Management Of Cervicogenic Headache Research Articles

Effectiveness of Myofacial Release versus Proprioceptive Neuro Facilitation Technique on Pain and Range of Motion in Patients with Cervicogenic Headache

Background: Cervicogenic headache is a prevalent condition characterized by headaches caused by cervical musculoskeletal impairments. The effectiveness of Myofascial Release (MFR) and Proprioceptive Neuromuscular Facilitation (PNF) in managing this condition has been explored, with varying outcomes on pain intensity, cervical range of motion (ROM), and functional disability. Objective: To compare the efficacy of MFR and PNF techniques in reducing pain and improving ROM in patients with cervicogenic headache. Methods: This randomized control trial included 30 female participants diagnosed with cervicogenic headache. Participants were randomly assigned to receive either MFR or PNF treatments over a period of 4 weeks, with sessions conducted twice weekly. Outcome measures included pain intensity assessed by the Visual Analog Scale (VAS), cervical ROM measured using a universal goniometer, and functional disability evaluated through the Neck Disability Index (NDI). Data were analyzed using SPSS version 25, employing t-tests for within-group comparisons and ANOVA for between-group analyses. Results: Both MFR and PNF groups showed significant improvements post-treatment. The MFR group demonstrated a reduction in VAS scores from 6.73 ± 0.593 to 4.26 ± 0.703 (p<0.001), and the PNF group from 6.73 ± 0.593 to 5.26 ± 0.432 (p<0.001). Cervical ROM and NDI scores also significantly improved in both groups. Comparative analysis revealed MFR to be more effective in enhancing cervical rotation (MFR: 70.13 ± 3.020 to 80.20 ± 2.840; PNF: 60.33 ± 2.690 to 64.06 ± 2.548; p<0.05) and reducing NDI scores (MFR: 48.33 ± 5.56 to 17.53 ± 5.46; PNF: 10.00 ± 2.267 to 8.93 ± 1.667; p<0.001). Conclusion: Both MFR and PNF are effective in treating cervicogenic headache, significantly reducing pain intensity and improving cervical ROM and functional disability. MFR, however, exhibited a superior efficacy in enhancing cervical rotation and reducing NDI scores, suggesting it may offer additional benefits in the management of cervicogenic headache.

Is device guided training targeted to the craniocervical flexor and extensor muscles efficacious? A preliminary randomized controlled trial in a cervicogenic headache population

BackgroundSpecific neck exercise is effective in the management of cervicogenic headache (CH). The Spinertial device was designed to facilitate craniocervical flexion and extension training, but its efficacy, judged on change in headache impact, has not been tested. ObjectiveTo compare guided and progressive resisted specific neck exercise targeted to the craniocervical flexors and extensors (SNE-fe) performed with Spinertial device to progressive SNE-fe without the device in a cohort with CH. DesignRandomised controlled trial. MethodsTwenty-eight participants with CH were randomly allocated to the Spinertial group (SG) or SNE-fe exercise group without the device (EG). Both groups performed 12 sessions of SNE-fe over six-weeks. The primary outcome was headache impact (HIT-6). Secondary outcomes were the craniocervical flexion test (CCFT), upper cervical (UCS) and lower cervical range of movement, flexion rotation test (FRT) analysed as more or less restricted side (MRS, LRS), the self-reported global rating of change (GROC-scale) and satisfaction with the exercise program (PACES). Outcomes were measured at baseline, post-intervention (T1) and after 1-month (T2). ResultsSignificant between-groups differences were found favouring the SG for HIT-6 (T1 p = 0.010, d = 0.5; T2 p < 0.004, d = 0.4), CCFT, UCS ROM, FRT MRS, FRT LRS, PACES and GROC-scale (T1: all p < 0.01; T2: all p < 0.01). Effects sizes were large (>0.8) at T1 and T2. No between-groups differences were found for lower cervical ROM. ConclusionTraining with the Spinertial was more effective than SNE without the device for improving the impact of headache, the endurance of deep neck flexors and UCS ROM in participants with CH.

Effectiveness of different physiotherapy interventions in the management of cervicogenic headache: a pilot randomized controlled trial

ABSTRACT Background Cervicogenic headache is a secondary headache which leads to decreased functional activity, quality of life and functional disability. Objective To determine the feasibility and acceptability of different physiotherapy interventions in the management of cervicogenic headache and to determine sample size for a full trial. Trial design A pilot randomized controlled trial. Settings Various physiotherapy outpatient department. Methods Participants suffering from cervicogenic headache with age 20- 60 years were randomly allocated into four groups. Sessions were given over 4 weeks 4 times a week (16 sessions). The primary outcomes were feasibility of participant recruitment, assessment procedure, retention, adherence, and acceptability. The secondary outcomes were headache impact test-6 for a headache disability, headache diary for headache intensity, frequency, duration, and neck disability index for neck pain, disability measured at baseline, 4th week, and follow up after 1 month. Result 178 subjects were screened based on selection criteria. Out of them, 93 (52%) were eligible and 80 (86%) participated in the study. 96.25% of participants completed the final 8-week assessment. Overall 93.75% of participants completed the entire assessment item across all time points. 95% completed all treatment sessions. 97.5–100% of participants were satisfied with the treatment protocol. No adverse effects were reported by participants. Based on the data obtained from the pilot trial, sample size was determined as 35 participants in each group. Conclusion The results indicate that the trial methodology and intervention are feasible for implementing a full-powered randomized controlled trial to determine the effectiveness of physiotherapy intervention in the management of cervicogenic headache.

Cervicogenic Headache: Current Perspectives.

Cervicogenic headache is a distinct type of headache described in 1980s by Sjaastad, a Norwegian neurologist. It is a not so uncommon headache, which is usually under-diagnosed resulting in suboptimal quality-of-life. The aim of this study was to review the current recommendations on diagnosis and management of cervicogenic headache. A PubMed search was done for the recent articles on 'cervicogenic headache' published in English literature with the aim of recognizing the current perspectives on cervicogenic headache. The diagnosis of cervicogenic headache is based on clinical criteria mentioned by the International Headache Society (IHS) and Cervicogenic Headache International Study Group (CHISG). Cervical nerve block may confirm the nociceptive source in majority of cases and is included in CHISG criteria. Non-invasive diagnostic methods like echogenicity of muscles, diffusion tensor imaging (DTI) and single-photon emission tomography (SPECT) are proposed by some authors for avoiding complications associated with blocks. Mainstay of management is physical therapy. Surgical interventions for cervical degenerative disease may relief an associated headache but such interventions are not performed solely for cervicogenic headache. Headaches with a cervical spine nociceptive source are increasingly being recognized. Current diagnostic criteria and management options are reviewed here.

Efficacy of three different conservative interventions in the management of cervicogenic headache

Efficacy of three different conservative interventions in the management of cervicogenic headache

A Comparative Study on Effectiveness of Craniosacral Therapy Versus Self Sustained Natural Apophyseal Glide (SNAG) in the management of Cervicogenic Headache

Background: Headache that is caused by the structures of the upper neck is called cervicogenic headache. It usually starts on one or both sides of the upper neck area and then spreads to different area in forehead and face , there is a continuous need for some non-pharmacological intervention in the management of headache. Objective: The aim of the study is to find the effectiveness of Craniosacral therapy and SNAG in cervicogenic headache patients to reduce the headache symptoms and improve the quality of life. Methodology: Total number of participants in this study in 30 subjects and randomly allocated to two groups, 15 patients with cervico-genic headache in group A receives Cranio-sacral therapy and 15 in group B receives SNAG. The period of intervention for each participant was 3 weeks alternative days and total study duration was 3 months. Discussion: From the statistical tool it has been analyzed the group A shows significant reduction of headache symptoms and the level of pain than compared with group B. Conclusion: It has been concluded that craniosacral therapy shows that more significant reduction of headache symptoms and pain in cervicogenic headache patients than compared with SNAG group.

Systematic Review of Radiofrequency Ablation and Pulsed Radiofrequency for Management of Cervicogenic Headaches.

Cervicogenic headache (CHA) is a secondary headache which has a source in the upper cervical spine. Many traditional analgesic choices lack good efficacy in managing the associated pain. As a result, in management of CHA, radiofrequency ablation (RFA) or pulse radiofrequency (PRF) has been tried with success. Our study investigated the use of RFA and PRF for the management of CHA. In the present investigation, a review of the literature was conducted using PubMed (1966 to February 2017). The quality assessment was determined using The Cochrane Risk of Bias. After initial search and consultation with experts, 34 articles were identified for initial review and 10 articles met inclusion for review. Criteria for inclusion were primarily based on identification of articles discussing cervicogenic headaches which were previously treatment resistant and occurred without any other pathology of the craniofacial region or inciting event such as trauma. This systematic review demonstrated that RFA and PRFA provide very limited benefit in the management of CHA. At present, there is no high-quality RCT and/or strong non-RCTs to support the use of these techniques, despite numerous case reports which have demonstrated benefit. This review is one of the first to provide a comprehensive overview of the use of RFA and PRF in the management of CHA.

Cervical Facet Injections in the Management of Cervicogenic Headaches

Cervicogenic headache is defined as headaches originating from cervical spine structures including cervical facet joints, cervical intervertebral discs, skeletal muscles, connective tissues, and neurovascular structures. Cervical facet injections with steroids have been used to alleviate cervicogenic headache secondary to cervical facet arthropathy. In this article, we will review the cervical spine anatomy, cervical facet injections, and the efficacy of cervical facet injections as a treatment for cervicogenic headache.

Systematic Review of Radiofrequency Ablation and Pulsed Radiofrequency for Management of Cervicogenic Headache

Background: Cervicogenic headache is a secondary headache that has a source in the upper cervical spine. There is a small but growing body of evidence to establish effectiveness of radiofrequency (RF) neurotomy, and the pulsed RF (PRF) procedure for management of cervicogenic headache. Objective: To investigate the clinical utility of RF neurotomy, and PRF ablation for the management of cervicogenic headache. Study Design: Systematic review. Methods: The review included relevant literature identified through searches of PubMed, Cochrane, Clinical trials, U.S. National Guideline Clearinghouse and EMBASE from 1960 to January 2014.The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria for randomized control trials and the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, and poor based on the quality of evidence. Outcomes Measured: The primary outcome measures were reduction in pain scores and improvement in quality of life. Results: The primary outcome measures were headache relief and improved quality of life. Twenty five studies were identified for full text review of these, 9 studies met inclusion criteria. There were 5 non-randomized, among them 4/5 were of moderate quality, 3/5 showed RF ablation and 1/5 showed PRF as an effective intervention for cervicogenic headache. There were 4 randomized trials among them 2/4 were of high quality, 3/4 investigated RF ablation as an intervention for CHA, 1/4 investigated PRF ablation as an intervention for CHA and none of the randomized studies showed strong evidence for RF and PRF ablation as an effective intervention for CHA. Limitations: In the selected studies there were inconsistencies between randomized trials, flaws in trial design, and gaps in the chain of evidence. Conclusion: There is limited evidence to support RF ablation for management of CHA as there are no high quality RCTs and/ or multiple consistent non-RCTs without methodological flaws. There is poor evidence to support PRF for CHA as there are no high quality RCTs or Non-RCTs. Key Words: Chronic pain, cervicogenic headache, radiofrequency (rf) neurotomy, pulsed radiofrequency (PRF) ablation, reduction in pain, improvement in quality of life, level of evidence

A Study to Compare the Efficacy of MFR along with Conventional Therapy v/s Conventional Therapy alone in the Management of Cervicogenic Headache

A Study to Compare the Efficacy of MFR along with Conventional Therapy v/s Conventional Therapy alone in the Management of Cervicogenic Headache

Manual therapies for cervicogenic headache: a systematic review

This paper systematically reviewed randomized clinical trials (RCT) assessing the efficacy of manual therapies for cervicogenic headache (CEH). A total of seven RCTs were identified, i.e. one study applied physiotherapy ± temporomadibular mobilization techniques and six studies applied cervical spinal manipulative therapy (SMT). The RCTs suggest that physiotherapy and SMT might be an effective treatment in the management of CEH, but the results are difficult to evaluate, since only one study included a control group that did not receive treatment. Furthermore, the RCTs mostly included participant with infrequent CEH. Future challenges regarding CEH are substantial both from a diagnostic and management point of view.

The Effect of the PostureJac on Deep Cervical Flexor Endurance: Implications in the Management of Cervicogenic Headache and Mechanical Neck Pain

The convergence of cervical and trigeminal afferents on second-order neurons in the trigeminocervical nucleus may refer pain from the upper cervical spine into the head and face. Furthermore, “bi-directional interactions” between trigeminal and upper cervical afferents may also explain neck symptoms of trigeminal origin (e.g., migraine). It is known that cervicogenic headache sufferers present with several musculoskeletal changes including poor endurance of the deep cervical flexor muscles. These intrinsic muscles of the neck contribute to stabilization and protection of the cervical spine and are critical for the control of both intervertebral motion and the cervical lordosis. The purpose of this study was to determine whether the use of the PostureJac (SomatoCentric Systems, Inc., Toronto, Ontario, Canada), a posture support and exercise jacket, was effective in enhancing deep cervical muscle endurance. Forty-five (45) female subjects, between the ages of 18 and 40 years, were randomly assigned to three groups consisting of the no-treatment control, the treatment-control (table stabilization), and the experimental (PostureJac) group. The outcome measure of deep cervical flexor muscle endurance was based on the Flexor Endurance Test and was recorded in seconds. The results indicated that the PostureJac group was superior to the no-treatment control (p=.001) and the treatmentcontrol (p=.004) groups in terms of increasing endurance of the deep cervical flexors. Consequently, the PostureJac may be a useful therapeutic tool in the management of cervicogenic headache and mechanical neck pain.

F207 THE EFFECTIVENESS OF BOTOX® INJECTION AND RADIAL SHOCKWAVE THERAPY IN THE MANAGEMENT OF CERVICOGENIC HEADACHE

European Journal of Pain SupplementsVolume 5, Issue S1 p. 126-127 F207 THE EFFECTIVENESS OF BOTOX® INJECTION AND RADIAL SHOCKWAVE THERAPY IN THE MANAGEMENT OF CERVICOGENIC HEADACHE Z. Elchami, Z. Elchami Pain and Headcahe Management COE, IMC, Jeddah, Saudi ArabiaSearch for more papers by this authorM.B. Issa, M.B. Issa Pain and Headcahe Management COE, IMC, Jeddah, Saudi ArabiaSearch for more papers by this authorM. Dusaran, M. Dusaran Pain and Headcahe Management COE, IMC, Jeddah, Saudi ArabiaSearch for more papers by this authorD. Magayano, D. Magayano Pain and Headcahe Management COE, IMC, Jeddah, Saudi ArabiaSearch for more papers by this author Z. Elchami, Z. Elchami Pain and Headcahe Management COE, IMC, Jeddah, Saudi ArabiaSearch for more papers by this authorM.B. Issa, M.B. Issa Pain and Headcahe Management COE, IMC, Jeddah, Saudi ArabiaSearch for more papers by this authorM. Dusaran, M. Dusaran Pain and Headcahe Management COE, IMC, Jeddah, Saudi ArabiaSearch for more papers by this authorD. Magayano, D. Magayano Pain and Headcahe Management COE, IMC, Jeddah, Saudi ArabiaSearch for more papers by this author First published: 30 January 2012 https://doi.org/10.1016/S1754-3207(11)70432-1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume5, IssueS1September 2011Pages 126-127 RelatedInformation

The Effect of the PostureJac on Deep Cervical Flexor Endurance: Implications in the Management of Cervicogenic Headache and Mechanical Neck Pain

The convergence of cervical and trigeminal afferents on second-order neurons in the trigeminocervical nucleus may refer pain from the upper cervical spine into the head and face. Furthermore, “bi-directional interactions” between trigeminal and upper cervical afferents may also explain neck symptoms of trigeminal origin (e.g., migraine). It is known that cervicogenic headache sufferers present with several musculoskeletal changes including poor endurance of the deep cervical flexor muscles. These intrinsic muscles of the neck contribute to stabilization and protection of the cervical spine and are critical for the control of both intervertebral motion and the cervical lordosis. The purpose of this study was to determine whether the use of the PostureJac (SomatoCentric Systems, Inc., Toronto, Ontario, Canada), a posture support and exercise jacket, was effective in enhancing deep cervical muscle endurance. Forty-five (45) female subjects, between the ages of 18 and 40 years, were randomly assigned to three groups consisting of the no-treatment control, the treatment-control (table stabilization), and the experimental (PostureJac) group. The outcome measure of deep cervical flexor muscle endurance was based on the Flexor Endurance Test and was recorded in seconds. The results indicated that the PostureJac group was superior to the no-treatment control (p=.001) and the treatmentcontrol (p=.004) groups in terms of increasing endurance of the deep cervical flexors. Consequently, the PostureJac may be a useful therapeutic tool in the management of cervicogenic headache and mechanical neck pain.

Efficacy of a C1-C2 Self-sustained Natural Apophyseal Glide (SNAG) in the Management of Cervicogenic Headache

Randomized, double-blind, placebo controlled trial. To determine the effect of a C1-C2 self-sustained natural apophyseal glide (SNAG) on cervicogenic headache. Cervicogenic headache is a common condition causing significant disability. Recent studies have shown a high incidence of C1-C2 dysfunction, evaluated by the flexion-rotation test (FRT), in subjects with cervicogenic headache. To manage this dysfunction, Mulligan has described a C1-C2 self-SNAG, though no studies have investigated the efficacy of this intervention approach. A sample of 32 subjects (mean _ SD age, 36 +/- 3 years) with cervicogenic headache and FRT limitation were randomized into a C1-C2 self-SNAG or placebo group. After an initial instruction and practice visit in the clinic, interventions consisted of exercises applied independently by the subject twice daily at home on a continual basis. FRT range was measured twice, before and immediately after the instruction and practice visit. Headache symptoms were determined by a headache index over time, assessed by questionnaire preintervention, at 4 weeks postintervention, and at 12 months postintervention. No differences were found in baseline measures between groups. Immediately after the initial instruction and practice visit performed with the supervision of the therapist, FRT range increased by 15 degrees (SD, 9) for the C1-C2 self-SNAG group (P < .001), which was significantly more than 5 degrees (SD, 5) for the placebo intervention (P < .001). There was also a significant interaction for the variable headache index between group and time (P < .001), indicating that group difference was dependent on time. There was no difference in headache index scores at baseline between groups. Headache index scores were substantially less in the C1-C2 self-SNAG group (mean +/- SD points at 4 weeks, 31 +/- 9; mean +/- SD points at 12 months, 24 +/- 9) compared to the placebo group (mean +/- SD points at 4 weeks, 51 +/- 15; mean +/- SD points at 12 months, 44 +/- 13) at 4 weeks (P < .001) and 12 months (P < .001), with an overall (+/-SD) reduction of 54% (+/-17%) for the individuals in the C1-C2 self-SNAG group. These results provide evidence for the efficacy of the C1-C2 self-SNAG technique in the management of individuals with cervicogenic headache.

Spinal Manipulative Therapy in the Management of Cervicogenic Headache

Patients suffering from cervicogenic headache (CeH) are commonly treated with spinal manipulative therapy. We have analyzed the quality and the outcomes of published, randomized, controlled trials assessing the effectiveness of spinal manipulation in CeH. Among 121 relevant articles, only two met all the inclusion criteria. Methodological quality scores were 8/10 and 7/10 points. Only one of the trials made use of a headache diary. Both the trials reported positive (+) results on headache intensity, headache duration, and medication intake, so that spinal manipulative therapy obtained strong evidence of effectiveness (level 1) with regard to these outcomes. Conversely, spinal manipulation obtained no more than limited evidence (level 3) in reducing headache frequency, as it was analyzed only in one study with positive (+) results. A greater number of well-designed, randomized, controlled trials are required to confirm or refute the effectiveness of spinal manipulation in the management of CeH.

Diagnosis and Management of Cervicogenic Headache

Upper cervical pain and/or headaches originating from the C0 to C3 segments are pain-states that are commonly encountered in the clinic. The upper cervical spine anatomically and biomechanically differs from the lower cervical spine. Patients with upper cervical disorders fall into two clinical groups: (1) local cervical syndrome; and (2) cervicocephalic syndrome. Symptoms associated with various forms of both disorders often overlap, making diagnosis a great challenge. The recognition and categorization of specific provocation and limitation patterns lend to effective and accurate diagnosis of local cervical and cervicocephalic conditions.

A patient with severe right frontal headache

As physiotherapists, our primary role in the field of headaches is the management of cervicogenic headaches, that is, headaches arising from musculoskeletal dysfunction in the cervical spine. A recent randomized controlled trial conducted in Australia demonstrated the benefits of specific therapeutic exercise and manipulative therapy for cervicogenic headaches (Jull et al., 2002). The problem with headaches is two-fold: (1) all headaches have commonalities in their anatomy and physiology in that they are mediated by the trigeminocervical nucleus (Bogduk, 1995); (2) there can be symptomatic overlap between many headache types as well as some seemingly common provocative factors (IHS, 1988; Leston, 1996; Hagen et al., 2002). Therefore, the ability of physiotherapists to identify cervicogenic headache, or to exclude it and refer accordingly is important, especially when acting as first contact practioners (Jull, 1994). This case study demonstrates the significance of recognizing headaches of nonmusculoskeletal origin.

Cervicogenic headache: practical approaches to therapy.

Cervicogenic headache is a relatively common and still controversial form of headache arising from structures in the neck. The estimated prevalence of the disorder varies considerably, ranging from 0.7% to 13.8%. Cervicogenic headache is a 'side-locked' or unilateral fixed headache characterised by a non-throbbing pain that starts in the neck and spreads to the ipsilateral oculo-fronto-temporal area. In patients with this disorder, attacks or chronic fluctuating periods of neck/head pain may be provoked/worsened by sustained neck movements or stimulation of ipsilateral tender points. The pathophysiology of cervicogenic headache probably depends on the effects of various local pain-producing or eliciting factors, such as intervertebral dysfunction, cytokines and nitric oxide. Frequent coexistence of a history of head traumas suggests these also play an important role. A reliable diagnosis of cervicogenic headache can be made based on the criteria established in 1998 by the Cervicogenic Headache International Study Group. Positive response after an appropriate nerve block is an essential diagnostic feature of the disorder. Differential diagnoses of cervicogenic headache include hemicrania continua, chronic paroxysmal hemicrania, occipital neuralgia, migraine and tension headache. Various therapies have been used in the management of cervicogenic headache. These range from lowly invasive, drug-based therapies to highly invasive, surgical-based therapies. This review evaluates use of drug therapy with paracetamol and NSAIDs, infliximab and botulinum toxin type A; manual modalities and transcutaneous electrical nerve stimulation therapy; local injection of anaesthetic or corticosteroids; and invasive surgical therapies for the treatment of cervicogenic headache. A curative therapy for cervicogenic headache will not be developed until increased knowledge of the aetiology and pathophysiology of the condition becomes available. In the meantime, limited evidence suggests that therapy with repeated injections of botulinum toxin type A may be the most safe and efficacious approach. The surgical approach, which includes decompression and radiofrequency lesions of the involved nerve structures, may also provide physicians with further options for refractory cervicogenic headache patients. Unfortunately, the paucity of experimental models for cervicogenic headache and the relative lack of biomolecular markers for the condition mean much is still unclear about cervicogenic headache and the disorder remains inadequately treated.

Triplication of the lesser occipital nerve

Triplication of the lesser occipital nerve (LON) was observed bilaterally in an adult male cadaver during routine prosection of the posterior triangle. The three LONs were studied to determine the clinical importance of this variation. The origin of one LON was from a nerve to the trapezius that had a common origin with the trunk of the supraclavicular nerve (C3,4) from the cervical plexus. Such a common origin of a LON may explain the pain referred to the shoulder and arm that is experienced by some patients with cervicogenic headache. Another LON ran across the roof of the posterior triangle, passed through the trapezius and was closely related to the point of exit of the greater occipital nerve (GON) from the trapezius. This LON supplied the nape of the neck, back of the scalp and the auricle. The anomalous course taken by this LON through the trapezius may be an explanation for cervicogenic headache precipitated by neck movement. The close relationship of this variant LON to the exit of the GON from the trapezius seems to be relevant to the management of cervicogenic headache. The authors suggest that the reason for the complete pain relief experienced by some patients with cervicogenic headache by anesthetic blockade of the GON may be because both the GON and LON are blocked simultaneously due to their proximity in these patients.