Cervicogenic Headache

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Original Editor - Christopher Covert

Lead Editors - Jeremy Brady, Mary Harris, Thomas Lawlor, Rick Wetherald

Search Strategy[edit | edit source]

Databases Searched: PubMed, CINAHL, Cochrane, JOSPT, Wiley

Keywords Searched: atlantioaxial, cervicogenic headache, cervical headache, cervical spine, joint mobilization, trigeminocervical

Search Timeline: 4/4/2011 -

Definition/Description[edit | edit source]

A chronic headache that arises from the atlanto-occipital and upper cervical joints and perceived in one or more regions of the head and/or face.[1] These occurs due to a neck disorder or lesion and feature the converging of trigeminal and cervical afferents in the trigeminocervical nucleus within the upper cervical spinal cord.[2] As a definition of cervicogenic headaches, the headache should be abolished following a diagnostic blockade or a cervical structure or its nerve supply.[3]

There is some evidence that multiple structures in the upper cervical spine can be the pain generating structure that is referring pain into the head, centered around structures innervated by C1, C2, and C3. This may include the joints, disc, ligaments, and musculature.[2] The lower cervical spine may play an indirect role in pain production if dysfunctional, but there is no evidence of a direct referral pattern.[2]

The International Headache Society (IHS) has validated cervicogenic headache as a headache type that is hypothesized to originate due to nociception in the cervical area. [4]

The diagnostic criteria described by the HIS are:

  1. Pain localized in the neck and occiput, which can spread to other areas in the head, such as forehead, orbital region, temples,vertex, or ears, usually unilateral.
  2. Pain is precipitated or aggravated by specific neck movements or sustained postures.
  3. At least one of the following:
    1. Resistance to or limitation of passive neck movements
    2. Changes in neck muscle contour, texture, tone, or response to active and passive stretching and contraction
    3. Abnormal tenderness of neck musculature
  4. Radiological examination reveals at least one of the following:
    1. Movement abnormalities in flexion/extension
    2. Abnormal posture
    3. Fractures, congenital abnormalities, bone tumors, rheumatoid arthritis, or other distinct pathology (not spondylosis orosteochondrosis)


Epidemiology/Etiology[edit | edit source]

Of all chronic headaches, the incidence of cervicogenic headache is estimated to be 14-18%.[5] So it is important we can distinguish cervicogenic headache from the other headaches like migraine, tension type headache.

Characteristics/Clinical Presentation[edit | edit source]

Cervicogenic headaches can be challenging to diagnose clinically.  In a 2002 study evaluating the efficacy of manual therapy and exercise in treating cervicogenic headaches, Jull et al included headache patients with a unilateral or unilateral dominant headache that was exacerbated by neck movement or postures and had tenderness at the level of the upper three cervical spine joints.[6] Excluded were those with a bilateral headache and those with symptoms that typify migraine headaches.[6]

Differential Diagnosis[edit | edit source]

Patients presenting with headaches should be screened for serious medical pathologies potentially creating the symptoms.  Differential diagnosis among the various headache types including tension type, migraine, and cluster should follow in order to determine if the patient's headache has a cervicogenic component.  The International Headache Society[7] has developed classification criteria to aid in differential diagnosis among headache types.

An other possibility to distinguish cervicogenic headache from migraine and tension headache is the use of a Cybex dynamometry. [8]The test that used this Cybex dynamometry showed that the ranges of cervical flexion, extension and rotation were significantly less in patients with cervicogenic than in patients with migraine and tension type headache. Investigators also found that tenderness is also a factor that varies between patients with CGH and patients with migraine or tension type headache. The study of Bovim[9] measured pressure pain thresholds at ten points on the head and suboccipital region in patients with CGH, tension type headache and migraine. When he summed all pressure pain thresholds, he found a lower score in patients with cervicogenic headache. The sensitivity of these tests (Cybex dynamometry, test of Bovim,…) was investigated in one study.

Examination[edit | edit source]

Medical Management (current best evidence)[edit | edit source]

Physical Therapy Management (current best evidence)[edit | edit source]

Jull et al[6] reported that a six week physiotherapy program including manual therapy and exercise interventions was an effective treatment option for reduction of cervicogenic headache symptoms and decreasing medication intake in both the short term and at one-year follow-up.

There are studies who investigated features of the articular, muscle and neural systems.
One of these studies investigated the relationship between the presence & severity of cervicogenic headache symptoms and the mobility of the neck with the aid of the function flexion-rotation test (FRT).[10] At the time of the test, the patient should feel no pain. In the flexion-rotation test procedure it is important that the neck of the patient is passively held in end range flexion. During this test, the therapist rotate the neck to each side until he feels resistance or until the patient says he’s in pain. At this end point, the examiner made a visual estimate of the rotation range and said on which side the FRT was positive or negative. The test was positive when the estimated range was reduced by more than 10° from the anticipated normal range (44°). In addition, an univariate linear regression analysis found a significant inverse association between headache severity and range of motion toward the most restricted side during the FRT for all the patients with cervicogenic headache.

Outcome Measures[edit | edit source]

  • Neck_Disability_Index
  • Headache Disability Index
  • Northwick Park Neck Pain Questionnaire
  • Numeric Pain Rating Scale
  • Pain visual analog scale
  • Headache frequency and duration

 

Key Research[edit | edit source]

Resources[edit | edit source]

1. Diagnosis and management of cervicogenic headache.    Sizer PS Jr, Phelps V, Azevedo E, Haye A, Vaught M.    Pain Pract. 2005 Sep;5(3):255-74.

2. The diagnostic validity of the cervical flexion-rotation test in C1/2-related cervicogenic headache.    Ogince M, Hall T, Robinson K, Blackmore AM.    Man Ther. 2007 Aug;12(3):256-62.

3. Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache.    Hall T, Chan HT, Christensen L, Odenthal B, Wells C, Robinson K.    J Orthop Sports Phys Ther. 2007 Mar;37(3):100-7.

4. Clinical evaluation of cervicogenic headache: a clinical perspective.    Fernández-de-Las-Peñas C.    J Man Manip Ther. 2008;16(2):81.

Recent Related Research (from Pubmed)[edit | edit source]

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Clinical Bottom Line[edit | edit source]

References[edit | edit source]

References will automatically be added here, see adding references tutorial.

  1. ↑ Goodman, C, Fuller, K. Pathology: Implications for the Physical Therapist. 3rd ed. St. Louis: Saunders Elsevier, 2009.
  2. ↑ 2.0 2.1 2.2 Bogduk N, Govind J. Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. Lancet Neurol 2009; 8: 959–68.
  3. ↑ HIS Classification ICHD-II. Cervicogenic headache [M99]. http://ihs-classification.org/en/02_klassifikation/03_teil2/11.02.01_cranial.html (accessed 13 April 2011).
  4. ↑ Headache Classifi cation Subcommittee of the International HeadacheSociety. The international classifi cation of headache disorders.2nd edition. Cephalalgia 2004;24:suppl 1.
  5. ↑ Pfaffenrath and Kaube(1990); Nilsson (1995)
  6. ↑ 6.0 6.1 6.2 Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002;27:1835–1843.
  7. ↑ http://ihs-classification.org/en/02_klassifikation/
  8. ↑ Zwart JA. Neck mobility in different headache disorders. Headache 1997;37:6–11.
  9. ↑ Bovim G. Cervicogenic headache, migraine, and tension-type headache. Pressure-pain threshold measurements. Pain 1992;51: 169–73.
  10. ↑ Toby M. Hall, MSc, Kathy Briffa, PhD, Diana Hopper, PhD, and Kim W. Robinson, BSc. The relationship between cervicogenic headache and impairment determined by the flexion-rotation test. Journal of Manipulative and Physiological Therapeutics;Volume 33: Number 9



Information to Re-parse[edit | edit source]

Another study [1]was looking for a pattern of musculoskeletal dysfunction which might better characterize cervicogenic headache for differential diagnosis. The study demonstrated that the cervicogenic headache group had less cervical flexion & extension and a higher incidence of pain associated with joint hypo mobility than de migraine and control group. They extensibility of the upper trapezius, levator scapulae, scalenes and the suboccipital extensors was assessed using standard clinical tests of muscle length.[2]They rated the extensibility on a 4-point scale[3] normal, slightly, moderately and very tight which, for analysis, was collapsed into a 2-point scale: normal (normal and slightly) and tight (moderate and very). This test found also a statistically significant difference between the incidence of tightness between the three groups for the upper trapezius, levator scapulae, scalenes and the suboccipital extensors which were more frequent in the cervicogenic headache group.

Recent Case Studies

J Man Manip Ther. 2007;15(1):10-24.

Orthopaedic manual physical therapy including thrust manipulation and exercise in the management of a patient with cervicogenic headache: a case report.
van Duijn J, van Duijn AJ, Nitsch W.

  1. ↑ G. Zito, G. Jull, I. Story. Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache. Manual Therapy 2006;11:118–129
  2. ↑ Evjenth and Hamberg. Janada 1994
  3. ↑ Treleaven (1994)
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