Physical Therapy Diagnosis and Management of a Patient with Chronic Daily Headache: A Case Report

Abstract

Chronic headaches are a significant health problem for patients and often a clinical enigma for the medical professionals who treat such patients. The purpose of this case report is to describe the physical therapy diagnosis and management of a patient with chronic daily headache. The patient was a 48-year-old woman with a medical diagnosis of combined common migraine headache and chronic tension-type headache. An exacerbation of these long-standing headache complaints had resulted in a chronic daily headache for the preceding eight months. Symptoms included bilateral headache, neck pain, left facial pain, and tinnitus. Outcome measures used included the Henry Ford Hospital Headache Disability Inventory (HDI) and the Neck Disability Index (NDI). Examination revealed myofascial, articular, postural, and neuromuscular impairments of the head and neck region. Treatment incorporated myofascial trigger point dry needling, orthopaedic manual physical therapy, exercise therapy, and patient education. On the final visit, the patient reported no headaches during the preceding month. There was a 31% improvement in the HDI emotional score, a 42% improvement in the functional score, and a 36% improvement in the total score for the HDI, the latter exceeding the minimal detectable change for the total score on this measure. The NDI at discharge showed an 18% improvement with a maximal improvement during the course of treatment of 26%. Both improvements exceeded the minimal clinically important difference for the NDI. This case report indicates that physical therapy diagnosis and management as described may be indicated for the conservative care of patients with chronic headaches.     

Cervicogenic Dizziness: A Case Report Illustrating Orthopaedic Manual and Vestibular Physical Therapy Comanagement

Abstract

The diagnosis and treatment of patients with dizziness of a cervical origin may pose a challenge for orthopaedic and vestibular physical therapy specialists. A thorough examination, which consists of a screening examination to rule out pathologies not amenable to sole physical therapy management and, if indicated, a physical therapy differential diagnostic process incorporating both cervical spine and vestibular tests and measures, may indicate an appropriate course of management. The treatment progression is then based on patient signs, symptoms, and response to physical therapy interventions. This case study describes the diagnosis, treatment, and outcomes of a patient with cervicogenic dizziness co-managed by a vestibular and an orthopaedic manual physical therapist.     

Physical Therapy Exercise Intervention Based on Classification Using the Patient Response Method: A Systematic Review of the Literature

Abstract

It has been suggested that inclusion into a study that categorizes patients in mutually exclusive, clinometric classifications should improve the outcome of an exercise based randomized clinical trial. This review examined the evidence regarding the effectiveness of physical therapist-directed therapeutic exercises when patients were classified using the patient response method. This systematic literature review restricted article inclusion to English-only articles that classified homogenous samples of low back pain patients using the patient response based method, demonstrated physical therapist-directed exercise interventions, and used specific outcome criteria for assessment of patient improvement. The PEDro scale was used to rate the methodological quality of the studies. Of 82 articles reviewed only 5 articles were accepted. All 5 met the PEDro standards for a high-quality study. Of the 5 articles, 4 demonstrated that physical therapy exercise intervention based on the patient response method of classification were significantly better than the pragmatic control comparisons; the remaining article indicated that exercise was less effective than manipulation. There appears to be a trend toward positive outcomes with physical therapy exercise intervention in trials restricted to the patient response method of classification; however, few studies have investigated this phenomenon.     

Manual joint mobilisation techniques,supervised physical activity,psychological treatment,acupuncture and patient education for patients with tension-type headache. A systematic review and meta-analysis

BackgroundTension-type headache (TTH) has been ranked the second most prevalent health condition worldwide. Non-pharmacological treatments for TTH are widely used as a supplement or an alternative to medical treatment. However, the evidence for their effects are limited. Therefore, the aim of this study was to review the evidence for manual joint mobilisation techniques, supervised physical activity, psychological treatment, acupuncture and patient education as treatments for TTH on the effect of headache frequency and quality of life.MethodsA systematic literature search was conducted from February to July 2020 for clinical guidelines, systematic reviews, and individual randomised controlled trials (RCT). The primary outcomes measured were days with headache and quality of life at the end of treatment along with a number of secondary outcomes. Meta-analyses were performed on eligible RCTs and pooled estimates of effects were calculated using the random-effect model. The overall certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach (GRADE). In addition, patient preferences were included in the evaluation.ResultsIn all, 13 RCTs were included. Acupuncture might have positive effects on both primary outcomes. Supervised physical activity might have a positive effect on pain intensity at the end of treatment and headache frequency at follow-up. Manual joint mobilisation techniques might have a positive effect on headache frequency and quality of life at follow-up. Psychological treatment might have a positive effect on stress symptoms at the end of treatment. No relevant RCTs were identified for patient education. The overall certainty of evidence was downgraded to low and very low. No serious adverse events were reported. A consensus recommendation was made for patient education and weak recommendations for the other interventions.ConclusionBased on identified benefits, certainty of evidence, and patient preferences, manual joint mobilisation techniques, supervised physical activity, psychological treatment, acupuncture, and patient education can be considered as non-pharmacological treatment approaches for TTH. Some positive effects were shown on headache frequency, quality of life, pain intensity and stress symptoms. Few studies and low sample sizes posed a challenge in drawing solid conclusions. Therefore, high-quality RCTs are warranted.Supplementary InformationThe online version contains supplementary material available at 10.1186/s10194-021-01298-4.     

Changes in Clinical Parameters in Patients with Tension-type Headache Following Massage Therapy: A Pilot Study

Abstract

Complementary and alternative medicine approaches to treatment for tension-type headache are increasingly popular among patients, but evidence supporting its efficacy is limited. The objective of this study was to assess short term changes on primary and secondary headache pain measures in patients with tension-type headache (TTH) receiving a structured massage therapy program with a focus on myofascial trigger point therapy. Participants were enrolled in an open label trial using a baseline control with four 3-week phases: baseline, massage (two 3-week phases) and follow-up. Twice weekly, 45-minute massage sessions commenced following the baseline phase. A daily headache diary was maintained throughout the study in which participants recorded headache incidence, intensity, and duration. The Headache Disability Index was administered upon study entry and at 3-week intervals thereafter. 18 subjects were enrolled with 16 completing all headache diary, evaluation, and massage assignments. Study participants reported a median of 7.5 years with TTH. Headache frequency decreased from 4.7±0.7 episodes per week during baseline to 3.7±0.9 during treatment period 2 (P<0.001); reduction was also noted during the follow-up phase (3.2±1.0). Secondary measures of headache also decreased across the study phases with headache intensity decreasing by 30% (P<0.01) and headache duration from 4.0±1.3 to 2.8±0.5 hours (P<0.05). A corresponding improvement in Headache Disability Index was found with massage (P<0.001). This pilot study provides preliminary evidence for reduction in headache pain and disability with massage therapy that targets myofascial trigger points, suggesting the need for more rigorously controlled studies.     

Effectiveness of the anodyne therapy system in treating diabetic peripheral neuropathy: a systematic review

Abstract

Objective: A systematic review was performed of clinical research on the efficacy of the anodyne therapy system (ATS) for treating patients with diabetic peripheral neuropathy.

Method: MedLine, CINAHL, Cochrane Databases, and Physical Therapy, the Journal of the American Physical Therapy Association web sites were searched in the 1986–2006 time period.

Results: Ten studies were identified. All studies evaluated patients who were on average >60 years of age; few identified disease duration or whether its onset was genetic or acquired. Two prospective, randomised, placebo-controlled studies were identified with one supporting its use. Results indicate efficacy for improving lower extremity sensation, balance, gait and decreasing fall risk, particularly if subjects have a relatively recent diabetic peripheral neuropathy onset (short duration).

Conclusion: Poor study designs, small sample sizes, limited information regarding treatment volume or intensity, concomitant use of conventional physical therapy modalities, and a lack of long-term follow-up decrease the validity of most studies. Well-designed, prospective, randomised, controlled trials with larger subject numbers are needed to determine true treatment effectiveness.     

Use of the Patellar-Pubic Percussion Test in the Diagnosis and Management of a Patient with a Non-Displaced Hip Fracture

Abstract

This case report describes the diagnosis and subsequent medical and physical therapy management of a 68-year-old patient with an undiagnosed non-displaced hip fracture. Initial plain film radiographs and a computed tomography (CT) scan of the involved hip were both interpreted as negative. One of the findings on the physical examination included a positive patellar-pubic percussion test (PPPT). This finding in a female patient of this age raised the suspicion of an occult hip fracture and she was referred back to her primary care physician. Repeat radiographs revealed a non-displaced hip fracture and the patient was treated surgically. The PPPT is an easy-to-implement clinical examination tool that may be extremely useful in physical therapy practice to guide the decision-making process for patients with suspected hip fractures. The utilization of the PPPT by the treating physical therapist for the patient in this case report contributed to a timely diagnosis, potentially preventing the disabling sequelae associated with a displaced femoral fracture.     

Physical Therapy and Manual Physical Therapy for Patients with Non-Specific Low-Back Pain: Differences in Patient Characteristics with Implications for Diagnostic Classification

Abstract

A previous study compared socio-demographic characteristics, health problem characteristics, and primary process data between a database sample of patients referred to physical therapy (PT) versus a sample of patients referred for specific manual physical therapy (MPT) diagnosis and management. This study did not differentiate between patients based on affected body region or diagnosis. The present study is a secondary analysis of these data for patients with non-specific low-back pain (LBP). Statistical analysis indicated that the MPT patient sample was significantly (P<0.01) different from the PT database sample with regard to socio-demographic data: The MPT patients were more often male, younger, had attained a higher level of post-secondary education, and were more often gainfully employed. The MPT sample was also significantly (P<0.01) different from the PT sample with regard to health problem characteristics indicating more often acute, recurrent, non-surgical LBP of shorter duration and unknown etiology in the MPT sample. Both samples were also significantly different with regard to the most common impairments, limitations in activities, and restrictions in participation. After correction for socio-demographic differences, both samples remained significantly different for pathology, recurrence, and mechanism of injury. Diagnosis and management with MPT resulted in a significantly better outcome at discharge than PT as determined by the therapist based on patient verbal report (P=0.0000); however, data on recurrence and the unclear influence of socio-demographic data as well as the absence of more reliable, valid, and responsive outcome measures render these outcome data somewhat equivocal. Interpretation of these data with regard to their potential use in diagnostic classification of patients with non-specific LBP is discussed.     

Abstracts of Current Literature

Abstract

The objective of our study was to determine the effectiveness of manual therapy for balancing C1 and a home exercise program, including active neck retraction exercises performed in a series of progressions, in the treatment of cervicogenic headache. The subjects included a 42-year-old male (Subject 1) and a 25-year-old female (Subject 2), both with a primary complaint of right-side suboccipital headache. Subject 1 was functionally limited in reading, sleeping, and playing basketball. Subject 2 reported problems with working, sleeping, and running on a treadmill. Both subjects met the criteria for cervicogenic headache as adapted from the International Headache Society. On Day 1, each subject completed three self-report measures: a numeric pain scale for both worst and average headache pain as well as the Patient Specific Functional Scale. Each subject was treated on Days 1, 3, and 5. Intervention included using a muscle energy technique for balancing C1 and a home program consisting of a progression of McKenzie's retraction/extension/rotation exercises. Each subject was told he/she may continue the home program on his/her own accord every 2 hours or as a headache occurred. On days 12 and 26, each subject completed the previous three self-report measures as well as the Global Rating Scale during blinded follow-up phone visits. The subjects demonstrated an increase in functional activities, a decrease in average and worst headache pain, and an overall improvement in their perception of change in the headache. Manual therapy in addition to a home program of active neck retraction exercises in a series of progressions was successful in relieving cervicogenic headache and improving function in two subjects. Patients with cervicogenic headaches could be empowered to alleviate their own symptoms with decreased physical therapy visits and decreased cost by having a manual therapy technique performed on them followed by a home exercise program.     

Ethics knowledge in physical therapy: a narrative review of the literature since 2000

Abstract

Objective: The purpose of this narrative review is to assess current physical therapy ethics knowledge by synthesizing literature published since 2000.

Method: This review builds on an earlier analysis.6 A rigorous search of major databases (including Medline, CINAHL, and PubMed) was conducted using specific keywords and explicit inclusion and exclusion criteria. The final review included 27 peer-reviewed articles and three editorials/lectures.

Results: Four themes of papers were identified that focused on (1) development of physical therapy ethics knowledge, (2) ethical issues related to conducting research, (3) how ethical issues are identified and managed and how ethical practice is taught, and (4) development of theoretical ethical decision-making models.

Discussion: The literature reflects a steady growth in interest in physical therapy ethics. Some 'gaps' in knowledge have been addressed but others have not, such as the impact of the institutional environment and cultural dimensions of practice on ethical reasoning. Research studies, using mostly qualitative approaches, identify similar issues but a synthesis of the findings is made difficult by lack of consistency in purpose and study design. While inclusion of ethics content in physical therapy curricula is recommended, little is known about how this is currently being achieved. Ethical theories are poorly integrated into the discussion of ethics in practice.

Conclusion: This review reveals the continuing need to ensure the development of physical therapy ethical knowledge by consistently incorporating both ethical theories and practice knowledge in education curricula and establishing a rigorous research agenda that accurately reflects the unique and multidimensional nature of clinical practice.     

Subject Index

Abstract

Shoulder pain is a common orthopedic condition seen by physical therapists, with many potential contributing factors and proposed treatments. Although manual physical therapy interventions for the cervicothoracic spine and ribs have been investigated for this patient population, the specific effects of these treatments have not been reported. The purpose of this investigational study is to report the immediate effects of thoracic spine and rib manipulation in patients with primary complaints of shoulder pain. Using a test-retest design, 21 subjects with shoulder pain were treated during a single treatment session with high-velocity thrust manipulation to the thoracic spine or upper ribs. Post-treatment effects demonstrated a 51% (32mm) reduction in shoulder pain, a corresponding increase in shoulder range of motion (30°-38°), and a mean patient-perceived global rating of change of 4.2 (median 5). These immediate post-treatment results suggest that thoracic and rib manipulative therapy is associated with improved shoulder pain and motion in patients with shoulder pain, and further these interventions support the concept of a regional interdependence between the thoracic spine, upper ribs, and shoulder.     

McGill Pain Questionnaire Scores Do Not Predict Outcomes of Outpatient Therapy for Patients with Low-Back Pain

Abstract

The purpose of this study was to determine the value of the McGill Pain Questionnaire (MPQ) as a predictor of two outcomes in patients receiving outpatient physical therapy services. The outcomes of interest were the patients' final Oswestry Low-Back Pain Questionnaire (OLBPQ) score and the change between the patients' initial and final OLBPQ scores. Predictive validity of the MPQ was examined in the context of other potentially informative variables. Data from 23 patients with low-back pain were analyzed. Data obtained at enrollment included initial MPQ and OLBPQ scores, demographics, compensation status, time since onset, injury type, employment type, and worker class. MPQ scores predicted neither outcome. Initial OLBPQ scores and compensation status, however, predicted outcomes. Together these variables explained 59.1 percent of the variance in the final OLBPQ score and 46.3 percent of the variance in the change (improvement) in the OLBPQ score. Results of this study do not support use of the MPQ as a predictor of functional outcome in outpatients with low-back pain.     

Mindfulness-based cognitive therapy for the treatment of headache pain: A mixed-methods analysis comparing treatment responders and treatment non-responders

ObjectivesOur recent pilot study demonstrated mindfulness-based cognitive therapy (MBCT) is a potentially efficacious headache pain treatment; however, it was not universally effective for all participants. This study sought to explore patient characteristics associated with MBCT treatment response and the potential processes of change that allowed treatment responders to improve and that were potentially lacking in the non-responders.DesignWe implemented a mixed-methods analysis of quantitative and qualitative data. The sample consisted of 21 participants, 14 of whom were classified as treatment responders (≥50% improvement in pain intensity and/or pain interference) and seven as non-responders (<50% improvement).SettingThe study was conducted at the Kilgo Headache Clinic and the University of Alabama Psychology Clinic.InterventionParticipants completed an 8-week MBCT treatment for headache pain management.MeasuresStandardized measures of pain, psychosocial outcomes, and non-specific therapy factors were obtained; all participants completed a post-treatment semi-structured interview.ResultsQuantitative data indicated a large effect size difference between responders and non-responders for pre- to post-treatment change in standardized measures of pain acceptance and catastrophizing, and a small to medium effect size differences on treatment dose indicators. Both groups showed improved psychosocial outcomes. Qualitatively, change in cognitive processes was a more salient qualitative theme within treatment responders; both groups commented on the importance of non-specific therapeutic factors. Barriers to mindfulness meditation were also commented on by participants across groups.ConclusionsResults indicated that change in pain related cognitions during an MBCT intervention for headache pain is a key factor underlying treatment response.     

Dizziness in Orthopaedic Physical Therapy Practice: History and Physical Examination

Abstract

Physical therapy (PT) differential diagnosis of patients complaining of dizziness centers on distinguishing those patients who might benefit from sole management by the physical therapist from those patients who require referral for medical-surgical differential diagnosis and (co) management. There is emerging evidence that PT management may suffice for patients with benign paroxysmal positional vertigo, cervicogenic dizziness, and musculoskeletal impairments leading to dysequilibrium. This article provides information on the history taking and physical examination relevant to patients with a main complaint of dizziness. The intention of the article is to enable the therapist to distinguish between patients complaining of dizziness due to these three conditions amenable to sole PT management and those patients who likely require referral. Where available, we have provided data on reliability and validity of the history items and physical tests described to help the clinician establish a level of research-based confidence with which to interpret history and physical examination findings. The decision to refer the patient for a medical-surgical evaluation is based on our findings, the interpretation of such findings in light of data on reliability and validity of history items and physical tests, an analysis of the risk of harm to the patient, and the response to seemingly appropriate intervention.     

A Multi-Structural Approach to Treatment of a Patient With Sub-Acromial Impingement: A Case Report

Abstract

Sub-acromial impingement is a condition commonly seen by physical therapists, however little evidence is available regarding the efficacy of this treatment. This case report describes the use of manual therapy and exercise, using a multi-structural approach to manage this condition. The subject was a 48-year-old retired physiotherapist complaining of recurrent shoulder pain during daily activities, although her daily function was not limited. Passive joint mobilization techniques of the cervical spine, costovertebral joints, and the glenohumeral joint as well as soft tissue mobilization techniques of the rotator cuff muscles were used. Exercises were prescribed to “set” the scapula in an optimal position and to facilitate and strengthen the rotator cuff muscles. After two treatments, the patient consulted an orthopaedic surgeon due to imminent decrease in funding for her treatment and a cortisone injection was administered. This decreased her pain immediately by 90%. However, two months later she attended three further physical therapy treatments because of recurrence of the pain. Six months after these treatments she was still pain-free. This case illustrates that physical therapy can be effective in the treatment of sub-acromial impingement, using a multi-structural approach to treatment.     

The Relaxation Response Resiliency Program (3RP) in Patients with Headache and Musculoskeletal Pain: A Retrospective Analysis of Clinical Data

BackgroundHeadache and musculoskeletal pain are associated with both physical and mental health symptoms, which together are mutually reinforcing. Addressing mental and physical health symptoms (including pain) concomitantly may provide an effective and efficient way to improve outcomes in this population. We tested an evidence-based, eight-session multimodal group program, the Relaxation Response Resiliency Program (3RP), in patients with headache and musculoskeletal pain. A total of 109 adults (30 with headaches, 79 with musculoskeletal pain).MethodsParticipant were 109 adults (30 with headaches, 79 with musculoskeletal pain) referred by their medical doctor, who completed a battery of questionnaires before and after completion of the 3RP.ResultsOn average, patients with headache and musculoskeletal pain had higher pretreatment scores for anxiety, depression, and somatization symptoms than the nonpatient normative sample for the Symptom Checklist 90—Revised. Significant improvements were identified from pre- to post-treatment in all mental health symptoms (moderate to large effects) and frequency of pain and co-occurring physical health symptoms (small to moderate effects). Patients also reported significant decreases in degree of discomfort and life interference, which were relatively more modest in the musculoskeletal pain group compared with the headache group.ConclusionsOverall, results of this study suggest that the 3RP may be an effective treatment for reducing pain and psychological symptoms in patients with headaches and musculoskeletal pain. Future work is needed to evaluate the 3RP via a randomized clinical trial in these patient populations.     

Characteristics of TMD headache – a systematic review

Abstract

Objective: This systematic review critically evaluated the literature on the subjective and physical characteristics of TMD-related headache, a symptom secondary to the syndrome temporomandibular disorders (TMD). The specific research question is: 'what are the diagnostic criteria that confirm temporomandibular involvement in headache presentations?'

Method: Electronic searches were conducted for MEDLINE, PubMed, and CINAHL from 1966 to September 2007. Hand searches for retrieved articles were also conducted to collect the data for this review. After applying inclusion criteria, 15 articles on TMD-related headache were found.

Results: The symptoms of TMD-related headache are frequently unilateral and often present in the pre-auricular, temple and retro-orbital regions of the head. The principal physical characteristics include tenderness of the ipsilateral masticatory muscles and reduced jaw opening, often with mandibular deviation.

Conclusion: Despite methodological problems such as low subject numbers and poorly documented sampling methods and inclusion criteria, the literature showed that TMD-related headache has identifiable diagnostic characteristics. This information could be used to develop guidelines to assist the identification of headaches which emanate from the temporomandibular structures.     

Manual examination in the diagnosis of cervicogenic headache: a systematic literature review

ObjectiveTo evaluate the diagnostic validity of manual examination techniques used to diagnose cervicogenic headache (CGH).BackgroundCervicogenic headache is a specific type of headache that originates from the cervical spine and is typically chronic in nature. Diagnostic criteria for CGH have been established by the International Headache Society (IHS) and are cited extensively in the literature. Diagnosis of CGH through manual examination is a more recent practice. To our knowledge, no systematic review of manual diagnosis of CGH has been performed.MethodsSearches of electronic databases (CINAHL, Cochrane Library, Medline, PEDro, Scopus, and SPORTDiscus) were conducted for research studies from July 2003 to February 2014. The GRADE approach was used to determine the quality of each paper.ResultsTwelve papers that fulfilled the inclusion and exclusion criteria were identified (12 observational studies). The level of evidence ranged from very low to low, and recommendations for use of specific manual techniques ranged from weak to strong.ConclusionsDespite low levels of evidence, manual examination of the cervical spine appears to aid the diagnostic process related to CGH and can be implemented by both experienced and inexperienced examiners.     

The ability of a sustained within-session finding of pain reduction during traction to dictate improved outcomes from a manual therapy approach on patients with osteoarthritis of the hip

Abstract

Objectives: The objectives of this study were to: (1) determine the association of a within-session finding after traction of the hip with self-report of well-being, pain, and self-report of function at 9 weeks; and (2) to determine if the interactions between the within-session finding and the outcome measure are different between groups of patients with hip OA who receive and who do not receive manual therapy.

Methods: Data were retrospectively analysed in 70 subjects who were part of a randomized control trial. Correlation analyses of within-session findings from the initial visit after traction of a concordantly painful hip were compared to self-report measures for function, pain, and well-being at 9 weeks. A comparison of slope coefficients between manual therapy and non-manual therapy groups was performed to determine the interactive aspects of the within-session finding.

Results: Although the correlations for the manual therapy group were higher than for the supervised neglect group, none of the correlational analyses for both groups was strong or significant. Significant differences in the slope coefficients for well-being and pain were found, suggesting that the interactions between the within-session findings and the targeted outcomes were different in the manual therapy group versus supervised neglect group.

Discussion: These findings suggest that within-session findings during the initial evaluation are not strongly related to a positive outcome after manual therapy, although the interaction of the finding of a within-session change and the use of manual therapy is more compelling than the finding in a sample of patients who did not receive manual therapy.     

Influential Variables Associated with Outcomes in Patients with Cervicogenic Headache

Cervicogenic headache (CGH) is a common sequela of upper cervical dysfunction with a significant impact on patients. Diagnosis and treatment have been well validated; however, few studies have described characteristics of patients that are associated with outcomes of physical therapy treatment of this disorder. A retrospective chart review of patient data was performed on a cohort of 44 patients with CGH. Patients had undergone a standardized physical therapy treatment approach that included spinal mobilization/manipulation and therapeutic exercise, and outcomes of treatment were determined by quantification of changes in headache pain intensity, headache frequency, and self-reported function. Multiple regression analysis was utilized to determine the relationship between a variety of patient-specific variables and these outcome measures. Increased patient age, provocation or relief of headache with movement, and being gainfully employed were all patient factors that were found to be significantly (P<0.05) related to improved outcomes.Key Words: Cervicogenic Headache, Physical Therapy, Treatment Characteristics, Manual TherapyAlthough cervicogenic headache (CGH) has been described as a “final common pathway” of cervical spine dysfunction¹, its true prevalence is difficult to determine due to inconsistent use of diagnostic criteria in the literature. Incidence of cervicogenic headache has been reported to range from 0.7% to as high as 13.8% in populations of patients suffering from headache disorders². Others have reported cervicogenic origins of higher values (14% to 18%) in all chronic headaches³.gThe anatomical basis for CGH is the convergence of the afferent input of the upper cervical spine nerve roots (C1-C3) with the afferent tracts of the trigeminal nerve in the trigeminocervical nucleus. This convergence results in cervical spine nociceptive input being expressed in the sensory distribution of the trigeminal nerve, most commonly the ophthalmic branch of the trigeminal nerve, which innervates the forehead, temple, and orbit and has its greatest topographic representation near the dorsal horns of spinal nerves C1-C3^4,5. Therefore, any structure innervated by C1, C2, or C3 spinal nerves can be implicated in the etiology of CGH. This includes the atlanto-occipital, median atlanto-axial, lateral atlanto-axial, and C2-3 zygapophyseal joints as well as the C2-3 intervertebral disc, suboccipital, upper posterior cervical, and upper paravertebral musculature, the trapezius and sternocleidomastoid muscles, upper cervical spinal dura mater, and the vertebral arteries^4–6. Because of the ability of afferent nerves to travel up to three segments cephalically or caudally in the cervical spinal cord, bony and soft tissue structures of the middle and lower cervical spine cannot be excluded from contributing to CGH^4,5.The diagnosis of CGH has been a source of contention in the literature ever since the inception of the term by Sjaastad et al in 19837-9. Currently, two major sets of diagnostic criteria exist for CGH (Table ​(Table1).1). The International Headache Society (IHS) accepted the diagnosis of CGH in 1988 as a type of secondary headache and, at that time, included criteria for its diagnosis in the International Classification of Headache Disorders, which was most recently updated in 2004¹⁰. However, the criteria established in 1990 by Sjaastad and the Cervicogenic Headache International Study Group (CHISG) and revised in 1998¹ are the most utilized clinically. The exception of the clinical utility of Sjaastad''s criteria is Point II, which stipulates the use of a nerve block to diagnose CGH in scientific works. The use of a nerve block may be impractical for daily clinical practice, despite being the only means by which a structure in the cervical spine can truly be isolated as the pain generator^5,11,12. Furthermore, although Point III of Sjaastad''s criteria specifies unilaterality of symptoms, the presence of bilateral symptoms or “unilaterality on two sides” has been documented^1,13. Differential diagnosis includes hemicrania continua, occipital neuralgia, migraine, and tension-type headache, with the differentiation of CGH from migraine and tension-type headache being the most challenging due to the overlap of many symptoms among these three disorders^2,14.

TABLE 1

Diagnostic criteria for cervicogenic headache