Cervicogenic Headaches

Normal Anatomy

• Vast amount of soft tissue and joints within the upper cervical spine

Normal Anatomy• Suboccipital nerve branches from C1

nerve root and supplies muscles of suboccipital region and atlano-occipital joint. Purely Motor. No sensory aspect

• Greater occipital and lesser occipital nerves branch from C2 nerve root and supplies C1/2 and C2/3, vertex and posterior scalp

• Third Occipital nerve branches from C3 nerve root supplying lower scalp and C2/3

• Relationship between the trigeminal nerve and upper cervical spinal nerves in the brain “Trigeminocervical nucleus”

Normal Anatomy

• Structures innervated by C1,2,3 spinal nerves– Atlanto occipital joint– Ligaments of the atlanto-occipital joint– C2,3 facet joints– Sub-occipital and upper posterior neck muscles– Upper cervical spinal dura mater– Verterbral arteries– C2-3 intervertebral discs– Trapezius and SCM muscles

Pathophysiology

• Dysfunction to the any structure supplied by the upper cervical nerves can cause pain anywhere within the distribution of these nerves

• This often results in “Cervicogenic Headaches” i.e a headache due to a cervical origin

Mechanism Of Injury

• Traumatic– Whiplash– Sporting tackle– Fall

• Insidious Onset– Poor Posture– Muscular Imbalance– Degenerative Disc

Disease/Spondylosis– Arthritis– Disc Herniation

Associated Pathologies/Differential Diagnosis

ClassificationCervicogenic Headache International Study Group diagnostic CriteriaMajor Criteria 1. Symptoms and signs of neck involvement

a. Precipitation of comparable symptoms by:1) Neck movement and/or sustained, awkward

head positioning, and/or 2) External pressure over the upper cervical or

occipital regionb. Restriction of range of motion in the neckc. Ipsilateral neck, shoulder or arm pain

2. Confirmation evidence by diagnostic anaesthetic block3. Unilaterality of the head pain, without sideshift

Head Pain Characteristics 4. Moderate-severe, non-throbbing pain, usually starting in the neck. Episodes of varying duration, or fluctuating, continuous pain

ClassificationCervicogenic Headache International Study Group diagnostic Criteria

Other Characteristic of some Importance 5. Only marginal or lack of effect of indomethacin. Only marginal of lack of effect of ergotamine and sumatriptan. Female gender. Not infrequent history of head of indirect neck trauma, usually of more than medium severity

Other Features of Lesser Importance 6. Various attack-related phenomena, only occasionally present, and/or moderately expressed when present:

a) Nauseab) Phono- and photophobiac) Dizzinessd) Ipsilateral “blurred vision”e) Difficulties swallowingf) Ipsilateral oedema, mostly in the

periocular area

Subjective

• A Headache in Occipital or trigeminal nerve distribution

• Aggravated by neck movements or positions• Neck, shoulder or arm pain• Non throbbing• Traumatic or insidious onset

Objective

• Abnormal cervical posture• Altered and painful cervical movements-

usually extension and ipsilateral rotation• Restricted upper cervical movements, usually

ipsilateral rotation• Pain on sustained postures, usually protraction• Pain on palpation sub occipital soft tissue

Special Tests

• Cervical Flexion-Rotation Test– Patient supine, Full passive

cervical flexion. Passive rotation. Abnormal finding if restricted/ painful/ reproduction of headache with rotation towards the side of headache

– Full flexion initially allows rotation to purely assess the upper cervical spine

Further Investigation

• Diagnosis usually made clinically• Imaging used to investigate/exclude more

serious pathology• Blood work used to exclude other pathology• Zygapophyseal joint, cervical nerve or medial

branch blockage

Conservative - Management• Ergonomic advise1. Restore normal mobility

– Decrease inflammation if present with massage, ice, NSAID’s– Reduce tone of hypertonic muscles with soft tissue therapy and diaphragmatic breathing– Increase mobility of upper cervical spine, particularly flexion and rotation

2. Restore Normal Motor Control and Strength– Deep Neck Flexors– Deep Cervical Extensors– Scapular stabilisers

3. Restore Dynamic Stability

Full comprehensive rehabilitation protocol see Page (2011) Cervicogenic Headaches: An Evidence Led Approach to Clinical ManagementFull comprehensive manual therapy approach see Fernandez-de-las-Penas & Coutney (2014) Clinical Reasoning for Manual Therapy Management of Tension Type and Cervicogenic Headache

Surgical - Management

• Anaesthetic injections– Spinal nerve, medial branch or facet joint blockade

• Radiofrequency thermal neurolysis• Surgical Liberation of occipital nerve• Surgery to underlying pathology (e.g disc

pathology)

References• Jull et al (2002) A Randomized Controlled Trial of Exercise and Manipulative Therapy

for Cervicogenic Headache. Spine• Bondi (2005) Cervicogenic Headache: A Review of Diagnostic and Treatment

Strategies. JAOA• Zito et al (2006) Clinical tests of musculoskeletal dysfunction in the diagnosis of

cervicogenic headache. Manual Therapy• Piekartz et al (2007) Neurodynamic responses in children with migraine or

cervicogenic headache versus a control group. A comparative study. Manual Therapy• Hall et al (2008) Cinical Evaluation of Cervicogenic Headache: A Clinical Perspective.

The Journal of Manual and Manipulative Therapy• Page (2011) Cervicgenic Headaches: An Evidence leg approach to clinical

management. IJSPT• Fernandez-de-las-Penas (2014) Clinical Reasoning for manual therapy management of

tension type and cervicogenic headache. The Journal of Manual and Manipulative Therapy