The flexion-rotation test and active cervical mobility--a comparative measurement study in cervicogenic headache

A single blind, age and gender matched, comparative measurement study was designed to assess active range of cervical motion and passive range of rotation in cervical flexion in asymptomatic and cervicogenic headache subjects. Both procedures are commonly used in clinical practice to evaluate patients with cervicogenic headache. We studied 20 women and eight men with side dominant cervicogenic headache (mean age 43.3 years) matched with 28 asymptomatic subjects. Two experienced manipulative therapists, who were blind to each other's measurement, noted active ranges of cervical motion and passive cervical rotation performed in the flexion-rotation test using the Cervical Range of Motion Device. Headache severity was assessed by a questionnaire. Additionally, one therapist prior to neck motion assessment determined the dominant symptomatic cervical motion segment. Active cervical motion in each direction was identical between the cervicogenic and control groups. In contrast, average rotation in flexion was 44 degrees to each side in the asymptomatic group and 28 degrees towards the headache side in the symptomatic group. C1-2 was deemed to be the dominant segmental level of headache origin in 24 of 28 subjects. In those 24 subjects range of rotation during the flexion-rotation test was inversely correlated to headache severity.     

Pulsed radiofrequency of the second cervical ganglion (C2) for the treatment of cervicogenic headache

In this case series report, two patients with cervicogenic headache were selected. After initial positive response to the greater occipital nerve block, pulse radiofrequency (PRF) was performed on the position of the second cervical ganglion (C2). Two patients reported 100% pain relief lasting for 6 months. The lateral puncture is safer and more comfortable than the posterior site. This case study demonstrates the effectiveness of PRF to treat cervicogenic headache originating from the C2 nerve. However, we need to further evaluate the results using more samples.     

Interobserver reliability of diagnostic criteria for cervicogenic headache

To assess the interobserver reliability in distinguishing cervicogenic headache (CEH) from migraine without aura and tension-type headache we conducted a study keeping as closely as possible to daily clinical practice. In contrast to other reliability studies, which use data from clinical patient records or semi-structured interviews recorded on videotape ('in vitro' design), we examined 'live' patients ('in vivo' design). Twenty-four headache patients participated in our 'in vivo' design experiment. During a session, each physician performed a physical examination and queried six patients in succession using a semi-structured interview. Diagnosis was carried out in accordance with the International Headache Society (IHS) criteria and the criteria from Sjaastad and co-workers. Kappa statistics were used: 0.83 between the expert headache neurologists; 0.74/0.73 between the expert anesthesiologist in (head) pain treatment and both expert neurologists respectively; kappa ranged from 0.43 to 0.62 between the other physicians. The results of our 'in vivo' design study show that the reliability in diagnosing CEH, when strictly applying the criteria from Sjaastad and co-workers, is similar to the reliability in diagnosing migraine and tension-type headache according the IHS criteria.     

A case of post-traumatic cervicogenic headache treated by cervical cord stimulation

The case of a 26-year-old woman suffering from cervical trauma with disc herniation presenting with arm and neck pain is presented. She underwent cervical discectomy with fusion because the pain did not improve with medical therapies; as the neck pain resumed after surgery, a cervical cord neurostimulator was implanted, with improvement for cervicogenic headache. This report underlines the presence of two pathologies and the relationship between C2 and trigeminal pathways.     

Blink reflex R2 amplitudes in cervicogenic headache, chronic tension-type headache and migraine

Blink reflex R2 amplitude was investigated in seven patients with cervicogenic headache (CEH), 12 patients with chronic tension-type headache, 23 patients with migraine (10 with aura) and 17 headache-free controls. Standard electrical stimulation of the supraorbital nerve was applied and the response was recorded from the ipsilateral and the contralateral orbicularis oculi muscles. Low R2 amplitude was found in CEH patients compared with control subjects. Headache is unilateral in CEH and the ipsilateral and contralateral responses after stimulation on the painful side were most depressed. R2 amplitude was not significantly affected in migraine and tension headache patients. The results suggest that lower brainstem excitability is reduced in CEH. A state of hypoactivity may be present in caudal trigeminal nucleus neurons on the symptomatic side.     

A case of post–traumatic cervicogenic headache treated by cervical cord stimulation

The case of a 26–year–old woman suffering from cervical trauma with disc herniation presenting with arm and neck pain is presented. She underwent cervical discectomy with fusion because the pain did not improve with medical therapies; as the neck pain resumed after surgery, a cervical cord neurostimulator was implanted, with improvement for cervicogenic headache. This report underlines the presence of two pathologies and the relationship between C2 and trigeminal pathways.     

The blink reflex in chronic tension-type headache, migraine, and cervicogenic headache

R1 and R2 blink reflex latencies were investigated blind in 10 patients with cervicogenic headache, 11 patients with chronic tension-type headache, 11 patients with migraine, and 9 headache-free controls. There were no R1 or R2 latency differences between the four groups. The latency of R1 increased significantly with headache duration in tension-type headache patients. Shorter R1 latencies were found on the symptomatic side than on the non-symptomatic side in cervicogenic headache patients. The results suggest that a state of hyperactivity may be present in the ipsilateral trigeminal nucleus in cervicogenic headache. Hypoactivity, however, may develop over time in tension-type headache.     

Spinal manipulative therapy in the management of cervicogenic headache

Patients suffering from cervicogenic headache (CeH) are commonly treated with spinal manipulative therapy. We have analyzed the quality and the outcomes of published, randomized, controlled trials assessing the effectiveness of spinal manipulation in CeH. Among 121 relevant articles, only two met all the inclusion criteria. Methodological quality scores were 8/10 and 7/10 points. Only one of the trials made use of a headache diary. Both the trials reported positive (+) results on headache intensity, headache duration, and medication intake, so that spinal manipulative therapy obtained strong evidence of effectiveness (level 1) with regard to these outcomes. Conversely, spinal manipulation obtained no more than limited evidence (level 3) in reducing headache frequency, as it was analyzed only in one study with positive (+) results. A greater number of well-designed, randomized, controlled trials are required to confirm or refute the effectiveness of spinal manipulation in the management of CeH.     

Reliability of manual examination and frequency of symptomatic cervical motion segment dysfunction in cervicogenic headache

This study investigated the reliability of manual examination procedures and the frequency that each or multiple segments in the upper cervical spine above the C4 vertebra were the dominant source of pain in subjects with cervicogenic headache (CGH). Eighty subjects were evaluated, 60 with CGH (39 females, mean age 33 years) and arbitrarily a further 20 asymptomatic subjects (13 females, mean age 34 years) included to reduce examiner bias, but subsequently omitted from data analysis. Two experienced physiotherapists examined on the same day each subject with standard manual examination procedures, independently rating each segment in the upper cervical spine above the C4 vertebra for involvement. Examiners were blind to each other’s findings and the subject’s clinical status. Standard and adjusted Kappa coefficients were calculated for each segment in symptomatic subjects only. Chi-squared analysis for goodness of fit was used to identify the segment that was most frequently determined the predominant symptomatic segment. Manual examination above the C4 vertebra showed good reliability. The C1/2 segment was most commonly symptomatic, with a positive finding at this segment in 63% of cases. The high frequency of C1/2 involvement in CGH highlights the importance of examination and treatment procedures for this motion segment.     

The influence of age, gender, lifestyle factors and sub-clinical neck pain on the cervical flexion-rotation test and cervical range of motion

The flexion-rotation test (FRT) is commonly used when assessing cervicogenic headache. Additionally, active range of motion (AROM) is frequently used to evaluate impairment in neck pain. No studies have investigated the interaction of the FRT and AROM with age, gender, pain and lifestyle factors. The purpose of this study was to determine the influence of these factors on the FRT and cervical AROM. A group of 66 participants (aged 20-78) were studied, 28 experienced sub-clinical neck pain (recurrent neck pain or discomfort which has not received treatment from a healthcare professional) while 38 did not. Age, gender, lifestyle factors and sub-clinical neck pain were assessed using a questionnaire. Measurement of AROM was performed by two examiners blind to the results of the questionnaire. Multiple linear regression analysis found that 59% of the variance in the FRT was explained by the presence of sub-clinical pain and cervical lateral flexion measures. Secondly, 58-72% of the variance in active cervical ROM measures was influenced by factors including the FRT, gender and movements of the neck in other planes. This study found that lifestyle factors do not influence the cervical FRT and AROM.     

颈2横突局部注射配合直线偏振光近红外线治疗颈源性头痛的疗效观察

目的观察颈2横突局部注射配合直线偏振光近红外线治疗颈源性头痛的疗效。方法56例确诊为颈源性头痛患者随机分为2组治疗组28例,予颈2横突局部注射得保松加直线偏振光近红外线局部照射治疗;对照组28例,予颈2横突局部注射得保松。评估2组患者治疗前、后疼痛的程度并观察治疗效果。结果2组患者治疗后VAS评分分别与治疗前比较均有下降,差异有统计学意义(P<0.05);并且治疗组VAS评分下降(6.1±1.8)分,较对照组的(3.8±2.5)分明显,二者间差异有统计学意义(P<0.05)。治疗组的治愈率为82.1%,好转率为14.3%,无效率为3.6%;对照组的治愈率为46.4%,好转率为32.1%,无效率为21.4%,2组间疗效比较差异有统计学意义(P<0.05)。结论颈2横突局部注射配合直线偏振光近红外线治疗颈源性头痛的疗效显著,患者头痛症状可得到明显改善,较单用颈2横突局部注射治疗效果好。     

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.     

The cervicogenic headache from the spiral surgery point of view--a pilot study

In a retrospective analysis of 299 consecutive patients with degenerative cervical spine disease the incidence of cervicogenic headache and the results of conservative and operative therapy have been investigated. Cervicogenic headache was noted in 117 of 299 patients (40%). 73 of those patients were treated conservatively. The cervicogenic headache resolved in 10% or improved in 27% and remained unchanged in 63% of the patients. 44 of these patients were operated by ventral discectomy, which was indicated in case of neurological deficit and painful shoulder-arm syndrome refractory to conservative treatment. In none of these patients the operation was indicated by the cervicogenic headache. In the postoperative follow-up with a mean of 6 months the headache resolved in 20%, improved in 60% and remained unchanged in 20% of the patients. These results suggest the existence of a cervicogenic headache, i.e. a headache due to disorders of the cervical spine, and the chance of successful operative treatment.     

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.     

Use of cervical spine manipulation under anesthesia for management of cervical disk herniation, cervical radiculopathy, and associated cervicogenic headache syndrome

OBJECTIVE: To demonstrate the benefits of cervical spine manipulation with the patient under anesthesia as an approach to treating a patient with chronic cervical disk herniation, associated cervical radiculopathy, and cervicogenic headache syndrome. CLINICAL FEATURES: The patient had neck pain with radiating paresthesia into the right upper extremity and incapacitating headaches and had no response to 6 months of conservative therapy. Treatment included spinal manipulative therapy, physical therapy, anti-inflammatory medication, and acupuncture. Magnetic resonance imaging, electromyography, and somatosensory evoked potential examination all revealed positive diagnostic findings. INTERVENTION AND OUTCOME: Treatment included 3 successive days of cervical spine manipulation with the patient under anesthesia. The patient had immediate relief after the first procedure. Her neck and arm pain were reported to be 50% better after the first trial, and her headaches were better by 80% after the third trial. Four months after the last procedure the patient reported a 95% improvement in her overall condition. CONCLUSION: Cervical spine manipulation with the patient under anesthesia has a place in the chiropractic arena. It is a useful tool for treating chronic discopathic disease complicated by cervical radiculopathy and cervicogenic headache syndrome. The beneficial results of this procedure are contingent on careful patient selection and proper training of qualified chiropractic physicians.     

阻滞联合手法复位治疗颈源性头痛的疗效分析

目的:探讨高位颈椎旁阻滞联合手法复位对颈源性头痛的治疗效果。方法:40例颈源性头痛患者随机分为两组(A,n=20例;B,n=20例),A组接受颈2椎旁阻滞治疗,B组接受手法复位联合颈2椎旁阻滞治疗。比较治疗前后及不同治疗方法治疗后不同时间段,患者的轻、中度头痛天数、剧烈头痛的发作次数及服药剂量。结果:A组接受治疗后1—2个月、3—4个月,患者的每月轻、中度头痛天数、剧烈头痛发作次数及口服非甾体类抗炎药物(NSAID)的剂量分别为:2.5±1.1d、1.0±0.30次、200±50mg/d和7.6±3.5d、1.6±0.4次、860±80mg/d均较治疗前2个月明显减少,差异有极显著意义(P<0.01);B组治疗后1—2个月、3—4个月的数据分别为:2.3±1.0d、1.2±0.45次、300±75mg/d和3.7±2.3d、1.0±0.33次、350±100mg/d,较治疗前2个月明显减少,差异有极显著意义(P<0.01);B组治疗后3—4个月,患者每月头痛天数、剧烈头痛发作次数及口服NSAID的剂量均较A组:7.6±3.5d、1.6±0.4次和860±80mg/d明显减少,差异有显著意义(P<0.05)。结论:高位颈椎旁阻滞联合手法复位治疗颈源性头痛疗效优于单纯高位颈椎旁阻滞,但其远期疗效尚待探讨。     

Radiofrequency denervation of facet joints C2-C6 in cervicogenic headache: a randomized, double-blind, sham-controlled study

Cervicogenic headache is still a controversial disease entity, and good and reliable treatment is lacking. In the present randomized, sham-controlled, patient- and evaluator-blinded study, 12 patients with a disabling, long-standing and treatment-resistant strictly unilateral cervicogenic headache were included. The diagnosis was based on purely clinical criteria. Six were randomized to receive radiofrequency neurotomy of facet joints C2-C6 ipsilateral to the pain, and six were randomized to sham treatment. Patients were followed for 2 years with diary registration of pain for 14-days periods after 1, 3, 6, 12, 18 and 24 months, and also followed with algometry and neck mobility measurements at 3, 12 and 24 months. Side-effects were minor and short-lasting, and those patients who were treated with neurotomy were somewhat improved at 3 months, but later there were no marked differences between the groups. In conclusion, the procedure is probably not beneficial in cervicogenic headache.