Practical Assessment and Treatment of Cervicogenic Headaches
Introduction[edit | edit source]
As discussed here, cervicogenic headache (CGH) is a secondary headache condition that affects between 2.5 and 4.1 percent of the population.[1] CGH begins in the neck or occipital region and can refer to the face and head. The specific sources of CGH are any structures innervated by the C1 to C3 nerve roots.[1] Pain occurs more frequently in the suboccipital region,[2] although they can also refer to the orbital and frontal regions.[3]
While only the upper three cervical spinal segments are specifically recognised as pain generators for CGH, a number of other structures also play an important role in the CGH, including upper trapezius and sternocleidomastoid.
This page will explore the practical assessment and treatment of CGH, building on content discussed in the pages linked to above.
Evidence for the Physiotherapy in the Management of CGH[edit | edit source]
Because CGH is related to musculoskeletal dysfunction and muscle imbalances, a multimodal management physiotherapy approach is considered an important part of the management of these headaches.[4]
There is specific evidence to support the use of physiotherapy for the management of CGH.[4][5][6][7][8]
In one study, Jull and colleagues examined the effect of a six week intervention of manipulative therapy, exercise therapy or a combination of the two and compared outcomes with a control group.[6] After the intervention period, 81 percent of participants in the combined manual therapy and exercise group had a 50 percent reduction in headache and 42 percent had a 100 percent reduction.[6]
71 percent of participants in the manipulative therapy group had a 50 percent reduction in headaches and 33 percent had a 100 percent reduction. Results in the exercise alone group were similar with 76 percent reporting 50 percent reduction and 31 percent reporting 100 percent reduction. 29 percent of the control group had a 50 percent reduction, but only 4 percent had 100 percent reduction.[6]
Assessment[edit | edit source]
When assessing CGH, it is important to consider structures beyond the upper three cervical segments. While not all patients will be symptomatic in all the areas discussed here, management will be enhanced if all dysfunctional areas are identified and addressed.[9]
Information on a full cervical spine examination is discussed here, including the subjective assessment. Key points relevant to CGH are discussed here, but it is important to remember to find out about:[9]
- Headache history
- Intensity of headache
- Headache frequency
- Duration of headaches
- Irritability levels
It is also essential to screen for any red flags during the subjective and objective assessment. Specific cervical red flags include:[9]
- Cranial artery dysfunction
- Intracranial issues
- Cervical spine instability
Headache red flags are discussed here and here.
Upper limb tension tests are also necessary to rule out any radiculopathies.
Assuming red flags are ruled out, an objective CGH assessment should examine:[9]
Upper Cervical Spine[edit | edit source]
- Range of motion testing (flexion, extension, side flexion, rotation)
- OA nod (C0-1)
- Cervical flexion rotation test (to assess C1-2)
- This test has been found to have the highest reliability and strongest diagnostic accuracy for cervicogenic headache[10]
- A range of 40 degrees or more is considered normal[11]
- A result less than 40 degrees is likely associated with C1-2 impairment, but it can also indicate soft tissue dysfunction (specifically the suboccipitals)[9]
- C2-3 (and beyond) can be assessed with PPIVMs and PAIVMs
- The first rib should also be assessed
Superior Scapula[edit | edit source]
- Posture - a slumped posture is often associated with CGH.[9] Assessing upper trapezius in a weight bearing position (sitting / standing) indicates if there is any overactivity. If tension decreases in upright sitting or supine, there is likely overuse of upper trapezius.[12]
- Scapula function
- Elevate arms to check for major dyskinesia
- Assess scapula movement during exercise:
- Prone shoulder extension / abduction - check for upper trapezius activation and control
Sternocleidomastoid[edit | edit source]
- Unlike upper trapezius, there may not be substantial increases in SCM tone in sitting[13]
- Posture is again significant, specifically a forward head posture[4][13]
- The nod test can be used to determine how SCM is functioning in relation to the deep neck flexors.[4] Initially, a single nod can be assessed followed by a sustained nod. The mean hold time of the deep neck flexors for men has been found to be 38.9 seconds and for women, it is 29 seconds.[14] When the patient performs this test, the therapist can palpate SCM and the anterior scalenes to determine how much activation is present[9]
- Breathing pattern assessment. Patients with chronic neck pain and deep neck flexor inhibition often present with overactive accessory respiratory muscles (including SCM and scalenes).[4] More information on a breathing assessment is available here, but it is important to check for chest vs abdominal breathing, mouth breathing, ratio to inhalation/exhalation etc.
References[edit | edit source]
- ↑ 1.0 1.1 Stovner LJ, Nichols E, Steiner T, Abd-Allah F, Abdelalim A, Al-Raddadi R et al. Global, regional, and national burden of migraine and tension-type headache, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology. 2018; 17(11): 954-76.
- ↑ Uthaikhup S, Barbero M, Falla D, Sremakaew M, Tanrprawate S, Nudsasarn A. Profiling the Extent and Location of Pain in Migraine and Cervicogenic Headache: A Cross-sectional Single-Site Observational Study. Pain Med. 2020 Sep 11:pnaa282.
- ↑ Kaplan A. Introduction to Cervicogenic Headache Course. Physioplus, 2020.
- ↑ 4.0 4.1 4.2 4.3 4.4 Page P. Cervicogenic headaches: an evidence-led approach to clinical management. Int J Sports Phys Ther. 2011;6(3):254-66.
- ↑ Hall T, Chan HT, Christensen L, Odenthal B, Wells C, Robinson K. Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache. J Orthop Sports Phys Ther. 2007; 37(3): 100-7.
- ↑ 6.0 6.1 6.2 6.3 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.
- ↑ Mohamed AA, Shendy WS, Semary M, Mourad HS, Battecha KH, Soliman ES et al. Combined use of cervical headache snag and cervical snag half rotation techniques in the treatment of cervicogenic headache. J Phys Ther Sci. 2019; 31(4): 376-81.
- ↑ Kocjan J. Effect of a C1-2 Mulligan sustained natural apophyseal glide (SNAG) in the treatment of cervicogenic headache. J of Education, Health, and Sport. 2015; 5(6): 79-87.
- ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 Kaplan A. Practical Assessment and Treatment of Cervicogenic Headaches Course. Physioplus, 2020.
- ↑ Rubio-Ochoa J, Benítez-Martínez J, Lluch E, Santacruz-Zaragozá S, Gómez-Contreras P, Cook CE. Physical examination tests for screening and diagnosis of cervicogenic headache: A systematic review. Man Ther. 2016; 21: 35-40.
- ↑ Kaplan A. Cervicogenic Headache - Upper Cervical Course. Physioplus, 2020.
- ↑ Kaplan A. Superior Scapula - Cervigenic Headaches Course. Physioplus, 2020.
- ↑ 13.0 13.1 Kaplan A. Cervicogenic Headaches - Anterior Neck Course. Physioplus, 2020.
- ↑ Domenech MA, Sizer PS, Dedrick GS, McGalliard MK, Brismee JM. The deep neck flexor endurance test: normative data scores in healthy adults. PM R. 2011; 3(2): 105-10.
