Expertise Out of Place: Cervicogenic Headache Criteria

Cervicogenic headache (CGH) is, by definition, a musculoskeletal disorder. Its origins lie in cervical joint dysfunction, noxious afferent input, and provocation-responsiveness at the upper cervical spine. Yet paradoxically, the diagnostic criteria for CGH were established not by musculoskeletal clinicians but by neurologists.

This inversion of expertise is difficult to rationalise. It would be unthinkable for a musculoskeletal physiotherapist to define the diagnostic framework for multiple sclerosis. Why then should neurologists, highly skilled within their own domain but not in manual cervical assessment, define CGH?

Criteria Skewed by Exclusion

The consequences are predictable. Criteria constructed through a neurological lens emphasise exclusion of alternative diagnoses rather than detection of cervical dysfunction. They prioritise what neurology can rule out over what skilled musculoskeletal assessment can reveal.

As a result, the “gold standard” is narrow, rigid, and often unfit for purpose; subtle cervical joint restrictions and muscle spasm are overlooked, abnormal afferent input from the upper cervical spine is disregarded, and provocation followed by symptom resolution, the clinical hallmark of CGH, is underweighted or absent.

Patients fall through these gaps, their presentations dismissed simply because they do not align with criteria written by those untrained in musculoskeletal medicine.

Overlap Misunderstood

Adding further complexity, neurologists themselves acknowledge that CGH and migraine frequently overlap. Yet without the tools to evaluate cervical dysfunction, the neck is reduced to a minor player, a “shadow” in the diagnostic process. Overlap is then seen as confusion rather than recognition of shared mechanisms within the trigeminocervical complex.

Had musculoskeletal clinicians been central to the original process, the overlap could have been reframed not as diagnostic ambiguity but as evidence of convergence between cervical and trigeminal pathways.

Rebalancing Authority

The real question, then, is not why neurologists took the lead, but why musculoskeletal clinicians ceded authority over a musculoskeletal condition. By abdicating expertise, the professions allowed diagnostic frameworks to be shaped in ways that do not reflect clinical reality.

The path forward requires the collective effort and realignment of expertise.

Criteria must evolve collaboratively, integrating the neurological perspective with the indispensable skills of musculoskeletal physiotherapists and manual therapists. Without this, CGH will remain defined by what it is not, rather than by what it truly is. Your involvement in this process is crucial, and together, we can make a significant difference in the diagnosis and treatment of CGH.

Conclusion

CGH diagnostic criteria should no longer be dictated solely by neurology. To serve patients effectively, frameworks must reflect the clinical realities of upper cervical dysfunction, guided by those best equipped to assess and treat it. Our ultimate goal is to provide the best possible care for our patients, and this requires a collaborative approach that corrects a historic misalignment of expertise and provides patients with criteria grounded in both science and skilled clinical practice.