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  • Michele Curatolo

Neck pain and headache: Can stem from the C1-2 joint


Neck pain is common, and frequently disabling

About 70% of the population experiences at least one episode of neck pain in a time span of one year. Among them, 50-75% will have long-term recurrent neck pain. Neck pain ranks 6th among all medical conditions causing disability. The very high prevalence, frequent disability, and enormous societal costs associated wit neck pain make this condition a public health issue of utmost importance.

Where does neck pain come from?

Neck pain can arise from joints, discs, muscle, fasciae, ligaments, and nerves, among others. A reliable identification of the source of pain can be challenging, as explained in these blogs.

The C1-2 joint can be a source of neck pain and headache

The lateral atlanto-axial joint (C1-2) can be a source of neck pain and headache. Osteoarthritis and fractures are the most common causes.
The lateral atlanto-axial joint (C1-2) is depicted green.

This joint connects the first (atlas) and second (axis) cervical vertebrae on both sides, and is therefore also called lateral atlanto-axial joint (green-colored in the picture above). Its function is mainly to allow right and left rotation of the head. Osteoarthritis of the C1-2 joint is frequent, particularly in older adults, with a prevalence of 5-50% depending on the patient population and diagnostic criteria. Fractures of the C1-2 segment after falls or other accidents are also causes of neck pain and headache.

How do we know that pain can arise from the C1-2 joint? In an study on healthy volunteers [1], injection of a fluid into the joint induced pain at the upper region of the neck and at the back of the head. In patients with osteoarthritis of the C1-2 joint, injecting a local anesthetic into the joint leads to pain relief in over 60% of patients [2-3]. The image below shows a fluoroscopy-guided injection of the left C1-2 joint.

Fluoroscopy-guided injection of the atlanto-axial (C1-2) joint can be performed to diagnose and treat C1-2 joint pain.
Antero-posterior (left panel) and lateral (right panel) image of a C1-2 injection.

While the effect of the local anesthetic wears off after few hours, injection of a steroid can provide longer-lasting pain relief [3]. If the steroid injection is ineffective, surgery on that joint (fusion) can be considered [4-5].

In summary:

  • Pain at the upper neck and headache can stem from the C1-2 joint.

  • More information here: Diagnostic, prognostic, and therapeutic blocks.

  • In patients with pain from C1-2 osteoarthritis, steroid injection or surgery can be effective.

Mechanisms of pain from the C1-2 joint are being investigated in our NIH-funded study. A collaboration with Ted Price lab.


  1. Dreyfuss P, Michaelsen M, Fletcher D. Atlanto-occipital and lateral atlanto-axial joint pain patterns. Spine. 1993;19:1125-31.

  2. Aprill C, Axinn MJ, Bogduk N. Occipital headaches stemming from the lateral atlanto-axial (C1-2) joint. Cephalalgia. 2002;22:15-22.

  3. Narouze SN, Casanova J, Mekhail N. The longitudinal effectiveness of lateral atlantoaxial intra-articular steroid injection in the treatment of cervicogenic headache. Pain Med. 2007;8(2):184-8.

  4. Hamilton DK, Smith JS, Sansur CA, Dumont AS, Shaffrey CI. C-2 neurectomy during atlantoaxial instrumented fusion in the elderly: patient satisfaction and surgical outcome. J Neurosurg Spine. 2011; 15(1): 3-8.

  5. Goel A, Desai KI, Muzumdar DP. Atlantoaxial fixation using plate and screw method: a report of 160 treated patients. Neurosurgery. 2002; 51(6): 1351-6; discussion 6-7.

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