Cervicogenic Headache

Cervicogenic Headache (CGH) is a common clinical occurrence. The first challenge being to identify if the patient is suffering from CGH as either the primary problem or as a component of a mixture of headache types. This is not always easy as purely basing it on subjective findings can be difficult.

Assessment of Headaches

From a physiotherapy perspective we have quite clear assessment guidelines to utilise to ascertain the liklihood of Cervicogenic Headaches (CGH).

Jull et al (2007) demonstrated that, collectively, the presence of the following have a sensitivity of 100% and a specificity of 94% in identifying CGH sufferers:

• Loss of cervical range of movement
• Pain on palaption of the cervical spine
• Diminshed performance on the craniocervical flexion test (CFT)

This was in a single headache group i.e. patients suffering from only 1 type of either Migraine, CGH or Tension Type Headache (TTH).

Interestingly when Amiri et al (2007) looked at utilising the above criteria in testing sufferers of multiple/mixed headache types (i.e. one or more of migraine, TTH or CGH coexisting) they found that:

• Patients with a cervicogenic component (e.g. co-existing migraine and CGH, or co-existing TTH and CGH) demonstrated the presence of the 3 signs described above.
• Patients with a mixture of migraine and TTH did not demonstrate the presensce of the 3 “cervicogenic signs” described above.
• Based on the above I think we can confidently utilise these criteria to ascertain the likelihood of CGH’s, or a cervicogenic component, being present in our headache sufffering patients.

Another test that is useful when assessing headache sufferers is the Flexion-Rotation Test (FRT). The following information is taken from all of the Hall et al (2010) articles in the references:

• The FRT primarily assesses function of the C1/2 motion segment.
• C1/2 segment was found to be most common symptomatic segment in a sample of 60 patients with CGH.
  • 63% C1/2
  • 30% C2/3
  • 7% C0/1
  • 0% C3/4.

The FRT procedure:

• With the subject relaxed in a supine position and the cervical spine passively maximally flexed, the head is passively rotated left and right.
• Range of motion in rotation is determined either by the subject reporting onset of pain or by firm resistance encountered by the therapist.
• The procedure tests the C1/2 segment/joint on the side the patients head is rotating towards.

Additional Information regarding the FRT:

• Average ROM in normals is 44 degrees
• Test is considered positive if less than 32 degrees
• In highly trained individuals:
  • Sensitivity = 91%
  • Specificity = 90%
• Test is deemed positive if there is a 10 degree reduction/difference side to side.
• FRT is significantly reduced in CGH sufferers when compared to likely migraine and/or mixed headache sufferers.
• Important to be aware that this test assesses C1/2 function and not other segments.

Page (2011) notes that other structures such tight muscles may also restrict this test, hence the importance of a thorough examination of all potential structures limiting cervical movement (I would add that neural tissue may also limit movement in the cervical spine. Other cervical joints may also limit the movement! Hence if we can reproduce some symptoms on palpation of C1/2 this can lend support to any positive result of the FRT).

What is the Evidence for Physical Therapy Treatment of CGH?

• Chaibi and Russell (2012) conducted a systematic review on manual therapies for CGH. Conclusions being:
  • Physiotherapy and Spinal Manipulative Therapy (SMT) might be an effective treatment in the management of CGH but the results are difficult to evaluate since only one reviewed Randomised Controlled Trial (RCT) (the Jull et al study to follow) included a control group that did not receive treatment. Furthermore the RCT’s reviewed (7 reviewed in total) mostly included participants with infrequent CGH.

• Jull et al (2002)
  • A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache.
  • 200 participants who met the diagnostic criteria for cervicogenic headache were randomized into four groups: manipulative therapy group, exercise therapy group, combined therapy group, and a control group. The primary outcome was a change in headache frequency.
  • Other outcomes included changes in headache intensity and duration, the Northwick Park Neck Pain Index, medication intake, and patient satisfaction. Physical outcomes included pain on neck movement, upper cervical joint tenderness, a craniocervical flexion muscle test, and a photographic measure of posture.
  • Results being:
    • There were no differences in headache-related and demographic characteristics between the groups at baseline.
    • At the 12-month follow-up assessment, both manipulative therapy and specific exercise had significantly reduced headache frequency and intensity, and the neck pain and effects were maintained (P < 0.05 for all).
    • The combined therapies was not significantly superior to either therapy alone, but 10% more patients gained relief with the combination. Effect sizes were at least moderate and clinically relevant.

• Page (2011) summarises the following with regards to current evidence based management of CGH’s:
  • Frequently do not respond to medications.
  • Multimodal management (modalties, manual therapy and therapeutic exercise) is recommended to address individual impairments.
  • Few studies have investigated the effect of modalities (e.g. TENS, Laser).
  • Manual Therapy
    • Several studies have shown that spinal manipulative therapy is effective for CGH.
    • Randomised controlled trials show manual therapy provides better outcomes to CGH patients than no treatment.
    • Patients with neck pain with or without headache have more short-term relief when manual therapy is combined with exercise, when compared to exercise alone.
  • Muscle Stretching
    • CGH patients often have tightness of muscle such as sternocleidomastoid, upper trapezius. levator scapula, scalenes, sub occipitals, pectorals major and minor.
    • No research was reported specifying benefits of stretching/releasing these muscles.
  • Therapeutic Exercise
    • Few studies have focussed on effectiveness of exercise in patients with CGH.
    • Given this clinicians must make clinical decisions on exercise prescription based on research conducted in patients with chronic neck pain.

References:

Amiri M, Jull G, Bullock-Saxton J, Darnell R, Lander C. Cervical musculoskeletal impairment in frequent intermittent headache. Part 2: subjects with concurrent headache types. Cephalalgia. 2007 Aug;27(8):891-8.