The familiar corner table is set, and this evening, Watson’s colleague has chosen the Brunello di Montalcino; deep, earthy, and promising. Watson studies the wine intently, swirling it gently, before turning to his colleague with a bemused smile.
Why are cervicogenic headache criteria defined neurologically, when the disorder is musculoskeletal?
“Do you know what has always amused me? That the diagnostic criteria for cervicogenic headache (CGH), by definition a musculoskeletal event, were established by Neurologists, not musculoskeletal clinicians.”
His colleague almost splutters into his glass. “It’s extraordinary. Like asking a gastroenterologist to establish diagnostic criteria for an anterior cruciate ligament tear.” Watson laughs softly. “Exactly. Would anyone seriously propose that? And yet, when it comes to CGH, somehow this inversion of expertise has become normal.”
Expertise Out of Place
Watson’s colleague frowns thoughtfully. “Neurologists are, of course, highly skilled in their own domain. But when the fundamental disorder is musculoskeletal, why would the criteria be built by those with little training in musculoskeletal assessment?”
Watson nods. “This is not a slight on neurology – it is a matter of scope. No one would expect me, as a Musculoskeletal Physiotherapist, to define the neurological diagnostic criteria for multiple sclerosis. That would be absurd. Yet here we are, decades into a framework where the very clinicians most skilled in musculoskeletal dysfunction are left out of the process.”
Consequences of Exclusion
Watson’s colleague leans forward, lowering his voice as if to confide a secret. “And the consequences are obvious. The criteria are skewed toward what can be excluded neurologically, not what can be detected clinically in the upper cervical spine. So the definition ends up being narrow, rigid, and, dare I say, unfit for purpose.”
Watson tilts his glass. “Which means patients suffer. If the gold-standard criteria overlook the subtleties of cervical dysfunction, joint restriction, abnormal afferent input, and mechanical provocation followed by resolution, then many genuine cases are dismissed. They don’t ‘fit’ the neurologically drafted framework.”
The Irony of Overlap
His colleague, smiling wryly, adds: “The irony is that Neurologists themselves often admit that CGH and Migraine overlap. Yet without the tools to assess cervical function properly, they reduce the neck to a shadow – a minor player at best.”
“Indeed,” Watson agrees. “But if the clinicians most skilled in manual assessment had been central in writing the criteria, the overlap would be better understood. Not as diagnostic confusion, but as shared mechanisms at the trigeminocervical complex.”
Reclaiming the Conversation
Watson sets his glass down firmly. “So, perhaps the question isn’t ‘Why did Neurologists do it?’ but ‘Why did musculoskeletal clinicians allow it?’ Somewhere along the way, we ceded authority over a musculoskeletal problem to another discipline.”
His colleague’s eyes narrow thoughtfully. “Then the way forward is clear. The criteria must evolve — shaped not by exclusionary neurology alone, but by collaboration. Neurologists, yes, but also musculoskeletal physiotherapists, manual therapists, and others skilled in the art of cervical assessment. Without that, CGH will always be defined in ways that don’t reflect reality.”
A Toast to Realignment
Watson raises his Brunello with a grin. “So, to realignment. Not of vertebrae, but of expertise. To ensuring that those with the skill to assess the upper cervical spine are central in defining its disorders.”
His colleague clinks glasses. “To common sense. And to the patients who deserve criteria written by those who can actually feel what they’re talking about.”
The Brunello lingers on the palate – rich, grounded, and perhaps quietly revolutionary?
