Headaches

Headaches are very common and arise from different sources within the head and neck. Across the globe, 46% of people experience one or more type of headaches. In the United States, migraine headaches affect 12% of the population, including 18% of women, 6% of men, and 10% of children. This affects 1 in 4 households. Headaches arising from the neck affect over 4% of the population.

Sensory nerves from both the head and upper neck bring pain information into the upper spinal cord. This is why problems in the upper neck can be felt as headache, and problems in the face or head can be felt as also neck pain. The Denver Spine and Pain Institute providers can diagnose the source of your headache pain and direct treatment accordingly. We commonly work with neurologists and primary care providers to diagnose and manage headaches, especially when there is an upper neck problem that leads to aggravation or increased frequency of primary headaches such as migraine. We make use of careful history, physical exam, and imaging to arrive at a diagnosis and to create an individualized treatment plan, often teaming up with physical therapy, manual therapy, the use of medications, relaxation training, and other psychological approaches as part of our Connected Care Approach.

Headaches can be broken down by source into the following categories:

• Headaches arising from structures of the face and neck
• Primary headaches (migraine, cluster)
• Cervicogenic headaches (headaches arising from the neck)

Headache Red Flag Emergencies

There are some headaches that require immediate medical attention. Headaches that arise along with the following symptoms should all be assessed quickly:

• Systemic symptoms or compromise such as fever
• Persistent or progressive vomiting
• Stiff neck
• Pregnancy
• Cancer or immunocompromised status
• Clotting disorders or the use of blood thinners
• Neurological signs or symptoms such as:
  • Confusion
  • Weakness
  • Abnormal sensations
  • Seizures
  • Falling

Similarly, if the onset of the headache is sudden and severe, or the onset is in someone greater than 40 years old, these also should not be ignored. If a prior headache history is different or progressive from the current headache, these should also be evaluated by your medical provider or your local emergency room department.

Headaches Arising from Structures of the Face and Neck

• Sinus headaches – these present as headaches in one or more regions of the face, ears or teeth and are usually described as a deep aching and non-pulsatile pain. They can be associated with nasal drainage, and usually resolve within 7 days of treatment of sinusitis.
• Dental pain – most often caused by cavities that reach and inflame the inner pulp of the tooth, or infection associated with gum disease. Either of these can present with local pain. Cavities often are associated with sensitivity of the tooth to cold or sweets or pressure. When discovered, a referral to a dentist will be made.
• Temporomandibular joint (TMJ) dysfunction – often felt right at the joint near the ear and associated with difficulty or pain while chewing. There can be locking of the joint or cracking or popping due to rough cartilage surfaces in the joint. Specialized PT, oral splints and temporary medication use can be helpful.
• Salivary gland disorders – these can be associated with a bad taste in your mouth, dry mouth, difficulty opening your mouth, pain in your face or mouth or swelling in your face or neck. This can be caused by infections, obstruction, or cancer, and should be evaluated by an ear nose and throat (ENT) physician. Other disorders such as mumps or Sjogren’s syndrome can cause a similar set of signs and symptoms.
• Eye disorders – can be associated with severe, sudden eye pain, recurrent pain in or around the eye, vision disturbances or visual changes such as floaters, night blindness, seating floating spots, halos, spider webs, double vision, blurred vision, or other abnormal visions. Night blindness, headache, light sensitivity, dry eyes, red eyes, or excessive tearing can also indicate significant eye problems that would warrant referral to an ophthalmologist or optometrist.
• Blood vessel abnormalities
  • Giant cell arteritis (GCA) – the most common form of vascular inflammation that tends to occur in people over 50 years of age and most often in women. This is a serious problem that can go on to cause stroke, heart attack, blindness, or other serious consequences of blood vessel blockage. It may show up as headache, tenderness and thickening of the arteries near your temples. It is important to notify your medical provider and have this checked out quickly. There are laboratory assessments and blood vessel biopsies that can be used to diagnose and treat this problem quickly. GCA can show up as systemic illness and can be confused with polymyalgia rheumatica, another rheumatologic disorder.
  • Vertebral, Carotid, or other neck and head arterial dissection – blood vessels can become injured, and the lining of the arteries can become separated from the middle muscular layer. This is painful but also can be dangerous as it may cause blockage of the artery and thus stroke. This commonly involves the vertebral artery and can be associated with even minor trauma, as well as blunt trauma, bicycle or motor vehicle accidents, or manual therapeutic treatments. Symptoms can include pain of the face and head, often one-sided and severe, as well as neurological problems such as loss of taste, sensation, tingling, dizziness, nausea and vomiting, double vision, trouble swallowing, balance or equilibrium problems, hearing loss or weakness/paralysis, numbness of the body. If you are experiencing any of these symptoms, please seek emergency medical care.

Central Neuropathic Pain (MS, stroke) and Facial Neuralgias (Nerve Pain)

Central neuropathic pain is a neurological condition caused by damage to the brain, brain stem or spinal cord. It can be caused by stroke, multiple sclerosis, tumors, epilepsy, trauma, or Parkinson’s disease. The pain is often described as prickling, tingling, pressing, piercing, aching, burning or brief but severe episodes of sharp pain. It can be felt in any part of the body, including the head, face, and neck.

Post-radiation treatments for cancer or other radiation exposure may cause injury to nerves and neuropathic pain, sometimes years after the exposure. This would be treated like other forms of neuropathic or neuroinflammation related pain.

• Trigeminal neuralgia – this is the most common form of facial neuralgia and presents with severe episodes of pain along the forehead, cheek, or jaw. It can be triggered by chewing, swallowing, talking, yawning, smells, or touching of the face in the area of pain. There may be an underlying level of continuous pain with these episodes of severe, short-lived pain. Trigeminal neuralgia is a severe problem that can be treated with medications, surgical microvascular decompression, gamma-knife radiation, or other treatment approaches.
• Glossopharyngeal neuralgia – this is another cranial nerve that can cause neuropathic pain along the base of the tongue and throat. It can involve severe episodic pain, provoked by chewing, swallowing, yawning, or talking. It is also treated with medications and occasionally microvascular decompression surgery.
• Trigeminal Autonomic Cephalalgias (TAC) – these are autonomic headaches which involve a reflex between the trigeminal nerves and parasympathetic system causing redness and tearing of the eye, a runny, stuffy nose and flushing and sweating of the face.
• Eagle Syndrome – is characterized by recurrent pain in the middle part of the throat and face. It is rare, but sometimes seen after throat trauma or tonsillectomy. Symptoms include dull and persistent throat pain that may radiate to the ear and worsen with head rotation, as well as difficulty swallowing, the feeling of something stuck in your throat or even broader symptoms such as headache, dizziness or ringing of your ears. This is due to inflammation of the small pointy bone just below your ear that connects to a ligament that goes to the hyoid bone around the throat (stylohyoid ligament inflammation).
• Neck-Tongue Syndrome (NTS) – this is a condition where sudden rotation of the head can cause tingling, burning or other forms of pain in the tongue. It happens due to a pinched nerve in the upper neck caused by instability or looseness of the C1-2 joint with intermittent pinching of the C2 nerve. Treatment involves care addressing the upper cervical spine.
• Burning Mouth Syndrome (BMS) – this involves a feeling of burning of the tongue or inner lining of the mouth. Symptoms include occasional burning of the mouth during the day, relief at night, aggravation with anxiety, and is occasionally associated with food allergies.

Primary Headache (migraine, cluster, others)

Migraine headaches can occur with or without an aura and can be chronic or episodic. The mechanism for migraine headache occurs through a dysfunction of the trigeminovascular system within the brain, which causes activation and stimulation of the nerves, and dilation of the blood vessels through chemicals such as calcitonin-gene related peptide (CGRP), substance P, and neurokinin A. The result is inflammation and pain, called neurogenic inflammation. Many of the treatments for migraine headache target this neuroinflammation, and some of the newer medications specifically target the CGRPs.

• Classic migraine headache – Migraine headaches generally come with the features described with the acronym POUND: Pulsing type pain, One day duration, Unilateral (one-sided) location, Nausea or vomiting, and Disabling intensity. Other symptoms of migraine may include moderate to severe pain, headache which is worsened with physical activity and sensitivity to light or sound.
• Classic migraine headache with aura – All of the above symptoms apply, with the addition of these aura characteristics: visual, sensory, speech/language, motor, brain stem or retinal (visual) symptoms. These aura characteristics may spread over 5 minutes, followed within 60 minutes by a headache.
• Episodic migraines (EM) – involve less than 15 migraines or headaches per month. Approximately 92% of people with migraines have episodic migraines.
• Chronic migraines (CM) – involve greater than 15 migraines or headaches per month, for more than three months. Eight or more days of the month are usually migraines in this case, and approximately 8% of people with migraines have chronic migraines.
• Cluster headache – these are severe, one-sided headaches that often feel like a stabbing pain at the eye, and can occur overnight, waking you from sleep. They are associated with restlessness, redness or tearing of the eye, stuffy nose, and flushing or sweating of the face. These types of headaches can last 15 minutes to 3 hours and occur in “clusters,” which can be every other day to 8 times per day in frequency. These series can last weeks to months and may become chronic in 10-15% of cases.
• Tension-type headache – these headaches vary in frequency and can last 30 minutes to seven days. The pain usually does not inhibit activities and is described as dull and bandlike and is usually bilateral (on both sides of your head). It does not usually include nausea or vomiting but may include an aversion to light or sound. It is common but can often be addressed by PT, ergonomics, and relaxation training.
• Medication overuse headache (MOH) aka rebound headache – can occur when over the counter or prescribed pain medications, caffeine or migraine specific medications are used too frequently. You may experience withdrawal symptoms from the medication or the sparking of the next headache by missing a dose, which becomes a bad cycle and is difficult to break. This can lead to escalating medication use, escalating headaches and dependence on the medication.

Headaches Arising from the Neck (Cervicogenic Headache)

Anatomy

The nerves of the upper neck merge with the nerves coming into the upper spinal cord from your head and face (convergence) before sending pain signals to your brain. Your brain has trouble deciding whether the pain is from your neck, head and face, or both. These types of headaches are called cervicogenic headaches, as they come from the neck (cervical spine). Injury, mechanical stress causing irritation, or inflammation of joints, discs or nerves of the upper neck can cause these headaches.

Prevalence

These cervicogenic headaches effect over 4% of the general population and up to one third of all patients with headaches have cervicogenic headaches. They can also occur along with other types of headaches, including migraine headaches. When this is the case, the headaches from the neck often spark migraine headaches, leading to higher frequency and severity of the migraine problem. Treating the neck problem can not only alleviate the headaches from the neck but also help reduce the severity of the migraine or other headache problem.

Diagnosis

The providers at The Denver Spine and Pain Institute are frequently asked to diagnose and treat headaches, especially looking for headaches that come from the neck. We often treat these in conjunction with neurologists, primary care doctors and other physicians. The diagnostic process begins with a careful history, physical examination, and the use of imaging to assist, as well. When needed, diagnostic injections can be performed to pinpoint the source of the neck pain and headaches. Physical therapy and medication treatment responses can also sometimes be helpful in determining your specific diagnosis. We gather information from all sources and use this to make a specific diagnosis and create an individualized treatment plan for you.