Expert panel’s guideline on cervicogenic headache: The Chinese Association for the Study of Pain recommendation

Table 1 Grading of Recommendations, Assessment, Development and Evaluation system for rating quality of evidence

Quality of evidence	Definition
High quality	Further research is very unlikely to change confidence in the estimate of effect
Moderate quality	Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate
Low quality	Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate
Very low quality	Any estimate of effect is very uncertain

Table 2 Grading of Recommendations, Assessment, Development and Evaluation system for strength of recommendations

Recommendation strength	Definition
Strong	When the desirable effects of an intervention clearly outweigh the undesirable effects or clearly do not
Weak (‘‘conditional’’ or‘‘discretionary’’)	When the trade-offs are less certain either because of low-quality evidence or because evidence suggests that desirable and undesirable effects are closely balanced

Table 3 Chinese Association for the Study of Pain recommendations for the management of cervicogenic headache

Item	Recommendation	Quality	Strength
Pharmacologic management	Pharmacologic treatment is recommended as the first-line therapy for CEH	Moderate	Strong
	NSAIDs are recommended for patients with CEH	Low	Weak
	Muscle relaxants are recommended for patients with CEH	Moderate	Strong
	Antiepileptic drugs are conditionally recommended for patients with CEH	Low	Weak
	Antidepressants are recommended for CEH patients with serve anxiety and depression	Low	Strong
Anesthetic blockade	Anesthetic joint injection or nerve block are often used both diagnostically and therapeutically	Moderate	Strong
	Atlantoaxial joint injection for patients with suboccipital or occipital pain aggravated by cervical rotation or pain due to inflammatory stimuli	Low	Weak
	C2-C3 zygapophyseal joint injection can be considered for patients with upper neck pain spreading to the occipital region or pain that increases when the neck is rotated or back is stretched	Low	Weak
	Selective nerve root injection could be used in patients with cervical spondylotic radiculopathy	Low	Strong
	Third occipital nerve block can be used to diagnose CEH and predict the efficacy of radiofrequency treatment	Low	Strong
	The occipital nerve injection is used to diagnose and treat occipital pain.	Low	Strong
	Imaging technology (ultrasound, X-ray and CT) are recommended for guidance of invasive therapies	High	Strong
	Glucocorticoid injection is recommended for CEH	Low	Strong
Minimally invasive interventional management	Radiofrequency intervention is conditionally recommended for patients with persistent CEH	Moderate	Strong
	Pulse radiofrequency is preferred over ablation for patients with persistent CEH	Low	Strong
	Ozone injection is recommended for CEH	Low	Weak
	PLDD is conditionally recommended for CEH	Low	Weak
Surgical procedures	Surgery is not recommended for CEH unless there is compelling evidence of a surgically amenable lesion causing the cervicogenic headache that is refractory to all reasonable nonsurgical treatments	Low	Strong
	Nonpharmacological and nonsurgical therapy is recommended as a complementary management for CEH	Low	Strong
Physical therapy	Physical therapy is the preferred initial treatment recommended for CEH	Moderate	Weak
	Cervical manipulation and mobilization are recommended for CEH	Moderate	Strong
TCM	TCM is conditionally recommended for CEH.	Low	Weak
Psychological therapy	Patients with refractory severe CHE need psychological assessment and intervention	Low	Strong
Health education	Health education is recommended for CEH	Low	Strong

CEH: Cervicogenic headache; CT: Computed tomography; NSAIDs: Nonsteroidal anti-inflammatory drugs; PLDD: Percutaneous laser disc decompression; TCM: Traditional Chinese medicine.