the cervical spine Part 3: minor injuries. Clin Biomech (Bristol, Avon), 2001. 16(4): p. 267-75.
