Anterior Neck and Cervicogenic Headaches
Introduction[edit | edit source]
As discussed here, cervicogenic headache (CGH) is caused primarily by dysfunction in the upper cervical spine. However, patients with CGH are also highly likely to have myofascial trigger point pain from overactivity in their anterior neck muscles, including sternocleidomastoid (SCM), as well as upper trapezius and temporalis.[1]
While there is debate over whether or not the SCM is specifically implicated in CGH,[2] its trigger points have a similar referral pattern to that seen in CGH.[1] The anterior neck should, therefore, be considered and addressed when assessing and treating CGH. The following video shows the most common SCM trigger points and their referral patterns.
Please click the links for more information on assessing and managing the upper cervical spine and the superior scapular region for patients with CGH. This page explores the assessment and management of CGH related to dysfunction in the anterior neck.
Potential Causes for Anterior Neck Dysfunction[edit | edit source]
- Poor posture
- Deep neck flexors dysfunction
- Disordered breathing pattern
Assessment[edit | edit source]
Posture - Janda Upper Crossed Syndrome[edit | edit source]
It is important to assess the posture of patients presenting with CHG. In particular, the upper crossed syndrome is a postural pattern commonly seen in patients with neck pain and headaches.[1] It refers to a specific pattern of:[4]
- Muscle activation (particularly in the neck, trunk, and scapular muscles)
- Altered movement (i.e. scapula dyskinesia)
These altered patterns exist alongside recognised postural changes, including:[4][5]
- Forward head position
- Rounded shoulder posture
- Increased thoracic kyphosis
These changes have an impact on the biomechanics of the non-contractile parts of the cervical spine. Because of these changes, individuals with upper crossed posture typically have more active (or over-active) neck muscles in order to achieve cervical stability.[5]
Common changes associated with upper crossed posture are:[1][2][5]
- Inhibited deep neck flexors
- Overactive or tight pectoral muscles
- Overactive upper trapezius
- Inhibited lower trapezius and serratus anterior
Deep Neck Flexors[edit | edit source]
CGH and neck pain are often associated with weak or inhibited deep neck flexors.[2] To assess the strength and endurance of the deep neck flexors, you can position your patient in supine with knees bent. The patient is then asked to lift his / her head and look at his / her toes. A normal test would result in a smooth reversal of cervical lordosis and the chin would remain tucked. If the patient has deep neck flexor weakness, SCM tends to compensate. The patient may also protract his / her chin at the beginning of the movement.[1]
The craniocervical flexion test (CCF), described by Jull and colleagues, can also be used to assess deep neck flexor strength.[1] It is a reliable measure of deep neck flexor performance.[6] It has been found that, during this test, greater activation of the superficial flexor muscles indicates reduced deep cervical flexor activity.[7]
It does, however, rely on the use of an inflatable cuff (biofeedback) to perform. The cuff is placed under the patient’s neck while she / he lies supine. The patient is asked to nod, and maintain a target pressure on the cuff. Cuff pressure is increased by 2 mm/Hg over five levels, with progressive increases in the range of craniocervical flexion. The test is concluded if / when the patient performs craniocervical flexion while maintaining 30 mm Hg.[1]
When performing these assessments, it is important to look for contraction of the SCM during the nodding movement. Normally, this muscle would not activate during a nodding motion.[2] Falla and colleagues demonstrated that individuals without neck pain had less SCM and scalene muscle activity during this movement on EMG when compared to individuals with neck pain.[8] The activation patterns became more pronounced as the degree of flexion increased.[8] Inhibited deep neck flexors typically lead to, or correlate with, hypertonic and overactive SCM.[2]
Palpation[edit | edit source]
It is important to consider muscle dysfunction and its relationship to CGH. Palpating SCM for trigger points may recreate a patient’s CGH.[1][2]
Treatment[edit | edit source]
Deep Neck Flexors[edit | edit source]
Low-load craniocervical programmes, which focus specifically on motor control of the deep neck flexors have been shown to be beneficial for neck pain and headache.[2] In particular, Jull and colleagues found that six weeks of performing craniocervical flexion exercises were as effective as spinal manipulation at reducing cervical pain, and headache frequency and intensity for up to one year.[9]
These exercises are typically performed using some form of pressure sensor biofeedback. A range of different protocols are discussed here, but patients are usually directed to perform craniocervical flexion (i.e. nodding) aiming for a target pressure of 20 mmHG. They then work their way up to around 30 mmHg.[2] While performing the exercises, patients should be advised not to:[2]
- Lift their head from the table
- Drop their head back onto the table
- Over-activate SCM and anterior scalenes
The specific repeitions, length of hold and approach varies across studies, but patients are generally asked to maintain craniocervical flexion for between two and ten seconds, followed by a rest period, before the pressure is increased in increments of 2 mmHg.[10][9]
If therapists do not have access to a biofeedback device, it is possible to ask the patient to palpate his / her SCM while performing the chin nodding exercise. The patient will be able to feel if his / her SCM activates and then use this as a guide to know if she / her is performing the exercise correctly (i.e. trying to avoid activation of SCM).[2]
NB: while deep neck flexors are often weak, it may also be beneficial to identify other dysfunctions first that may be contributing to muscle imbalances. This might include occipitoatlantal stiffness. Kaplan notes that clinically, patients may have low strength on muscle testing, but when other areas, like hypomobility or trigger points of SCM, are addressed, the deep neck flexors will improve on retesting as they are less inhibited.[2]
Breathing[edit | edit source]
As discussed here, there is limited research exploring the relationship between breathing and headaches. However, there is some evidence to suggest that diaphragmatic breathing helps to reduce psychological distress, which is often associated with headache.[11][12][13] Moreover, if patients are using their upper chest to breathe, they will be over-using their accessory respiratory muscles (SCM and scalenes)[1][2] These muscles are often over-active in patients with chronic neck pain associated with deep neck flexor weakness. Chest breathing will help to facilitate these muscle imbalances with each breath.[1] Thus, breathing retraining may have a positive impact on SCM overactivity.
Breathing retraining is discussed in detail here, but some cues for the patient might include:[2]
- Lying supine: place one hand on stomach and feel it raising up and down (i.e provide tactile feedback)
- If the patient is unable to feel this, it is possible to provide a little resistance from a small weight or theraband across the abdomen. This may help cue the patient and facilitate increased movement of the lower ribs and stomach
References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Page P. Cervicogenic headaches: an evidence-led approach to clinical management. Int J Sports Phys Ther. 2011; 6(3): 254-66.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 Kaplan A. Cervicogenic Headaches - Anterior Neck Course. Physioplus, 2020.
- ↑ NAT Education. Sternocleidomastoid Muscle (SCM) Trigger Points. Available from: https://www.youtube.com/watch?v=kOYm9xZMCdg [last accessed 22/12/2020]
- ↑ 4.0 4.1 Seidi F, Bayattork M, Minoonejad H, Andersen LL, Page P. Comprehensive corrective exercise program improves alignment, muscle activation and movement pattern of men with upper crossed syndrome: randomized controlled trial. Sci Rep. 2020; 10(1): 20688.
- ↑ 5.0 5.1 5.2 Arshadi R, Ghasemi GA, Samadi H. Effects of an 8-week selective corrective exercises program on electromyography activity of scapular and neck muscles in persons with upper crossed syndrome: Randomized controlled trial. Phys Ther Sport. 2019; 37: 113-9.
- ↑ Falla D, Jull G, Dall'Alba P, Rainoldi A, Merletti R. An electromyographic analysis of the deep cervical flexor muscles in performance of craniocervical flexion. Phys Ther. 2003; 83(10): 899-906.
- ↑ Jull G, Falla D. Does increased superficial neck flexor activity in the craniocervical flexion test reflect reduced deep flexor activity in people with neck pain? Man Ther. 2016; 25: 43-7.
- ↑ 8.0 8.1 Falla DL, Jull GA, Hodges PW. Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test. Spine (Phila Pa 1976). 2004; 29(19): 2108-14.
- ↑ 9.0 9.1 Jull GA, Falla D, Vicenzino B, Hodges PW. The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain. Man Ther. 2009; 14(6): 696-701.
- ↑ Park SK, Yang DJ, Kim JH, Heo JW, Uhm YH, Yoon JH. Analysis of mechanical properties of cervical muscles in patients with cervicogenic headache. J Phys Ther Sci. 2017; 29(2): 332-5.
- ↑ Kristoffersen ES, Aaseth K, Grande RB, Lundqvist C, Russell MB. Psychological distress, neuroticism and disability associated with secondary chronic headache in the general population - the Akershus study of chronic headache. J Headache Pain. 2018;19(1):62.
- ↑ Ma X, Yue ZQ, Gong ZQ, et al. The Effect of Diaphragmatic Breathing on Attention, Negative Affect and Stress in Healthy Adults. Front Psychol. 2017; 8: 874.
- ↑ Hopper SI, Murray SL, Ferrara LR, Singleton JK. Effectiveness of diaphragmatic breathing for reducing physiological and psychological stress in adults: a quantitative systematic review. JBI Database System Rev Implement Rep. 2019; 17(9): 1855-76.
