Cervicogenic Headache

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Original Editor - Christopher Covert

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

Search Strategy

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

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

Search Timeline: April 4^th 2011 - May 1^st, 2011

Definition/Description

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. These occur 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. By definition the headache should be abolished following a diagnostic blockade of a cervical structure or its nerve supply.

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. The lower cervical spine may play an indirect role in pain production if dysfunctional, but there is no evidence of a direct referral pattern.

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.

Epidemiology/Etiology

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

The term cervicogenic headache (CGH) was coined almost 3 decades ago, and the general condition of pain located in the head but originating in the cervical spine was described over 100 years ago. It is similar to other non-specific spinal conditions in its relative lack of high level evidence regarding pathoanatomical etiology. Since there is no objective test set for diffinitive diagnosis of CGH, the condition is ruled in, and treatment chosen, based on the patient's subjective report of pain patterns. (Haldeman)

Through controlled nerve blocking of various structures in the cervical spine, it appears that the zygoapophyseal joints, especially those of C2/C3, are the most common sources of CGH pain. This finding is even more common in patients with a history of whiplash.

Characteristics/Clinical Presentation

Challenging to diagnose clinically, but often includes the below:

• Unilateral “ram’s horn” or unilateral dominant headache
  • Excluding those with bilateral headache or symptoms that typify migrane headaches
• Exacerbated by neck movement or posture
• Tenderness of the upper 3 cervical spine joints
• Associated with neck pain or dysfunction
  

Differential Diagnosis

Type	Location	Intensity	Frequency	Duration
Cluster	Unilateral (orbital, supraorbital, temporal)	Severe	1x every other day -> 8x day	15-180 minutes
Paroxysmal hemicranes	Unilateral	Severe	5+/day, more than 1/2 time, lower frequency may occur	Short (2-3 minutes)
Migrane without aura	Unilateral: Frontotemporal (adults), Occipital (children)	Moderate-Severe	>14 days/month	4-72 hours

For more detailed classification information

        Another possibility to distinguish cervicogenic headache from migraine and tension headache is the use of a Cybex dynamometry. 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 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 was investigated in one study.

Examination

The diagnostic criteria described by the IHS 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)

"Red flags"

1. Sudden onset of a new severe headache;
2. A worsening pattern of a pre-existing headache in the absence of obvious predisposing factors;
3. Headache associated with fever, neck stiff ness, skin rash, and with a history of cancer, HIV, or other systemic illness;
4. Headache associated with focal neurologic signs other than typical aura;
5. Moderate or severe headache triggered by cough, exertion, or bearing down; and
6. New onset of a headache during or following pregnancy26.

Patients with one or more red flags should be referred for an immediate medical consultation and further investigation. – hall “jmmt 0016-“

Flexion-Rotation Test (FRT): pt feels no pn at time of test, passively held at end-range flexion. Rotate the neck to each side until resistance or pt pn felt. Make visual estimate of range. positive test = range reduced by 10° from anticipated normal range (44°). Inverse relationship between headache severity of cervicogenic headaches and ROM towards most restricted side was statistically significant. ↑ 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.

Pt’s had a lower pressure pain thresholdwith CGH than with migrane and tension – Bovim ↑ Bovim G. Cervicogenic headache, migraine, and tension-type headache. Pressure-pain threshold measurements. Pain 1992;51: 169–73.

Medical Management (current best evidence)

The failure to conclusively demonstrate a specific disease or dysfunction of the neck in relation to cervicogenic headache has been an impediment to specific treatment for individuals with the diagnosis.

Cervical epidural steroid injections Indicated for multilevel disc or spine degeneration

Nerve Blocks Disrupting the cascade of signals leading to sensitization to central mechanisms via:

• Nerve blocks
• Trigger point injections
• Radiofrequency thermal neurolysis

Current best evidence suggests that there is not sufficient evidence meeting the EBM criteria to support the use of RF facet denervation for cervicogenic headaches.

Surgical interventions Often only provide temporary relief with the possibility of longer intensification of pain. Procedures Include:

• Neurotomy
• Dorsal rhizotomy
• Microvascular decompression of nerve roots

Other Medications

Tricyclic antidepressants - Used at lower dosage than required for pts diagnosed with depression

Muscle relaxants - Related to the CNS, may be beneficial, evidence is still pending

Botulinum toxin - A neurotoxin injected into tender muscles to reduce hypertonia

Physical Therapy Management (current best evidence)

The preferred practice pattern for cervicogenic headache is 5D: Impaired Motor Function and Sensory Integrity Associated with Nonprogressive Disorders of the Central Nervous System-Acquired in Adolescence or Adulthood. Goodman states that " Although this type of headache is responsive to therapy oriented at treating the soft tissue restrictions, the method of examination, assessment, and treatment needs to be specific to the neck and occiput."[1]

(1) Goodman Catherine C., Fuller Kenda S. Pathology: Implications for the Physical Therapist. 3rd ed. St. Louis: Saunders Elsevier, 2009. p1562

Treatment should include cervical spine manipulation or mobilization and strengthening exercises for the deep neck and upper quarter muscles.(1) Additionally, thoracic spine thrust manipulation and exercise had been shown reduce the neck pain which is a contributing cause to cervicogenic headaches.(2) The C1-C2 self-sustained natural apophyseal glide (SNAG) exercise has also been shown to be effective for reducing cervicogenic headaches symptoms.(3)

(1) Preliminary Examination of a Proposed Treatment-Based Classification System for Patients Receiving Physical Therapy Interventions for Neck Pain, Physical Therapy 2007Julie M Fritz, Gerard P Brennan P (2) Examination of a Cliical Prediction Rule to Indentify Patients with Neck Pain likely to benefit from thoracic spine thrust manipulation and a general cervical range of motion exercise: Muti-Center Randomized Clinical Trial. Cleland et al, Physical Therapy 2010 (3) Hall et al JOSPT 2007

Jull et al 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 Cervical_Flexion-Rotation_Test  (FRT). 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

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

 

Resources

International Headache Society

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)

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References

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Information to Re-parse

Another study 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.They rated the extensibility on a 4-point scale 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.