Exploring Pain Phenotyping in Cervicogenic Headache Management

Intervention trials for cervicogenic headache (CGH) often yield equivocal results with marked treatment effect heterogeneity, possibly reflecting variations in underlying pain mechanisms throughout the CGH population. Pain phenotyping or classifying patients into subgroups based on their predominant pain mechanism may facilitate more precise CGH treatment. This review aims to explore the role of pain phenotyping in CGH management.

Clinical evidence suggests two predominant pain mechanisms in the CGH population: nociceptive and nociplastic. Arguably, treatments for nociceptive pain should address the source of peripheral nociception, and treatments for nociplastic pain should address factors contributing to maladaptive central pain modulation. Due to centrally mediated analgesic effects, muscle relaxants are strongly recommended for managing both nociceptive and nociplastic CGH pain. Antidepressant medications may be most relevant for nociplastic CGH pain. Cervical spinal mobilization and manipulation interventions are strongly recommended for both nociceptive and nociplastic CGH pain. Nociplastic CGH pain may benefit from educational interventions regarding lifestyle factors such as physical activity, diet and weight management, sleep hygiene, and stress reduction. The anesthetic blockade, glucocorticoid injection, and radiofrequency denervation are strongly recommended for nociceptive CGH pain. Patients with persistent nociplastic CGH pain may benefit from neuromodulation interventions. Pain phenotyping may facilitate more precise clinical management of patients with CGH. This review provides evidence-informed recommendations for CGH pain phenotyping, including specific subgroups, clinical criteria, and stratified treatment approaches. Further prospective investigation is needed to determine the effects of pain phenotyping on clinical outcomes in patients with CGH.