Diagnosis and Management of Cervicogenic Headache and Local Cervical Syndrome with Multiple Pain Generators

Abstract

Numerous pain generators can be responsible for cervicogenic headache and pain in both the cervical and thoracic regions. A 45-year-old female presented in the clinic with a 20-year history of cervicogenic and migraine headaches, accompanied by a prolonged history of local cervical and interscapular pain. The cervicogenic symptoms were attributed to secondary discrelated changes in the cervical spine, as evidenced by specific provocation behaviors and segmental limitation patterns. The patient was educated regarding the presenting problems, and ergonomic changes were initiated. The limitations were addressed with joint-specific mobilization techniques, accompanied by specific home exercises. The patient demonstrated initial rapid improvements that were characterized by reduced symptoms and increased motion, followed by gradual full motion recovery and resolution of cervicogenic symptoms. This recovery pattern suggests the efficacy of manual techniques in the management of cervicogenic headaches and local cervical syndrome, even in the context of rather prolonged symptoms.     

Self-Referral and the Boutique Hospital Industry

Abstract

Six individuals suffering from chronic cervicogenic headache were the subjects of a series of case studies involving manual therapy, exercise, and a home-exercise program. Headache duration ranged from three months to twenty years. During the course of treatment, the subjects maintained a journal tracking duration, frequency, and intensity of their headaches as well as any relieving factors. The purpose of this series of studies was to describe the use of manual therapy and exercise in the treatment of chronic cervicogenic headaches. Subjects were treated using a custom home-exercise protocol; manual therapy involving soft tissue and non-thrust joint manipulation, aerobic conditioning, and resistance exercise. The Pain Disability Index (PDI) was used as the functional improvement scale. The PDI was administered pre-, post- and six months post-treatment. Five of the six subjects reported improvement. These five subjects were seen for an average of 5.9 sessions over an average of 3.8 weeks. The average improvement on the PDI was 29.5% at discharge and 28.8% at 6- month follow-up. The five subjects each reported the need to continue their home exercise program in order to control their headaches at 6-month follow-up. A voluntary decrease in medication intake was also reported by five of the six subjects at discharge. Six-month follow-up showed that these five patients were still taking less medication than reported at time of the intial examination. No follow-up data was available for the patient which reported no improvement. The results of these case studies seem to indicate that a treatment regimen of exercise and manual therapy can be beneficial in the treatment of chronic cervicogenic headaches.     

Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache

Persistent intermittent headache is a common disorder and is often accompanied by neck aching or stiffness, which could infer a cervical contribution to headache. However, the incidence of cervicogenic headache is estimated to be 14-18% of all chronic headaches, highlighting the need for clear criterion of cervical musculoskeletal impairment to identify cervicogenic headache sufferers who may benefit from treatments such as manual therapy. This study examined the presence of cervical musculoskeletal impairment in 77 subjects, 27 with cervicogenic headache, 25 with migraine with aura and 25 control subjects. Assessments included a photographic measure of posture, range of movement, cervical manual examination, pressure pain thresholds, muscle length, performance in the cranio-cervical flexion test and cervical kinaesthetic sense. The results indicated that when compared to the migraine with aura and control groups who scored similarly in the tests, the cervicogenic headache group had less range of cervical flexion/extension (P=0.048) and significantly higher incidences of painful upper cervical joint dysfunction assessed by manual examination (all P<0.05) and muscle tightness (P<0.05). Sternocleidomastoid normalized EMG values were higher in the latter three stages of the cranio-cervical flexion test although they failed to reach significance. There were no between group differences for other measures. A discriminant analysis revealed that manual examination could discriminate the cervicogenic headache group from the other subjects (migraine with aura and control subjects combined) with an 80% sensitivity.     

Physical impairments in cervicogenic headache: traumatic vs. nontraumatic onset

In order to quantify the physical impairments associated with different types of headache, 77 subjects belonging to four different groups (postmotor vehicle accident cervicogenic headache subjects, cervicogenic headache subjects nontraumatic, migraine patients and control subjects) were evaluated using the following variables: posture, cervical range of motion, strength of the neck flexors and extensors, endurance of the short neck flexors, manual segmental mobility, proprioception of the neck, and pain (McGill Pain Questionnaire and the skin roll test). The results of this study showed that postmotor vehicle accident cervicogenic patients have significantly limited active cervical range of motion (in flexion/extension and rotations), present decreased strength and endurance of neck flexors and decreased strength of the extensor muscles. Our results suggest that there are enough differences between the postmotor vehicle accident and nontraumatic cervicogenic headache subjects to warrant caution when analysing the data of these two subgroups together, as several studies have done in the past. The onset of headache is therefore an important variable that should be controlled for when attempting to characterize the physical impairments associated with cervicogenic headache.     

颈源性头痛的研究进展

自从颈源性头痛1983年被提出后,对此研究取得了一定的进展。颈源性头痛是指由颈椎或颈部软组织病损所引起的以慢性、单侧头部疼痛为主要表现的综合征,其疼痛性质是一种牵涉痛,它的病理生理学机制是位于下行三叉神经脊束的传入纤维与高位颈神经的传入纤维在位于高位颈髓后角的三叉颈神经核发生会聚。目前其诸多诊断标准中以由国际头痛协会和颈源性头痛国际研究组提出的诊断标准最有影响力。主张采用包括麻醉药物、阻滞、外科治疗等治疗计划。     

Are "cervicogenic" headaches due to myofascial pain and cervical spine dysfunction?

The purpose of this investigation was to evaluate whether the pain of cervicogenic headache could be due to referred symptoms from myofascial trigger points. The presence or absence of cervical spine dysfunction was also of interest. Eleven patients with cervicogenic headaches were systematically examined for myofascial trigger points and cervical spine dysfunction. All patients had at least three myofascial trigger points on the symptomatic side. In eight of these patients, trigger point palpation clearly reproduced their headache. There were 70 myofascial trigger points (35 "very tender", 35 "tender") and 17 non-myofascial tender points on the symptomatic side, compared to 22 myofascial trigger points (one "very tender", 21 "tender") and 19 non-myofascial tender points on the asymptomatic side. These differences were statistically significant [chi-square (2df) = 22.04, p less than 0.0001]. All patients had some evidence of cervical dysfunction. Ten patients (91%) had specific segmental dysfunction of occiput on atlas and/or atlas on axis. Five patients were entered into a non-invasive, interdisciplinary pain management program designed to treat cervical spine dysfunction and myofascial pain. Treated patients reported a significant decrease in the frequency and intensity of their headaches during a median two-year follow-up. It is concluded that myofascial trigger points may be an important pain producing mechanism in cervicogenic headache and that segmental cervical dysfunction is a common feature in such patients. Conservative, non-surgical treatment appears to be effective in reducing the frequency and intensity of cervicogenic headache. These data suggest that surgical approaches should be reserved only for those patients who fail conservative therapy.     

Zervikogene Kopfschmerzen können eine akute Sinusitis imitieren

Background

For many patients with head- and facial pain and no other symptoms the referral diagnosis of untreatable sinus headache could not be confirmed and cervicogenic head and neck pain was diagnosed by osteopathy. The present study attempts to clarify some aspects regarding cervicogenic complaints.

Study design

A prospective observational study was carried out on adults referred to an ENT practice in 2006.

Patients and methods

A total of 57 patients referred with head and facial pain without any additional sinusitis symptoms were investigated. These included 48 females with an average age of 46 years (range 18–72 years) and 9 males with an average age of 43 years (range 36–70 years). One quarter of the patients had already been treated with up to 3 different antibiotics. The diagnosis included previous medical history, ENT and manual therapeutic status, x-ray and possibly computed tomography imaging of the paranasal sinuses as well as basic neurological and/or orthopedic examinations.

Results

Of the 57 patients with isolated head and facial pain 17% (n=10) had acute sinusitis based on x-ray findings and in general the duration was less than 2 weeks. The remaining 83% (n=47) had cervicogenic headache with a duration of up to 16 weeks (median 4 weeks) and 87% of those were female. In 70% of the patients with cervicogenic complaints, a clear improvement of the pain could be achieved by self-administered isometric and stretching exercises.

Conclusion

Although the present study is small, it could be demonstrated that cervicogenic headache is frequent in women. Most of the patients showed an improvement in symptoms by carrying out self-administered stretching exercises.     

Cervicogenic Headache - The Clinical Picture, Radiological Findings and Hypotheses on Its Pathophysiology

SYNOPSIS
The clinical picture of 15 patients with "cervicogenic headache" is presented. The patients suffered from constant one-sided headaches, upon which were superimposed acute attacks. The pain could be precipitated and intensified mechanically. It was accompanied in one third of the patients by ipsilateral lacrimation, conjunctival injection, lid edema and visual blurring. Other concomitant symptoms were phono- and photophobia, nausea and vomiting. A C2 blockade always led to temporary pain relief.Routine X-rays of the cervical spine and functional radio-graphs in flexion and extension did not reveal any findings specific for cervicogenic headache when compared to 18 control subjects. Hypotheses on the pathophysiology of cervicogenic headache are presented.     

Cervical musculoskeletal impairment in frequent intermittent headache. Part 1: Subjects with single headaches

Musculoskeletal disorders are considered the underlying cause of cervicogenic headache, but neck pain is commonly associated with migraine and tension-type headaches. This study tested musculoskeletal function in these headache types. From a group of 196 community-based volunteers with headache, 73 had a single headache classifiable as migraine (n = 22), tension-type (n = 33) or cervicogenic headache (n = 18); 57 subjects acted as controls. Range of movement, manual examination of cervical segments, cervical flexor and extensor strength, the cranio-cervical flexion test (CCFT), cross-sectional area of selected extensor muscles at C2 (ultrasound imaging) and cervical kinaesthetic sense were measured by a blinded examiner. In all but one measure (kinaesthetic sense), the cervicogenic headache group were significantly different from the migraine, tension-type headache and control groups (all P < 0.001). A discriminant function analysis revealed that collectively, restricted movement, in association with palpable upper cervical joint dysfunction and impairment in the CCFT, had 100% sensitivity and 94% specificity to identify cervicogenic headache. There was no evidence that the cervical musculoskeletal impairments assessed in this study were present in the migraine and tension-type headache groups. Further research is required to validate the predictive capacity of this pattern of impairment to differentially diagnose cervicogenic headache.     

Side-Locked Unilaterality and Pain Localization in Long-Lasting Headaches: Migraine, Tension-Type Headache, and Cervicogenic Headache

SYNOPSIS
Side-locked unilaterality and specific localization of pain are not as well-defined clinical characteristics in long-lasting headaches (duration more than 4 hours) as they are in short-lasting forms. We examined side-locked unilaterality and pain distribution at onset and at peak headache in 74 patients with different forms of long-lasting headache: migraine and tension-type headache (IHS) and cervicogenic headache (according to Sjaastad et al). Side-locked unilaterality of pain was found in all forms, but to differing extents-20.8% in migraine, 12.5% in tension-type headache, while it was a mandatory criterion for cervicogenic headache. The pain tended to localize anteriorly, particularly at onset, in migraine; was more diffuse in tension-type headache; and always began in the occipitonuchal region in cervicogenic headache. Our results may contribute to a better clinical definition of long-lasting headaches.     

Inter-examiner reliability to detect painful upper cervical joint dysfunction

The presence of painful upper cervical joint dysfunction is a diagnostic criterion for cervicogenic headache. This preliminary study investigated whether independent examiners for a planned multicentre study of treatment of cervicogenic headache sufferers would agree on the presence or not of joint dysfunction for inclusion/exclusion of subjects into the trial. Ten subjects with or without neck pain and headache were recruited in each of four centres (total 40 subjects). Examiners manually assessed subjects' upper cervical regions in a single blind manner. There was excellent to complete agreement between each pair of examiners on which subjects should be allowed to enter the study and 70 per cent agreement between examiners on the two most dysfunctional joints in symptomatic subjects. There can be confidence that an homogenous headache group will enter the planned trial.     

Cervicogenic Headache: Responses to Nitroglycerin, Oxygen, Ergotamine and Morphine

SYNOPSIS
The responses in cervicogenic headache to four different agents have been studied. Nitroglycerin was given sublingually to 27 patients. Eighteen patients got more than 20% increase of their headache. Of those with any headache increase at all, 12 got bilateral and 12 unilateral pain. The typical late cluster headache response to nitroglycerin was not seen in cervicogenic headache. The provocative effect of nitroglycerin seemed less marked in cervicogenic than in cluster headache. Oxygen inhalation, a frequently used treatment for cluster headache, was given to 14 patients with cervicogenic headache. In general, the effect seemed uncertain and probably clearly inferior to the effect in cluster headache. Ergotamine treatment (given to 13 patients) also seemed to be of little avail in cervicogenic headache. Morphine injections given to 11 cervicogenic headache patients resulted in "marked" improvement in 4, but complete pain freedom was only seen in 2 cases. In our opinion, the present results add further evidence to the view that different etiologic and pathogenetic factors underlie cervicogenic headache and cluster headache.     

悬吊运动训练对颈源性头痛的疗效

目的观察悬吊运动训练治疗颈源性头痛的临床疗效。方法颈源性头痛患者60 例,按就诊顺序分为两组。Ⅰ组(n=30)行C2椎旁阻滞,每周1 次;Ⅱ组(n=30)在颈椎旁阻滞基础上配合悬吊运动训练,悬吊运动训练每周3 次。均治疗4 周。观察治疗前与治疗后1 个月、3 个月、6 个月的疼痛视觉模拟评分(VAS)、每月疼痛发作次数及临床疗效。结果治疗后VAS评分,Ⅰ组治疗后1 个月、3 个月,Ⅱ组治疗后1 个月、3 个月、6 个月均较治疗前显著改善(P<0.001);治疗后3 个月、6 个月,Ⅱ组较Ⅰ组改善更显著(P<0.001)。治疗后疼痛发作次数,Ⅰ组治疗后1 个月、3 个月,Ⅱ组治疗后1 个月、3 个月、6 个月均较治疗前减少(P<0.05);治疗后3 个月、6 个月,Ⅱ组较Ⅰ组减少更明显(P<0.05)。治疗后Ⅰ组优良率33.3%,Ⅱ组73.3% (P<0.01)。结论配合悬吊运动训练治疗颈源性头痛优于单一采用颈椎旁阻滞,远期效果更佳。     

Effects of active head retraction with retraction/extension and occipital release on the pressure pain threshold of cervical and scapular trigger points

Pain in the cervical and scapular regions is often associated with trigger points in these regions. Although there are many types of manual therapies used in the clinic to relieve trigger points, there is no documented research to validate their efficacy. The aim of this study was to evaluate the effectiveness of a single session of each of two manual therapy techniques on the pressure pain thresholds of trigger points in the cervical and scapular regions. Sixty volunteers with one or more trigger points were recruited. Subjects were randomly assigned to groups receiving one treatment session of head retraction and retraction/extension exercises, occipital release, or no treatment. A pre-test and post-test of pressure pain threshold were performed on each subject using a pressure algometer. A one-way analysis of covariance, using the pre-test as the covariate, was conducted to analyse the data. The results of the analysis indicated that there were no significant differences between the groups. No changes in trigger point sensitivity, as measured by pressure pain thresholds, were found after one treatment of retraction with retraction/extension exercises and one treatment of occipital release. One treatment of either retraction with retraction/extension exercises or occipital release is not effective in changing the pressure pain thresholds of cervical and scapular trigger points. Further studies need to address the effectiveness of multiple treatment sessions for each technique.     

Relaxation training: a self-help approach for children with headaches.

Children and adolescents frequently complain about recurrent nonmalignant headaches. Relaxation exercises are one possible treatment for these headaches. As the role of occupational therapy in pediatric pain management emerges, relaxation training is becoming one of the treatment activities. The present study investigated the efficacy of progressive relaxation exercises in reducing headache complaints, particularly those headaches of a mixed variety. Ten subjects with a mean age of 11.5 years completed the 6-week self-help program. A multiple-baseline across-subjects design was used. Baseline periods were randomly assigned and ranged from 7 to 25 days with treatment introduced in a time-staggered fashion across subjects. After completing their treatment, 8 of the 10 subjects had a mean increase of 15% in headache-free days. Specific guidelines for relaxation training are provided in the outlined treatment program.     

Cervical musculoskeletal impairment in frequent intermittent headache. Part 2: subjects with concurrent headache types

A pattern of musculoskeletal impairment inclusive of upper cervical joint dysfunction, combined with restricted cervical motion and impairment in muscle function, has been shown to differentiate cervicogenic headache from migraine and tension-type headache when reported as single headaches. It was questioned whether this pattern of cervical musculoskeletal impairment could discriminate a cervicogenic headache as one type of headache in more complex situations when persons report two or more headaches. Subjects with two or more concurrent frequent intermittent headache types (n = 108) and 57 non-headache control subjects were assessed using a set of physical measures for the cervical musculoskeletal system. Discriminant and cluster analyses revealed that 36 subjects had the pattern of musculoskeletal impairment consistent with cervicogenic headache. Isolated features of physical impairment, e.g. range of movement (cervical extension), were not helpful in differentiating cervicogenic headache. There were no differences in measures of cervical musculoskeletal impairment undertaken in this study between control subjects and those classified with non-cervicogenic headaches.     

Cervicogenic headache: Diagnostic evaluation and treatment strategies

Cervicogenic headache is a chronic, hemicranial pain syndrome in which the source of pain is located in the cervical spine or soft tissues of the neck but the sensation of pain is referred to the head. The trigeminocervical nucleus is a region of the upper cervical spinal cord where sensory nerve fibers in the descending tract of the trigeminal nerve converge with sensory fibers from the upper cervical roots. This convergence of upper cervical and trigeminal nociceptive pathways allows the referral of pain signals from the neck to the trigeminal sensory receptive fields of the face and head. The clinical presentation of cervicogenic headache suggests that there is an activation of the trigeminovascular neuroinflammatory cascade, which is thought to be one of the important pathophysiologic mechanisms of migraine. Another convergence of sensorimotor fibers has been described involving intercommunication between the spinal accessory nerve (CN XI), the upper cervical nerve roots, and ultimately the descending tract of the trigeminal nerve. This neural network may be the basis for the wellrecognized patterns of referred pain from the trapezius and sternocleidomastoid muscles to the face and head. Diagnostic criteria have been established for cervicogenic headache but its presenting characteristics may be difficult to distinguish from migraine, tension-type headache, or hemicrania continua. A multidisciplinary treatment program integrating pharmacologic, nonpharmacologic, anesthetic, and rehabilitative interventions is recommended. This article reviews the clinical presentation of cervicogenic headache, its diagnostic evaluation, and treatment strategies.     

Lower cervical disc prolapse may cause cervicogenic headache: prospective study in patients undergoing surgery

In 1983 Sjaastad published for the first time diagnostic criteria for cervicogenic headache. Until now there have been no prospective studies investigating whether cervical disc prolapse can cause cervicogenic headache. Between July 2002 and July 2003 50 patients with cervical disc prolapse proven by computed tomography, myelography or magnetic resonance imaging were recruited and prospectively followed for 3 months. Patients were asked at different time points about headache and neck pain by questionnaires and structured interviews. These data were collected prior to and 7 and 90 days after surgery for the disc prolapse. Fifty patients with lumbar disc prolapse, matched for age and sex, undergoing surgery were recruited as controls. Headache and neck pain was diagnosed according to International Headache Society (IHS) criteria. Twelve of 50 patients with cervical disc prolapse reported new headache and neck pain. Seven patients (58%) fulfilled the 2004 IHS criteria for cervicogenic headache. Two of 50 patients with lumbar disc prolapse had new headaches. Their headaches did not fulfil the criteria for cervicogenic headache. One week after surgery, 8/12 patients with cervical disc prolapse and headache reported to be pain free. One patient was improved and three were unchanged. Three months after cervical prolapse surgery, seven patients were pain free, three improved and two unchanged. This prospective study shows an association of low cervical prolapse with cervicogenic headache: headache and neck pain improves or disappears in 80% of patients after surgery for the cervical disc prolapse. These results indicate that pain afferents from the lower cervical roots can converge on the cervical trigeminal nucleus and the nucleus caudalis.     

Headache and the cervical spine: a critical review

Headache related to the cervical spine is often misdiagnosed and treated inadequately because of confusing and varying terminology. Primary headaches such as tension-type headache and migraine are incorrectly categorized as "cervicogenic" merely because of their occipital localization. Cervicogenic headache as described by Sjaastad presents as a unilateral headache of fluctuating intensity increased by movement of the head and typically radiates from occipital to frontal regions. Definition, pathophysiology, differential diagnoses and therapy of cervicogenic headache are demonstrated. Ipsilateral blockades of the C2 root and/or greater occipital nerve allow a differentiation between cervicogenic headache and primary headache syndromes such as migraine or tension-type headache. Neither pharmacological nor surgical or chiropractic procedures lead to a significant improvement or remission of cervicogenic headache. Pains of various anatomical regions possibly join into a common anatomical pathway, then present as cervicogenic headache, which should therefore be understood as a homogeneous but also unspecific pattern of reaction.     

Cervicogenic headache, migraine, and tension-type headache. Pressure-pain threshold measurements.

Pressure-pain threshold (PPT) measurements were performed with a pressure algometer, at 22 specified points in the head in patients with cervicogenic headache (n = 32), migraine (with and without aura) (n = 26) and tension-type headache (n = 17). Comparisons were made with a group of healthy controls (n = 20). The average PPT differed significantly between the groups (ANOVA, F = 9.5, P < 0.0005), largely caused by the low threshold in cervicogenic headache patients. There were no significant differences between controls and the 2 other headache groups. In the cervicogenic headache group, the lowest PPT was found in the occipital part of the head on the side with pain predominance. The ratio between the dominant and non-dominant sides (all 11 points on each side) was 0.85 in cervicogenic headache, whereas it was 0.99 in migraine patients with side preponderance of the pain. The present results support the view that the pathogenesis of cervicogenic headache differs from that of migraine and tension-type headache. The results may further support the theory that fibres from the C2 level (innervating the occipital part of the head) may be included in the pathogenetic mechanism in cervicogenic headache.