Diagnosis and Management of Cervicogenic Headache

copy 2005 World Institute of Pain 1530-708505$1500Pain Practice Volume 5 Issue 3 2005 255ndash274

Blackwell Science LtdOxford UKPPRPain Practice1530-70852005 World Institute of Pain 2005

5

3255274Miscellaneous

Diagnosis and Management of Cervicogenic HeadacheSIZER JR Et al

Address correspondence and reprint requests to Phillip S Sizer Jr PhDPT OCS FAAOMPT Texas Tech University Health Science Center Schoolof Allied Health Doctorate of Science Program in Physical Therapy3601 4th St Lubbock TX 79430 USA Tel 806-743-3902 E-mailPhilSizerTTUHSCEDU

TUTORIAL

Diagnosis and Management of

Cervicogenic Headache

Phillip S Sizer Jr PhD PT OCS FAAOMPT

dagger

Valerie Phelps PT OCS FAAOMPT

daggerDagger

Esteban Azevedo MPT COMT CSCS

sect

Amy Haye MPT COMT

sect

Megan Vaught MPT OCS

daggerpara

Texas Tech University Health Science Center Lubbock Texas

dagger

International Academy of Orthopedic Medicine-US Tucson Arizona

Dagger

Advanced Pain Therapeutics of Alaska Anchorage Alaska

sect

Modern Physical Therapy Kansas City Missouri

para

Abbott Northwestern Hospital Minneapolis Minnesota USA

Abstract

Upper cervical pain andor headaches originat-ing from the C0 to C3 segments are pain-states that arecommonly encountered in the clinic The upper cervical spineanatomically and biomechanically differs from the lower cer-vical spine Patients with upper cervical disorders fall into twoclinical groups (1) local cervical syndrome and (2) cervico-cephalic syndrome Symptoms associated with various formsof both disorders often overlap making diagnosis a greatchallenge The recognition and categorization of specificprovocation and limitation patterns lend to effective andaccurate diagnosis of local cervical and cervicocephalicconditions

Key Words

cephalgia cervical cranial pains headachedisorders

INTRODUCTION

Upper cervical pain andor cervicogenic headaches aredisorders that are frequently encountered in the generalpublic Approximately 70 to 90 of adults report a

minimum of one headache annually with only 5 seek-ing medical attention

1

and a portion of these headachesoriginate from the cervical spine (approximately178)

2

Sjaastad et al suggested that the cervicogenicheadache group comprises one of the three large groupsof headache sufferers accompanied by tension type andmigraine This is of no surprise considering the numer-ous pain generators located in the C0 to C3 region ofthe spine

3

In 1990 the International Headache Society estab-lished criteria for diagnosing cervicogenic headacheThese included (1) pain localized to neck and occipitalregion which may project to forehead orbital regiontemples vertex or ears and (2) pain that is precipitatedor aggravated by specific neck movements or sustainedneck posture In addition the criteria suggested that atleast one of the following occurs (1) resistance to orlimitation of passive neck movements (2) changes inneck muscle contour texture tone or response to activeand passive stretching and contraction and (3) abnor-mal tenderness of neck muscles Radiological examina-tion of cervicogenic headache reveals at least one of thefollowing (1) movement abnormalities in flexionextension (2) abnormal posture and (3) fractures con-genital abnormalities bone tumors rheumatoid arthri-tis or other distinct pathology (not spondylosis orosteochondrosis)

4

256 bull

sizer jr et al

The complex architecture of the upper cervical artic-ular system affords considerable mobility

5

This in con-cert with the considerable weight of the cranium and itscontents renders the muscles ligaments tendons andjoints to injury predilection Mechanical cervical spinepathology produces painful and limited cervical move-ment as a consequence of dysfunction in the musclesand C0 to C2 articulations Additionally affliction inthe C2C3 intervertebral disc zygapophyseal joints(ZAJ) andor uncovertebral joints (UVJ)

6

can contrib-ute to the clinical presentation complicated by thehypomobile adaptation

7ndash9

andor hypermobilityin-stability

7

of the upper cervical spine in the context ofaging Finally the clinician is challenged with under-standing the role of systemic disease

10ndash13

or trauma

14ndash20

in the patientrsquos upper cervical clinical picture

PATHOANATOMY

The upper cervical spinal motion segments are distinc-tively different on several accounts from segments in thelower cervical spine and each architectural componentof the upper cervical spine contributes to the structuraldistinctions observed in this spine region The atlas (C1Figure 1) is typified by an absent vertebral body where

its bony ring serves as an intercalated ldquorelay centerrdquobetween the occiput and C2 The C1 lateral masses inaccompaniment with the anterior and posterior archesborder the triangular spinal foramen that accommodatesthe brainstem The posterior arch found caudal to theocciput lacks a spinous process and is difficult to pal-pate because of its depth beneath the dorsal skin of theneck The long C1 transverse processes have transverseforamina that accommodate the vertebral arteries whichcontinue on to course through grooves on the posteriorlateral masses These grooves or occasional tunnelsaccommodate the vertebral arteries as they loop for asecond time in the upper cervical region Bony adapta-tions can be witnessed in this region that can producevertebrobasilar insufficiency (VBI) as a consequence ofvertebral artery function compromise

21

This conditionis especially observed in females who exhibit architec-tural differences in the previously described grooves

22

The cranial articular surfaces of C1 are large andconcave in both the frontal and parasagittal planes Thisshape complements the kidney-bean-shaped articularsurfaces of the occiput that are oriented ventromedialto dorsolateral 50

infin

to 60

infin

from the frontal plane Theseellipsoid C0C1 joints permit the considerable flexionextension as well as small amount of sidebending thatare required of the head in function

The most prevalent feature of the axis (or C2) is thedens which is the asparagus-shaped projection thatemerges from the front of the C2 bony segment Thisdens or odontoid process serves as a pivot aroundwhich C1 and the head turn (Figure 2)

23

and is highlyprone to deformity an architectural feature with whichclinicians must be aware before incorporating manualtechniques to the upper cervical spine The dens mayvary in its orientation in the cervical space as well asthe depth and orientation of the tip and dorsal notchwhich serve as a barrier to vertical disarticulation of theC1 vertebra Axial separation is prevented between C1and C2 because of the strong constraint by the trans-verse ligament positioned behind a normally configureddens Any deformity to the dens (such as that found inDowns syndrome)

24

could potentially reduce upper cer-vical stability produce excessive separation and meritavoiding any therapeutic cervical traction maneuvers Inaddition a gap which can be appreciated on sagittalview X-ray between the dens and the anterior arch ofC1 is full of cartilage and should not exceed 3 mm evenduring cervical flexion or extension Otherwise onemay suspect atlantodental dislocation or lesions of theligaments articular capsules or facet joints

Figure 1

The atlas (C1) 1 Facet for the dens 2 anterior tubercle3 posterior tubercle 4 transverse foramen 5 groove for thevertebral artery 6 cartilage over superior articular facet(Reprinted from Racz GB Anderson SR Sizer PS Phelps V Atlan-tooccipital and atlantoaxial injections in the treatment of head-ache and neck pain In Waldman S ed

Interventional PainManagement

2

nd

edn pp 295ndash305 2000 with permission fromElsevier)

Diagnosis and Management of Cervicogenic Headache

bull 257

The upper cervical spinal motion segments (C0C1and C1C2 atlanto-occipital and atlantoaxial segmentsrespectively) are distinctively different on severalaccounts from segments in the lower cervical spineBoth motion segments lack the intervertebral discs anduncinate processes found in lower cervical segmentsRather they rely on distinctive central and lateral artic-ular systems to create stability while affording consid-erable mobility to the head and neck Additionally the

orientation of these articular processes differs fromlower cervical zygapophyseal surfaces in each anatomi-cal plane The convex occipital condyles sit in the supe-rior articular facets of C1 which form deep concavesockets on each side of the vertebral structure On theother hand four synovial articular systems can beobserved between C1 and C2 two central joints andtwo lateral joints The anterior atlantoaxial joint oratlantodental joint is observed between the dens andthe anterior arch of the atlas Posterior to the dens liesa synovial compartment between the dens and trans-verse ligament of atlas (TLA) (lower component of thecruciform ligament) also called the atlantodentalbursa

23

From a sagittal view the left and right biconvexlateral atlantoaxial joints (Figure 3) are characterizedby thick articular cartilage (14 to 32 mm) and sur-rounded by intra-articular menisci that emerge fromflaccid roomy joint capsules These menisci fill in theincongruent joint spaces and are subject to degrada-tion producing sharp local catching pain that resultsfrom interposition with rotation between C1 andC2

23

These four joint systems allow for flexionextension and rotation with very little sidebendingafforded

Figure 2

The axis (C2) (a) cranial view (b) sagittal view 1 Densor odontoid process 2 superior articular facet 3 spinous process4 groove for transverse ligament of atlas (TLA) 5 facet for ante-rior arch of the atlas 6 transverse foramen (Reprinted from RaczGB Anderson SR Sizer PS Phelps V Atlantooccipital and atlan-toaxial injections in the treatment of headache and neck painIn Waldman S ed

Interventional Pain Management

2

nd

ednpp 295ndash305 2000 with permission from Elsevier)

(a)

(b)

Figure 3

Lateral atlantoaxial joint (C1C2) Biconvexity in the sag-ittal plane (Reprinted from Racz GB Anderson SR Sizer PSPhelps V Atlantooccipital and atlantoaxial injections in the treat-ment of headache and neck pain In Waldman S ed

Interven-tional Pain

Management

2nd edn pp 295ndash305 2000 withpermission from Elsevier)

258 bull

sizer jr et al

Ligament integrity is essential between the bonystructures of the upper cervical spine because of theclose proximity of the brainstem and spinal cord(Figure 4) The TLA courses between lateral masses ofC2 posterior to the dens prohibiting any separationbetween C1 and C2 Although the ligament is primarilytype I collagen it exhibits the aggrecan link proteinsand type II collagen that are characteristic of fibrocar-tilage These substances found primarily in the proxim-ity of the ligamentrsquos contact with the dens demonstratethe consistent load on the ligament throughout variousmovements of the head and C1

25

This ligament preventsposterior tipping of the dens into the brainstem andspinal cord during movements of the head and neck

especially with cervical flexion Without this supportduring such a maneuver an individual could experiencebrainstemcord compression and a clinical ldquodropattackrdquo seen in context with any ligament compromisesustained during a whiplash injury

The TLA is assisted by the alar ligaments in main-taining a centralized dens position (Figure 5) Eleven- tothirteen-millimeter-long right and left occipital alar lig-ament branches course in all individuals from the pos-terior tip of the dens to the occiput These Type I collagenbranches are very stiff producing only a maximum of5 to 6 length deformation Right and left atlantalbranches course 3 to 4 mm from the anterior dens tothe posterior internal surface of the anterior arch of C1in select individuals The alar ligament system is tensionloaded during cervical extension sidebending and ipsi-lateral rotation thus lending the upper cervical spine tovery powerful and easily observable coupling behaviorsAny kinetic rotational motion is accompanied by signif-icant contralateral synkinetic sidebending activity andvisa versa especially when the patient is sitting (becauseof the gravity loading the articular facets)

2627

A com-promise to these coupling behaviors emerges in responseto an alar ligament disruption whereby cervical move-ments increase and coupling is distorted in the uppercervical spine

28

With the same compromise the vertebralartery is placed at greater risk for stretching injuries andor sympathetic plexus irritation

29

Figure 4

The ligaments of the upper cervical spine 1 Occiput 2posterior arch of the atlas 3 anterior arch of the atlas 4 densof the axis 5 posterior arch of C2 6 vertebral body of C3 7posterior atlanto-occipital membrane 8 ligamentum flavumC1C2 9 ligamentum flavum C2C3 10 anterior longitudinalligament 11 anterior atlanto-occipital membrane 12 apicalligament of the atlas 13 tectorial membrane 14 posterior lon-gitudinal ligament 15 transverse ligament of atlas (TLA) 16synovial compartment between the dens and the anterior archof the atlas (Reprinted from Racz GB Anderson SR Sizer PSPhelps V Atlantooccipital and atlantoaxial injections in the treat-ment of headache and neck pain In Waldman S ed


Management


Figure 5

The alar ligaments (dorsal view) 1 Left occipital alarligament 2 right occipital alar ligament 3 left atlantal alarligament 4 right atlantal alar ligament 5 occiput 6 left C1 7right C1 8 dens 9 left C2 10 right C2 (Reprinted from Racz GBAnderson SR Sizer PS Phelps V Atlantooccipital and atlantoaxialinjections in the treatment of headache and neck pain In Wald-man S ed


2nd edn pp 295ndash305 2000 with permission from Elsevier)


bull 259

The anterior atlantoaxial and atlanto-occipital mem-branes are an upper cervical continuation of the anteriorlongitudinal ligament from the lower cervical spineSimilarly the flaval ligament continues cranially as theposterior atlantoaxial and atlanto-occipital membranesWhile serving a similar stabilizing role these stiff andinelastic membranes are not as flexible as their lowercervical counterparts especially in the case of the elasticflaval ligament The nuchal ligament contributes to con-straining this region of the spine as a continuation ofthe interspinous and supraspinous ligaments This sys-tem demonstrates both a funicular component continu-ing cranially from the supraspinous ligament and alamellar component coursing ventrally from the funicu-lar component to spinous processes

30

This ligamentclearly constrains upper cervical movements especiallyduring full cervical flexion and retraction As a conse-quence the C0C1 segment paradoxically extends duringfull cervical flexion

31

Thus testing upper cervical flex-ion with full cervical retraction and upper cervicalextension with full cervical protraction can offer theclinician a view of the relative role the ligament is play-ing in a patientrsquos upper cervical limitations

32

Of historical concern for clinicians has been thecourse and configuration of the greater and lesser occip-ital nerves considering the relative importance theyhave been assigned as pain generators in selectedcervicocephalic disorders The greater occipital nerveemerges to course subcutaneously over the cranium atapproximately 05 to 28 cm lateral to the midline alongthe intermastoid line Similarly the lesser occipital nerveemerges at the mid-part of the posterior border of thesternocleidomastoid muscle approximately 3 to 5 cmlateral to the midline on the same intermastoid lineHowever considerable variance has been observed inthe locations of these nerves relative to one another aswell as in relation to the occipital artery

3334

The dorsal root ganglia (DRG) of C2 spinal nervesalong with their bony and soft tissue containers vary inshape and size appearing as oval spherical or spindle-like

35

These ganglia appear to be particularly vulnera-ble to compressive andor tension loading events Thespinal DRG is found to emerge anterior to the epist-rophic ligament (or posterior atlantoaxial membrane)and in the close proximity of the dorsal C1C2 lateraljoint capsule and a rich venous plexus

3637

The DRGcan be compressed by any of these structures Howeverneural deformity between the dorsolateral bony archesof C1 and C2 appears controversial

3536

Moreover theventral ramus of C2 can be stretched along its course

behind the articular processes associated with the C1C2lateral joint especially in response to certain rotatorycervical movements

38

Preganglionic sympathetic neurons coursing to thehead upper cervical spine and throat begin at cervico-thoracic levels from C8 to T4 whereas the sympatheticsupply to the mid- and lower cervical spine upper backand arm begins in a region of the spinal cord from T4to T9 Those neurons exit the ventral rami through thewhite communicating rami and enter the ascendingparavertebral ganglion chain and then synapse withpostganglionic fibers in the upper middle and lowercervical ganglia These arrangements play a role in man-aging the sympathetic contributions to chronic head-ache and neck pain

Noteworthy are the accessory nerve nuclei located inthe spinal cord between C1 and C4

39

Chronic uppercervical conditions may produce an increased sensationof tightness without increased muscle tone

40

in thepatientrsquos upper trapezius muscles by virtue of sensitiza-tion and reorganization of interneurons at those samecervical cord levels A similar neuroadaptive responsecan be observed originating from the cervical trigeminalnuclei found in the same levels of the spinal cord

39

Chronic cervical afference (especially pain) can sensitizethese cranial nerve nuclei resulting in chronic pain andheadache in the cutaneous trigeminal distribution (ldquocer-vicotrigeminal relayrdquo)

41

This explains the retro-orbitalpain so often encountered in patients with cervicogenicheadache

BIOMECHANICS

The principle motions allowed at the C0C1 motionsegment are designed primarily for head movement inthe sagittal plane about an axis that courses throughboth external auditory meati of the ears The uppercervical spine demonstrates a total maximum range ofapproximately 30

infin

to 35

infin

from a fully flexed to a fullyextended position with isolated flexion approaching10

infin

and isolated extension measuring approximately25

infin

To achieve this movement the convex occipitalcondyles arthrokinematically roll in the same directionof motion and slide in the opposite direction exhibitinga greater rolling vs sliding component during the move-ment This segment exhibits sidebending axis coursingthrough the nose where right sidebending producesoccipital condylar rolling to the right and sliding to theleft At the same time the atlas (C1) exhibits relativeright translation which can be easily palpated betweenthe lateral edge of the transverse process and the mas-

260 bull

sizer jr et al

toid process on the ipsilateral side Each of thesemotions can be impeded when any of these slidingmotions are lost suggesting the utility of therapeuticmanual techniques aimed at restoring the translatorybehaviors

4243

The greatest range of motion observed in any neckmotion segment is witnessed at C1C2 (the atlantoaxialsegment) Sagittal motion at C1C2 is limited to anteriorand posterior rocking (20

infin

total)

3242

whereas 40

infin

to 45

infin

axial rotation around a vertical axis through the densis allowed to each side

54244

With right rotation theright C1 inferior articular facet slides posterior to theright C2 superior articular facet and the left C1 facetanterior to left C2 Additionally the convex-on-convexrelationships of the C1C2 ZAJ allow the entire C1 seg-ment to exhibit caudal translation on C1 in a limitedfashion thus allowing further rotation without prema-ture movement constraint associated with tension load-ing of capsuloligamentous structures

Upper cervical sidebending directly influences move-ment at C2C3 Right sidebending at C0C1 tension loadsthe right occipital and left atlantal branches of the alarligament system thus producing right rotation of C2 onC3 as a consequence of the connection between theseligaments and the dens (Figures 6 7) This resultant

C2C3 right rotation creates a relative C1C2 left rota-tion creating the expected upper cervical contralateralcoupling

2745

Additionally C0 will not sidebend whenC2 cannot rotate on C3 thus generating an apparentupper cervical motion loss Therefore one should viewthe C2C3 motion segment as a ldquokeystonerdquo to uppercervical motion as normal C2C3 movement is essentialfor upper cervical function

Additional upper cervical motions are required tokeep the eyes level during cervical axial rotation Thealar ligaments force the occiput to sidebend opposite thedirection of rotation producing upper cervical contralat-eral coupling

2745

At the same time the lower cervicalspine sidebends in the same direction as the rotation soto counter the sidebending in the upper cervical spine

46

Instantaneously the cervical spine extends above and

Figure 6

Influence of the alar ligaments on coupled motion inthe upper cervical spine (C0 to C3 dorsal view) Left occipitalsidebending is accompanied by right occipital translation Righttranslation tension loads right occipital and left atlantal alarligaments (Reprinted from Racz GB Anderson SR Sizer PSPhelps V Atlantooccipital and atlantoaxial injections in the treat-ment of headache and neck pain In Waldman S ed


Management


Figure 7

Influence of the alar ligaments on coupled motion inthe upper cervical spine (C0 to C3 cranial view) Left occipitalsidebending is accompanied by right occipital translation Righttranslation tension loads right occipital and left atlantal alarligaments This tension behavior induces left rotation of C2 onC3 and subsequent right rotation of C1 on C2 (Reprinted fromRacz GB Anderson SR Sizer PS Phelps V Atlantooccipital andatlantoaxial injections in the treatment of headache and neckpain In Waldman S ed


2ndedn pp 295ndash305 2000 with permission from Elsevier)


bull 261

flexes below C3C4 Otherwise the individual will lookdown when attempting cervical axial rotation

A ldquochin tuckrdquo motion produces flexion at C0C1 andconsiderable load on the TLA Clinicians often use thisldquochin tuckrdquo motion therapeutically for treating lowercervical conditions or when attempting to correct pos-tural deviations however headaches may result becauseof these imposed stresses and tension loading on theposterior atlantoaxial membrane resulting in C2 seg-mental nerve compression (especially when accompa-nied by cervical rotation) Otherwise solitary segmentalmovements are impossible in the upper cervical spinein response to the powerful influence that the TLA andalar ligaments impose on kinematic behaviors Duringkinetic sidebending the upper cervical spine is obli-gated to rotate contralaterally Additionally sidebend-ing may require the upper cervical spine to flex orextend depending on each personrsquos unique kinematicbehaviors

2747ndash49

EXAMINATION

History

A patientrsquos gender occupation and age may lend to theprevalence of cervicocephalic symptoms or cervico-genic headache For example managerial and profes-sional occupations appear to be more related to cervicalpain and headache vs clerical or blue-collar jobs espe-cially in women

50

A similar female prevalence appearsin osteoarthritis in the upper cervical joints

9

Local cer-vical syndrome (LCS) most commonly occurs with indi-viduals between the ages of 20 and 45 years Primarydisc-related disorders usually occur in the younger agesof this group while the latter end of this same groupmarks the beginning of secondary disc-related disor-ders such as chronic internal disc disruption or jointarthropathies

51

Occipital numbness and tingling suggest lesions ofthe C1 to C3 roots Upper cervical pain occurring withupper cervical movement or specific head positions sug-gests pathology between the levels C0C1 and C2C3The local or referred pain produced from these levelscan be intermittent or constant in nature

952

possiblyaccompanied by dizziness nausea vomiting blurredvision photophobia and phonophobia

53ndash57

The location of the patientrsquos symptoms may suggestthe general location of the pain generator but specificlocalization is complicated by overlapping zones of painreference The ZAJ pain referral pattern from C1C2 islocal and unilateral in the suboccipital region whereas

C0C1 produces more diffuse unilateral suboccipitaland occipital pain

58

Further diagnostic difficulty ariseswhen considering that suboccipital and occipital paincould arise from internal disc irritation at C2C3 C3C4C4C5 and C5C6

59

Internal disc irritation of the vari-ous cervical disc levels can produce referred pain in amyriad of locations that overlap in the neck head faceand ear regions Because of this overlapping symptom-ology specific historical interpretation andor system-atic testing should be performed to differentiate betweenafflictions at each of these sites

60

The initiation and natural progression of a patientrsquossymptoms are worthy considerations Although cervico-cephalic symptoms can occur spontaneously they areoften precipitated by an awkward position of the neckfor an extended position such as awakening with a stiffneck and headache turning the head to back up the carand turning toward someone when sitting beside themin a conversation

5461

The duration of cervicocephalicsymptoms can be variable Fredriksen et al documenteda 13-year mean duration for occipital pain and uppercervical symptoms in a relatively small group Duringperiods of exacerbation their subjectsrsquo symptoms con-tinued for a period of 3 hours to 3 weeks while inter-vals between these flare-ups ranged from 2 days to2 months

61

Structural and functional complexities in the uppercervical spine frequently contribute to local cervical painand cervicogenic headaches

662

Symptoms arising fromthese regions are complicated by afflictions involving thedura mater vertebrobasilar arterial system and theautonomic nervous system

63ndash65

The vertebral arteriesand upper cervical dura are innervated by the first threecervical nerves making them capable of produce similarheadache symptoms

666

Moreover hemorrhage tumorsarteriovenous malformations and systemic diseases(such as temporal arteritis systemic arthritides hyper-tension migraine infections) must be differentiallyruled out when examining a patient with headache

Differential Diagnosis

Tension headaches which are frequently triggered bycentral sensitization and cervical trigeminal dysfunctionare nonpulsatile and more common in women

67ndash70

Ten-sion headaches produce band-like pain that bilaterallyradiates from the forehead to the occiput and possiblythe neck musculature This type of headache lacks thefeatures commonly associated with migraine headaches(unilateral throbbing pain nausea photophobia)

262 bull

sizer jr et al

Patients frequently describe this headache as a tightnesspressure andor dull ache Interestingly tension head-aches are not accompanied by changes in electromyo-graphy of cervical or facial musculature

71

Cluster headaches are severe headaches that areapparently triggered by melatonin and cortisol secretionabnormalities and subsequent circadian rhythm distur-bances in the inferior hypothalamus

72ndash75

Cluster head-aches are more common in males relatively rareepisodic frequented at night and characterized bytrigeminal nerve-mediated pain They are unilateralretro-orbital and possibly accompanied by ptosis andlacrimation

7677

However they are not typically accom-panied by nausea vomiting or seizures Cluster head-aches can be precipitated by alcohol consumption andrelieved by physical activity Painful cluster headacheattacks can persist for several weeks (or even years) whenchronic followed by variable periods of remission

7879

Migraine headaches are common severe and debil-itating However investigators have debated the etiologyof migraine suggesting either a vascular or neurologicalorigin

80

More recent evidence suggests that migraineheadaches may emerge from vascular changes in therostral brainstem (including midbrain pons and peri-aqueductal gray matter) in response to a trigeminopara-sympathetic reflex trigger

7981ndash84

Migraine headaches canclinically present in a fashion similar to cervicogenicheadaches in that they can be unilateral moderate tosevere and lasting from 4 to 72 hours They are moreoften in females throbbing and accompanied by nauseavomiting and photo- andor phonophobia Both cervi-cogenic headaches and migraines can produce parasthe-sias in the face arm tongue and palate complicatingthe diagnostic pictures of both conditions

Investigators have attempted to differentiatemigraine symptoms from those produced during cervi-cogenic headache Sjaastad et al reported that 90 ofmigraine patients experience initial pain that begins inthe forehead and temporal regions In contrast 73 ofcervicogenic headache patients report initial painextending from the neck into the head However differ-ences in these conditions may be indistinct during a full-blown attack of either a cervicogenic headache ormigraine

85

Unlike cervicogenic headache and the clusterheadache the migraine can alternate sides (also calledldquoside shiftrdquo) Unique to migraine headaches are visualauras andor halos around light sources While physicalactivity or positional changes frequently trigger cervico-genic headaches migraines are less likely to be affectedby those changes

86

Exertion headache is a bilateral throbbing headachethat is related to Valsalva-like behaviors associated withexertion resulting in an increase in intracranial pres-sure This form of headache triggered by heavy exertionor exhaustion is slow in onset slightly more frequentin females and lasts from a few minutes to a full day

87

JabJolt syndrome also called idiopathic stabbing head-ache produces brief paroxysmal episodes of headachepain that are sharp piercing brief irregular penetrat-ing and nonpulsatile The pain is unilateral in the tem-poral or fronto-orbital regions and is typically mild tomoderate in nature While JabJolt syndrome can imme-diately precede the onset of a migraine they are notnecessarily related to migraine incidence

88

Vertebrobasilar insufficiency is capable of producingheadache symptoms that are accompanied by vertigoand triggered by a compromise to the vertebral arteryon its cranial course to join the basilar artery

89

Thecompromise is related to tension that results in arterialcompromise or sympathetic plexus irritation (known asldquoFunctional VBIrdquo)

2939

This compromise activates alocal inflammation angiospasm vascular disregulationand possible latent fibrosis in the arterial wall Thearterial vulnerability can be located high in the proxim-ity of C1 and C2 transverse processes at the dorsome-dial margin of the atlantal lateral mass and at thejunction of both vertebral arteries with the basilarartery

Other causes of headache have been identified Head-aches can emerge after head trauma mediated by cen-tral and peripheral neural processes Investigators haveimplicated the sphenopalantine ganglion as a pain gen-erator in these headaches

90

Hypertension hypotensionischemic or hemorrhagic stroke vascular dissectionhematoma and vasculitis can produce headache symp-toms These frequently demonstrate rapid onset and areaccompanied by nausea vomiting and possible sei-zures Neuroimaging is indicated for the triage of theseheadaches especially when the symptoms are the firstand severe a new onset after age 50 years or one thatis progressive worsening after a subacute headacheThese headaches can be accompanied by decreased con-sciousness abnormal neurological examination out-comes and associated symptoms of meningismus andfever91

Inspection

Before initiating the physical examination the clinicianshould inspect the patient for postural abnormalitiesThese initial observations should include an appraisal

Diagnosis and Management of Cervicogenic Headache bull 263

of patientrsquos cervical lordosis which can be confirmed byradiographs Decreased cervical lordosis suggests akyphotic kink related to internal disc disruption9293 Onthe other hand increased cervical lordosis in elderpatients reflects advanced degenerative disc disease94

While observed cervical lordosis alterations can be clin-ically noteworthy they do not necessarily indicate seg-mental abnormalities95

Postural deviations can accompany selected uppercervical conditions Increased forward head postureresulting in upper cervical extension and a head positionoutside its base of support at the shoulder girdle can beobserved in patients suffering from a cervical posturalsyndrome This position potentially produces posteriorcapsular adaptation in the upper cervical spine andexposes those segments to abnormal and excessivestresses23 These deviations are likely related to dis-turbed sensory motor control along with gradualsegmental adaptation and dysfunction making themdifficult for patients to self-correct For example post-whiplash patients may be unable to reproduce a ldquoneu-tralrdquo head position during recovery At rest they dem-onstrate a tendency to position the head in slight axialrotation or sidebending which they perceive to bestraight When there is injury or dysfunction of thesensory receptors innervating or surrounding the cervi-cal structures (such as post-whiplash) impairment ofthese structures leads to altered proprioception and per-sistent postural deviations96

Specific upper cervical conditions can produce torti-collis in the cervical spine Upper cervical (C1C2)rotatory subluxation can produce cervical posturaldistortions as one might observe after trauma to theupper cervical ligaments Another cause of a dissociationof the dens from the C1 is Griselrsquos syndrome which isa nontraumatic atlantoaxial rotatory subluxation9798

This infrequent condition can be congenital (dens mal-formation or C1C2 ligament laxity) or can be the con-sequence of rheumatoid arthritis ankylosing spondylitispsoriasis infectious processes of the throat and upperrespiratory tract239799ndash101 This condition presents witha flexion-rotation-deviated head posture that is the effectof C1C2 dissociation23 potentially producing profoundconsequences that include spinal cord injury102

Clinical Examination

A clinical examination should help to confirm or ruleout various cervical pathologies that relate to thepatientrsquos history This examination is implemented forthe diagnosis of cervicocephalic conditions that can be

provoked during the examination The examinationincludes cervical movements in the sagittal (flexionextension protraction and retraction) transverse (rota-tion) and frontal (sidebending and sidenodding) planesThe clinician notes movement disturbances and provo-cation patterns that can reflect the location of the paingenerator and associated cervical dysfunctions

The upper cervical spine movement should comple-ment lower cervical segmental behaviors in keeping theeyes horizontally oriented in space If the upper cervicalsegments are hypomobile then this compensatory rela-tionship could be disturbed presenting itself in a num-ber of ldquodeviatedrdquo patterns when the patient performsactive cervical movements60 For example this may bewitnessed during full cervical rotation where thepatientrsquos upper cervical sidenodding limitations forcethe patient to ipsilateral sidebend whereas upper cervi-cal extension limitations require that the patient looksdown during the rotation Additionally when uppercervical sidenodding is limited full cervical sidebendingwill be performed primarily at the lower cervical spineand will appear as if the patient is laying the head onthe shoulder

Cervical retraction and protraction maximize uppercervical spine motion in the sagittal plane Active andpassive retraction where a chin tuck (upper cervicalflexion) is combined with lower cervical extension pro-duces greater upper cervical flexion than does simplecervical flexion Conversely protraction of the cervicalspine best tests maximal extension of the upper cervicalsegments32 While these can be provocative in lowercervical disc pathology they may suggest upper cervicalpathology when they produce cervicocephalic symp-toms If sagittal plane motions are the most provocativefor cervicocephalic symptoms then the clinician candifferentiate between involvements of the upper cervicaljoints vs the disc in the cervical disc segments If theclinician provokes the patientrsquos upper cervical symptomsduring protraction andor retraction the clinician canbegin to suspect involvement of structures found ineither the C0C1 or C1C2 motion segments Involvementof these segments is best represented by greatest provo-cation during rotation or sidenodding in a protractedandor retracted position If sidenodding in either pro-traction or retraction produces the greatest pain in theexamination then the clinician should suspect a paingenerator in the C0C1 joint system Similarly when thegreatest symptoms are provoked through rotation in aprotracted or retracted position then the C1C2 segmentshould be considered If the previous selective provoca-

264 bull sizer jr et al

tion tests do not produce or increase the patientrsquos symp-toms then greatest cervicocephalic pain during sagittalplane motions suggests cervical disc pathology

Zygapophyseal joint afflictions produce the greatestpain during three-dimensional rotation in concert withtheir role in constraining three-dimensional move-ments103104 When the patient reports the greatestcervicocephalic symptoms during active or passive cer-vical axial rotation in the transverse plane then theclinician should suspect ZAJ involvement the upper cer-vical disc segments When the pain generator is locatedin the C2C3 ZAJ capsular synovium then the patientmay experience greatest pain provocation with cervicalrotation and sidebending toward the side of pain alongwith extension at the end range On the other handwhen the patient experiences the greatest pain with rota-tion away from the side of pain accompanied by side-bending toward then the examiner should suspectinvolvement of the C2C3 ZAJ articular cartilage

A sidenod movement can be performed to emphasizeupper cervical motion in the frontal plane This testallows the clinician to assess motion in the upper cervi-cal segments (C0C1 through C2C3) as sidenodding isprimarily constrained by structures in this region4547105

If the greatest cervicocephalic symptoms are producedwith sidebending then 3-dimensional testing for theC2C3 UVJ should be implemented106 After sidebend-ing the patient should then ipsilaterally rotate produc-ing a motion that maximally stresses the UVJ capsuleand synovium on both the ipsilateral and contralateralside to the direction of sidebending107 Contralateralrotation can added to the sidebending so to compressthe C2C3 UVJ articular surfaces on the side ipsilateralto the direction of sidebending thus provoking a UVJarthropathy108

Mobility can be further evaluated through quick testsand segment-specific testing Movement C0 to C4 canbe screened by fully rotating the patientrsquos cervical spineto one direction followed by cervical flexion A flexionlimitation at the C0 to C4 segments is suggested whenthe patient is unable to flex Similarly if the individualis unable to achieve full rotation to one direction andin this position is unable to extend the head there islikely to be an upper cervical extension limitation(because full upper cervical extension is needed toachieve full cervical rotation)

A quick test for C1C2 rotation can be performed byasking the patient to sidebend fully and then from thisposition rotated in an ipsilateral direction If the patientperforms the sidebend and is unable to maintain the

nose in a forward facing position (ie the head alsorotates toward the sidebending side) there is likely to bea contralateral rotation limitation at C1C2 If thepatient is able to fully sidebend then they should be ableto ipsilaterally rotate a total of approximately 80infin to90infin from this position If not there is likely an ipsilat-eral rotation limitation at C1C2

Segmental mobility can be tested at each cervical discsegment using a sidebending end-feel test (Figure 8)23

The lateral aspect of a particular ZAJ is palpated alongthe articular pillar with the index finger pointing towardthe orbit108 Once palpated the cervical spine is pas-sively sidebent until an extension (closing) movement isdetected in the articular space This new position ismaintained while the palpating finger produces a spring-ing overpressure movement in a medial-ventral-cranial

Figure 8 Sidebending (lateral flexion) end-feel test to right (R)C2 on C3 While palpating the C2C3 segment in a segmentalsidebent position the therapist uses the same finger to producea springing overpressure movement in a medial and slightlyventral direction (Reprinted from Sizer P Phelps V Brismee JMDiagnosis and management of cervicogenic headache and localcervical syndrome with multiple pain generators J Man ManipTher 200210136ndash152 with permission from Journal of Manualand Manipulative Therapy)


direction toward the orbit60 Additionally the cliniciancan assess lateral translation testing of the C0C1 seg-ment as well as segmental rotation of C1 on a stabilizedC2

Special tests can be added to the upper cervical exam-ination The integrity of the ligaments and TLA shouldbe tested in a patient who has symptoms of upper cer-vical pain dizziness and nausea For the alar ligamenttest the clinician stabilizes the seated patientrsquos C2 seg-ment and attempts to sidenod the head after providingminimal traction to the cranium (see Figure 9)60 An alarligament lesion allows sidenodding of C0 to C2 in spiteof C2 vertebral stabilization whereas no motion isallowed with a healthy alar ligament1745

The TLA can be tested with the patient in a seatedposition (see Figure 10) For testing in the sagittal planethe clinician posteriorly stabilizes C2 by pushing theinferior articular processes caudal direction onto C3Then the clinician exerts a ventral translatory pullagainst the posterior arch of C1 and the cranium so topull C0 and C1 forward and allow the dens to moverelatively backward into the direction of the spinalcanal The TLA can be laterally tested by stabilizing C1at the lateral transverse process while attempting totranslate the head in a pure lateral direction An intactTLA will resist any C2 posterior subluxation whereasa compromised TLA allows C2 to translate posteriorlyinto the brain stem region of the spinal cord This exces-sive translation can provoke cord symptoms includingnausea dizziness andor deep agonizing pain

In addition to the above ligament tests patients withselected cervicocephalic symptoms (especially dizziness)should be evaluated for VBI This condition can bedetected through a series of movement tests that attemptto compromise the vertebral arteries as they coursethrough the transverse foramina to join the basilarartery in the subarachnoid space also known as the

Figure 9 Left alar ligament test standing to the side of thepatient with stability hand contacting C2 (thumb to left laminaand spinous process and index finger to right lamina) the mobil-ity hand contacts the patientrsquos right lateral occiput as picturedThe clinician provides mild distraction to the occiput and thensidenods the head to the right while stabilizing C2 preventingC2 rotation to the right Normally no sidenod motion is permit-ted The test is positive for ligament compromise if the sideno-dding is permitted (Reprinted from Hay A Azevedo E Phelps VSizer P Upper cervical disorders part I History inspection andclinical examination MD Consult 2004 Available at httphomemdconsultcomdasstatview34714741-2pers)

Figure 10 Dorsal transverse ligament of atlas (TLA) test Withthe stability hand contacting dorsal C2 (thumb to left and indexfinger to right dorsal C2 transverse process) and the mobilizinghand contacting the patientrsquos right and dorsal occiput and C1the clinician provides ventral-caudal stabilization to C2 accom-panied by gradual ventral translation of the occiput and C1Movement of the occiput takes C1 along ventrally If the TLA isintact C1 movement is arrested by the TLA The test is positivefor ligament compromise if symptoms are produced (Reprintedfrom Hay A Azevedo E Phelps V Sizer P Upper cervical disorderspart I history inspection and clinical examination MD Consult2004 Available at httphomemdconsultcomdasstatview34714741-2pers)


modified DeKleyn and Nieuwenehuyse tests23 Whilefunctional VBI can be triggered by positions of flexionor extension with rotation109 these positions do notnecessarily identify the patient at risk of experiencingvertebrobasilar artery dissection during spinal manipu-lation or trauma110111 suggesting limitations to the util-ity of the tests

Cervicomedullary conditions can accompany cervi-cocephalic syndrome When assessing reflexes for theupper cervical spine Babinski is only positive in aboutone-third of the cases of neural compression at the levelsof C0C1 and C1C2 However the scapulohumeralreflex has been found to be a more accurate test formyelopathy at C0 to C4 segments112

INTERPRETATION AND MANAGEMENT

Successful management of a cervicocephalic disorder ismore likely when the specific etiology is considered anddiagnosis-specific management strategies are imple-mented For example blockade measures can reducesymptoms associated with cervicogenic headache whilemigraine symptoms remain relatively untouched by sim-ilar blockade procedures In contrast the vasoactivemedications that are frequently effective in managingmigraines are less useful for treating cervicogenic head-ache While lithium andor melatonin can reduce clusterheadache frequency these interventions are not effectivewith cervicogenic or migraine headaches Finally whilesurgical release can ablate selected conditions that con-tribute to cervicogenic headache similar procedures donot address symptoms of migraine or cluster head-ache113 Therefore the clinician is encouraged to engagein diagnosis-specific measures when treating variousheadache conditions

Cervical Postural Syndrome

Cervical postural syndrome (CPS) can generate cervico-cephalic symptoms and precede primary disc-relateddisorders This syndrome is related to cervicothoracicmuscle imbalance and resulting aberrant posture It isoften seen in those who exhibit a persistent forwardhead posture and tired neck such as students draftingtechnicians and computer operators especially whenfemale Sustained positional activities such as pro-longed driving and bifocal use may contribute to itsonset While patients frequently report fatigue and tem-poral mandibular joint symptoms they rarely demon-strate a positive functional examination for limits andor symptom provocation23

The important conservative management strategiesfor these patients include postural re-education Pos-tural control is the result of motor programming that isdeveloped through extensive repetition Thus thesepatients are best treated with postural training that usessimple postural cues such as tape adhered lengthwisealong the thoracic spine that can serve as a cue to thepatient for maintaining upright postural positioning Inaddition extraocular muscle activation is incorporatedfor insuring cervical stabilization and postural con-trol114ndash116 while low-load isometrics exercises canaddress the diverse neuromuscular re-education needsassociated with this syndrome117 A patientrsquos cervicalrange of motion can be increased and pain decreasedwith cervical resistance training118119 Finally local infil-trations to muscle trigger-point regions can help amelio-rate muscle guarding and symptoms23120

Local Cervical Syndrome

The pain associated with LCS can be localized to theupper cervical spine In the context of upper cervicalafflictions the discussion will be limited to the C2C3segment While each segment can produce its ownregion of pain these zones overlap and can potentiallyextend above and below the level from which the painoriginated (as previously described)108121

An LCS can produce suboccipital local cervical symp-toms resulting from primary andor secondary disc-related disorders including (1) internal disc disruption(2) synovitis of the UVJ (3) chondropathy of the UVJ(4) synovitis of the ZAJ and (5) chondropathy of theZAJ The differential diagnosis of these conditions hasbeen previously discussed108

Diagnosis-specific management strategies can includeseveral different conservative and invasive measures forthe treatment of LCS Manual therapy treatments caninclude soft tissue mobilization joint-specific mobiliza-tion and neuromuscular re-education Internal disc dis-ruption is best treated with dorsal ventral mobilizationto the caudal vertebral body of the pain-generatingmotion segment6092 Pain-relieving and motion-improving manual therapy techniques are both neces-sary for the management of cervical ZAJ disordersOscillatory joint-specific gliding can be applied to thepain-generating segment while hypomobilities in adja-cent segments may can be treated with manual therapymeasures that are aimed at improving segmental exten-sion andor flexion mobility Segmental sidebending canbe best treated with UVJ mobilization where the cranialvertebral body is glided laterally while sidebending the


segment in the opposite direction to the gliding (ldquoSeg-mental Scoopingrdquo)60 Considering the neural and his-tochemical complexities of the cervical intervertebraldisc122123 and ZAJ124 invasive procedures can be utilizedto address pain from local cervical syndrome Discpathology can be treated with epidural steroidinjections125 while ZAJ pathology can be diagnosedand treated with medial branch blocks and radiofre-quency ablation respectively126ndash128

Cervicocephalic Syndrome

Cervicocephalic syndrome or cervicogenic headachesare typically unilateral in location (but can present bilat-erally) moderate to severe in nature and last 4 to72 hours They are commonly aggravated by physicalactivity such as cervical movement or prolonged pos-turing However these headaches can demonstrateunprecipitated attacks that could increase in frequencyover time and finally merge into a pattern of chronicfluctuating persistent headache symptoms They can bedull and diffuse as well as throbbing in nature Theycan be accompanied by photo- and phonophobia aswell as nausea and vomiting They are often accompa-nied by pain in the interscapular and upper trapezialregions as well as cervical motion limitations5686113

Cervicocephalic syndrome can be the result of severalof the same pain generators as LCS However the dis-tinguishing factor for cervicocephalic syndrome is thelocation of pain and the symptoms produced Cervico-cephalic syndrome includes symptoms produced in thehead and face Cervicocephalic symptoms can emergefrom (1) disc pathology at C2C3 to C5C659129 (2)C2C3 ZAJ synovitis (3) C2C3 ZAJ chondropathy (4)epidural irritation andor adhesion4 (5) C0C1 andC1C2 joint arthropathy (6) upper cervical nerve rootlesions (C0 to C3)43638 (7) upper cervical DRGimpingement3637 andor (8) cervicotrigeminal relay (C0to C4)130

The differential diagnosis and treatment of cervicaldisc and ZAJ conditions have been previously dis-cussed108 Cervical dural irritationadhesion can resultin diffuse-referred cervicocephalic pain because of itspolyzegmental innervation The cervical dura has adirect connection with the nuchal ligament and rectuscapitus posterior minor The connective tissue link spansthe dorsal intervertebral spaces of C0C1 and C1C2131

Consequently any cervical movements that tension loadthe dura andor roots such as flexion could provokesymptoms Onersquos suspicion of epidural adhesions can besubstantiated through fluoroscopically guided diagnos-

tic radiolucent injection and while difficult to addresswith conservative measures this condition may be effec-tively treated with fluoroscopically guided epidural ste-roid injection series125132

Upper cervical joint arthropathy presents withunique symptoms and can be diagnosed through joint-specific provocation tests Mild symptoms may be pro-duced with sagittal frontal and transverse plane move-ments However selected provocation tests will likely bethe most painful Joint arthropathy (synovitis or chon-dropathy) of a joint at C0C1 presents with unilateralvague pain over the suboccipital region and over theback of the ipsilateral occiput Trauma may precedesymptom onset and the affliction could be accompaniedby C1C2 hypermobility While absent of numbness orpain with Valsalva this condition is most provoked withprotraction (upper cervical extension) or retraction(upper cervical flexion) accompanied by sidenoddingThe patient may demonstrate joint mobility limits atC0C1 Investigators have demonstrated that joint-specific manual treatments and exercise are effectivein reducing symptoms associated with cervicogenicheadache133 Thus joint-specific mobilizations limita-tion-specific active movements and home exercise areindicated for patients with C0C1 limitations

Joint arthropathy at C1C2 will present as unilateralparamedian pain and will be most painful with rotationin a protracted or retracted position Once again thecondition will not be accompanied by numbness hypo-esthesia or symptoms with Valsalva A trauma historyis possible but not required to initiate this conditionwhich can present with hypo- or hypermobility atC1C2 Mobility alterations can be detected during theC1C2 joint-specific testing and hypermobility can beaccompanied by a positive alar ligament laxity suggest-ing upper cervical instability Hypomobilities at thislevel are effectively treated with joint-specific mobiliza-tions repetitive movement and home exercise In addi-tion to joint mobilizations postural re-education andneuromuscular re-education should be performed to thecervical spine However if the segments are too sensi-tized to treat manually or are not responding appropri-ately to manual therapy injections can be performed atthe C0C1 and C1C2 joints4 Hypermobilities are besttreated with a progressive cervical stabilization pro-gram This program emphasizes eye movements to acti-vate the cervico-ocular reflex system and activation ofthe deep anterior muscles of the cervical spine (such aslongus coli)134135 whose control can be altered duringfunctional movements of the neck and upper extremi-


ties134136 Radiologically appreciable upper cervicalinstability may merit surgical stabilization especiallywhen the transverse ligament of atlas is involved in thecompromise

Deformation of the C2 root and DRG can producecervicocephalic symptoms36 While chemically activatedroot mechanosensitivity and subsequent pain is gradualand progressive DRG deformation produces immediateincreased pressure and pain provocation137ndash141 In addi-tion neurophysiological after-discharges can be trig-gered for up to 25 minutes after DRG deformation isceased because of high Na+ channel concentration inthe DRG142143 Therefore this sharp mechanicallyinduced pain is differentiated from the gradual achingpain that results from chemically mediated mechanosen-sitivity of the root In addition although mechanicalinterventions could alter DRG-related pain pharmaco-logical management may be preferred for managingchemically triggered root-related pain144

Dorsal root ganglion compression between the dor-solateral bony arches of C1 and C2 has been suspectedfor producing unilateral suboccipital pain that is achingin nature along with lancinating pain up the back ofthe head during head and neck movement36 Whilerecent cadaveric analysis has questioned actual bonycontact between the C2 DRG and either C1 or C2 bonyarch structures35 no consideration was given for thepossible alterations in the neural container with a his-tory of trauma which is typically reported by thesepatients Patients will not complain of pain provocationduring valsalva but they can report occipital sensoryloss The patientrsquos symptoms are most easily triggeredduring full cervical protraction accompanied by con-tralateral rotation This affliction is best managed inva-sively with epidural catheterization in proximity of theC2 DRG along with progressive upper cervical stabili-zation activities36

In addition to the previously described C2 DRG com-pressive event the same ganglion can become entrappedunder the epistrophic ligament (or posterior atlantoaxialmembrane)37 These patients will frequently report atrauma history and complain of the previously describedoccipital lancinating pain along with constant unilat-eral or bilateral suboccipital pain However unlike theprevious affliction the patients will not demonstrateC1C2 hypermobility These patients consistently dem-onstrate absolute decreased sensation over the occiputOnce again there are no complaints of pain with Val-salva and symptoms will likely be provoked with pro-traction and contralateral rotation Conclusively this

affliction is differentiated from the previous afflictionthrough the negative trauma history loss of sensationand normal mobility at C1C2 Epidural catheterizationand radiofrequency lesioning can be attempted but thepatient may require partial surgical release of the epist-rophic ligament While this type of surgical interventioncan ablate entrapment and related symptoms postsur-gical scarring and contracture can lead to relapse113

SUMMARY

Upper cervical pain andor headaches originating fromthe C0 to C3 segments are pain-states that are com-monly encountered in the clinic The upper cervicalspine anatomically and biomechanically differs from thelower cervical spine Patients with upper cervical disor-ders fall into two clinical groups (1) local cervical syn-drome and (2) cervicocephalic syndrome Symptomsassociated with various forms of both disorders oftenoverlap making diagnosis a great challenge The recog-nition and categorization of specific provocation andlimitation patterns lend to effective and accurate diag-nosis of local cervical and cervicocephalic conditions

REFERENCES1 Spence J Migraine and other causes of headache

Ann Emerg Med 199627448ndash4502 Nilsson N The prevalence of cervicogenic headache

in a random population sample of 20ndash59 years old Spine1995201884ndash1888

3 Sjaastad O Fredriksen TA Stolt-Nielsen A Cervico-genic headache C2 rhizopathy and occipital neuralgia a con-nection Cephalalgia 19866189ndash195

4 Racz GB Anderson SR Sizer PS Phelps V Atlanto-occipital and atlanto-axial injections in the treatment of head-ache and neck pain In Waldman SD ed Interventional PainManagement 2nd edn Philadelphia PA WB Saunders Com-pany 2001295ndash306

5 Bogduk N The clinical anatomy of the cervical dor-sal rami Spine 19827319ndash330

6 Bogduk N Corrigan B Kelly P et al Cervical head-ache Med J Aust 1985143202ndash207

7 Ghanayem AJ Leventhal M Bohlman H Osteoar-throsis of the atlanto-axial joints J Bone Joint Surg 199678-A1300ndash1307

8 Zapletal J de Valois C Radiologic prevalence ofadvanced lateral C1ndash2 osteoarthritis Spine 1997222511ndash2513

9 Star MJ Curd JG Thorne RP Atlantoaxial lateralmass osteoarthritis A frequently overlooked cause of severeoccipitocervical pain Spine 199217S71ndashS76

10 Babini SM Cocco JA Babini JC de la Sota M ArturiA Marcos JC Atlantoaxial subluxation in systemic lupus


erythematosus further evidence of tendinous alterations JRheumatol 199017173ndash177

11 Collacott RA Ellsion D Harper W Newland CRay-Chaudhurt K Atlanto-occipital instability in Downrsquos syn-drome J Ment Defic Res 198933499ndash505

12 Jagjivan B Spencer PAS Hosking G Radiologicalscreening for atlanto-axial instability in Downrsquos syndromeClin Radiol 198839661ndash663

13 Wetzel FT La Rocca H Grieselrsquos syndrome ClinOrthop 1989240141ndash152

14 Penning L Acceleration injury of the cervical spineby hypertranslation of the head Part 1 Effect of normaltranslation of the head on cervical spine motion a radiologicalstudy Eur Spine J 199217ndash12

15 Panjabi MM Cholewicki J Nibu K et al Biome-chanics of whiplash injury Orthopade 199827813ndash819

16 Grifka J Hedtmann A Pape HG Witte H Bar HFBiomechanics of injury of the cervical spine Orthopade 199827802ndash812

17 Derrick LJ Chesworth BM Post-motor vehicle acci-dent alar ligament laxity J Orthop Sports Phys Ther 1992166ndash11

18 Fielding JW Cochran GVB Lasing JF III Hohl MTears of the transverse ligament of the atlas J Bone Joint Surg197456-A1683ndash1691

19 Kennedy JC Ligamentous injuries in the adolescentIn Kennedy JC ed The Injured Adolescent Knee BaltimoreMD Williams amp Wilkins 19791ndash42

20 Levine AM Edwards CC Traumatic lesions of theoccipitoatlantoaxial complex Clin Orthop 198923953ndash68

21 Aboumadawi A Solanki G Casey ATH CrockardHA Variation of the groove in the axis vertebra for the ver-tebral arterymdashimplications for instrumentation J Bone JointSurg 199779-B820ndash823

22 Ebraheim NA Xu RM Ahmad M Heck B Thequantitative anatomy of the vertebral artery groove of theatlas and its relation to the posterior atlantoaxial approachSpine 199823320ndash323

23 Winkel D Aufdemkampe G Matthijs O Meijer OGPhelps V Cervical spine functional anatomy In Diagnosisand Treatment of the Spine Gaithersburg Aspen PublishersInc 1996546ndash558

24 Karol LA Sheffield EG Crawford K Moody MKBrowne RH Reproducibility in the measurement of atlantooc-cipital instability in children with down syndrome Spine1996212463ndash2467

25 Milz S Schluter T Putz R Moriggl B Ralphs JRBenjamin M Fibrocartilage in the transverse ligament of thehuman atlas Spine 2001261765ndash1771

26 Lewit K Krausova L Beitrag zur flexion der halswir-belsaule Fortschr Roentgenstr 19629738

27 Ishii T Mukai Y Hosono N et al Kinematics of theupper cervical spine in rotationmdashin vivo three-dimensionalanalysis Spine 200429E139ndashE144

28 Panjabi MM Dvorak J Crisco J Oda T Grob DInstability in injury of the alar ligament A biomechanicalmodel Orthopade 199120112ndash120

29 Willauschus WG Kladny B Beyer WF Glueckert KArnold H Scheithauer R Lesions of the alar ligaments Spine1995202493ndash2498

30 Van der El [Wervelkolom Manuele Diagnostiek]Rotterdam Manthel 1992

31 Arlen A Die paradoxale keppbewegung der atlas inder funktionsdiagnostik der halswirbelsaule Man Med 1977116ndash20

32 Ordway NR Seymour RJ Donelson RG HojnowskiLS Edwards WT Cervical flexion extension protrusion andretraction A radiographic segmental analysis Spine 199924240ndash247

33 Becser N Bovim G Sjaastad O Extracranial nervesin the posterior part of the head anatomic variations and theirpossible clinical significance Spine 1998231435ndash1441

34 Madhavi C Holla SJ Triplication of the lesser occip-ital nerve Clin Anat 200417667ndash671

35 Bilge O An anatomic and morphometric study of C2nerve root ganglion and its corresponding foramen Spine200429495ndash499

36 Lu J Ebrahiem NA Anatomical consideration of C2nerve root ganglion Spine 199823649ndash652

37 Poletti CE Sweet WH Entrapment of the C2 rootand ganglion by the atlanto-epitrophic ligament clinical syn-drome and surgical anatomy Neurosurgery 199027288ndash290

38 Bogduk N An anatomical basis for the neck-tonguesyndrome J Neurol Neurosurg Psychiatry 198144202ndash208

39 Oostendorp R [Functional vertebrobasilar insuffi-ciency] Doctoral Thesis Nijmegen The Netherlands Univer-sity of Nijmegen 1988

40 Carlson CR Wynn KT Edwards J et al Ambulatoryelectromyogram activity in the upper trapezius region patientswith muscle pain vs pain-free control subjects Spine 199621595ndash599

41 Gawal MJ Rothbart PJ Occipital nerve block in themanagement of headache and cervical pain Cephalalgia1992129ndash13

42 Jofe M White A Panjabi M Clinically relevant kine-matics of the cervical spine In Sherk H Dunn E Eismont Feds The Cervical Spine 2nd edn Philadelphia PA JB Lip-pincott Company 198957ndash69

43 Worth DR Selvik G Movements of the cranioverte-bral joints In Grieve GP ed Modern Manual Therapy of theVertebral Column London Churchill Livingstone 198753ndash63

44 Panjabi M Dvorak J Duranceau J et al Three-dimensional movements of the upper cervical spine Spine198813726ndash728

45 Dvorak J Dvorak J [Manual Medicine Diagnosis]Stuttgart Thieme 1991


46 Penning L Wilmink JT Rotation of the cervical spinea CT study in normal subjects Spine 198712732ndash738

47 Jirout J Funktionelle Pathologie Und Klinik der Wir-belsaeule Stuttgart Gustav Fischer Verlag 1990

48 White AA Panjabi M Clinical Biomechanics of theSpine 2nd edn Philadelphia PA JB Lippincott Company1990

49 Von Guttman G X-ray diagnosis of spinal dysfunc-tion Manuelle Medizin 1982573ndash75

50 Grimmer K Relationship between occupation andepisodes of headache that match cervical origin pain patternsJ Occup Med 199335929ndash935

51 Manifold SG McCann PD Cervical radiculitis andshoulder disorders Clin Orthop 1999368105ndash113

52 Simeone FA Rothman RH Cervical disc disease InSimeone FA Rothman RH eds The Spine Philadelphia PAWB Saunders 1982

53 Hassenstein B The region of the occipital joints inrelation to the orientation in space system theory relatedrespectively biocybernetic stand points In Wolff H-D edThe Special Position of the Cervicooccipital Region BerlinSpringer 19881ndash17

54 Friedman MM Nelson AJ Head and neck painreview traditional and new perspectives J Orthop SportsPhys Ther 199624268ndash278

55 Bogduk N Cervical causes of headache and dizzi-ness In Grieve GP ed Modern Manual Therapy of the Ver-tebral Column New York Churchill Livingstone 1987289ndash302

56 Pfaffenrath V Dandekar R Pollman W Cervico-genic headachemdashthe clinical picture radiological findings andhypothesis on its pathophysiology Headache 198727495ndash499

57 Pfaffenrath V Kaube H Diagnostics of cervicogenicheadache Funct Neurol 19905159ndash164

58 Dreyfuss P Michaelsen M Fletcher D Atlanto-occipital and lateral atlanto-axial joint pain patterns Spine1994191125ndash1131

59 Shellhas KP Smith MD Gundry CR Pollei SR Cer-vical discogenic pain Prospective correlation of magnetic res-onance imaging and discography in asymptomatic subjectsand pain sufferers Spine 199621300ndash312

60 Sizer PS Phelps V Brismee JM Diagnosis and man-agement of cervicogenic headache and local cervical syndromewith multiple pain generators J Man Manip Ther 200210136ndash152

61 Fredriksen TA Hovdal H Sjaastad O ldquoCervicogenicheadacherdquo clinical manifestation Cephalalgia 19877147ndash160

62 Bogduk N Marsland A The cervical zygapophysealjoints as a source of neck pain Spine 198813610ndash617

63 Gawel MJ Rothbart P Chronic paroxysmal hemic-rania which appears to arise from either third ventricle pathol-ogy or internal carotid artery pathology Cephalalgia 199212327

64 Jansen J Vadokas V Vogelsang JP Cervical peri-dural anaesthesia an essential aid for the indication ofsurgical treatment of cervicogenic headache triggered bydegenerative diseases of the cervical spine Funct Neurol19981379ndash81

65 Jansen J Bardosi A Hildebrandt J Lucke A Cervi-cogenic hemicranial attacks associated with vascular irrita-tion or compression of the cervical nerve root C2 Clinicalmanifestations and morphological findings Pain 198939203ndash212

66 Bogduk N The anatomy and mechanism of cervicalheadaches In Proceedings of Cervical Headaches Sympo-sium Sydney Manipulative Therapists Association of Austra-lia 19839ndash23

67 Milanov I Bogdanova D Trigemino-cervical reflexin patients with headache Cephalalgia 20032335ndash38

68 Nardone R Tezzon F The trigemino-cervicalreflex in tension-type headache Eur J Neurol 200310307ndash312

69 Vandenheede M Schoenen J Central mechanisms intension-type headaches Curr Pain Headache Rep 20026392ndash400

70 Jensen R Peripheral and central mechanisms in ten-sion-type headache an update Cephalalgia 200323(suppl1)S49ndashS52

71 Millea PJ Brodie JJ Tension-type headache Am FamPhysician 200266797ndash804

72 Leone M Franzini A Broggi G Bussone G Hypo-thalamic deep brain stimulation for intractable chronic clusterheadache a 3-year follow-up Neurol Sci 200324(suppl2)S143ndashS145

73 May A Leone M Update on cluster headache CurrOpin Neurol 200316333ndash340

74 Pringsheim T Cluster headache evidence for a dis-order of circadian rhythm and hypothalamic function Can JNeurol Sci 20022933ndash40

75 May A Bahra A Buchel C Frackowiak RS GoadsbyPJ Hypothalamic activation in cluster headache attacks Lan-cet 1998352275ndash278

76 May A Goadsby PJ Hypothalamic involvement andactivation in cluster headache Curr Pain Headache Rep2001560ndash66

77 Dodick DW Capobianco DJ Treatment and man-agement of cluster headache Curr Pain Headache Rep 2001583ndash91

78 Campbell JK Diagnosis and treatment of clusterheadache J Pain Symptom Manag 19938155ndash164

79 May A Goadsby PJ The trigeminovascular sys-tem in humans pathophysiologic implications for primaryheadache syndromes of the neural influences on the cere-bral circulation J Cereb Blood Flow Metab 199919115ndash127

80 Parsons AA Strijbos PJ The neuronal versus vascu-lar hypothesis of migraine and cortical spreading depressionCurr Opin Pharmacol 2003373ndash77


81 Diener HC May A New aspects of migraine patho-physiology lessons learned from positron emission tomogra-phy Curr Opin Neurol 19969199ndash201

82 Goadsby PJ Neurovascular headache and a mid-brain vascular malformation evidence for a role of thebrainstem in chronic migraine Cephalalgia 200222107ndash111

83 Bahra A Matharu MS Buchel C Frackowiak RSGoadsby PJ Brainstem activation specific to migraine head-ache Lancet 20013571016ndash1017

84 Janig W Relationship between pain and autonomicphenomena in headache and other pain conditions Cephala-lgia 200323(suppl 1)S43ndashS48

85 Sjaastad O Fredriksen TA Sand T The localizationof the initial pain of attack A comparison between classicmigraine and cervicogenic headache Funct Neurol 1989473ndash78

86 Sjaastad O Cervicogenic headache the controversialheadache Clin Neurol Neurosurg 199294(suppl)S147ndashS149

87 Sjaastad O Bakketeig LS Exertional headache IVaga study of headache epidemiology Cephalgia 200222784ndash790

88 Sjaastad O Pettersen H Bakketeig LS Extracephalicjabsidiopathic stabs Vaga study of headache epidemiologyCephalgia 20032350ndash54

89 Lewit K [Pathomechanisms of cervical headaches]Psychiatr Neurol Med Psychol (Leipz) 197729661ndash671

90 Shah RV Racz GB Long-term relief of posttraumaticheadache by sphenopalatine ganglion pulsed radiofrequencylesioning a case report Arch Phys Med Rehabil 2004851013ndash1016

91 Szatajnkrycer M Jaunch EC Unusual headachesEmerg Med Clin N Am 199816741ndash760

92 Jenkner FL Das Cervikalsyndrom Manuelle undelektrische therapie Vienna Springer Verlag 1982

93 Dvorak J Epidemiology physical examination andneurodiagnostics Spine 1998232663ndash2673

94 Mihara H Ohnari K Hachiya M Kondo S YamadaK Cervical myelopathy caused by C3ndashC4 spondylosis in eld-erly patients a radiographic analysis of pathogenesis Spine200025796ndash800

95 Johnson GM The correlation between surface mea-surement of head and neck posture and the anatomic positionof the upper cervical vertebrae Spine 199823921ndash927

96 Loudon JD Ruhl M Field E Ability to reproducehead position after whiplash injury Spine 199722865ndash868

97 Wurm G Aichholzer M Nussbaumer K Acquiredtorticollis due to Griselrsquos syndrome case report and follow-upof non-traumatic atlantoaxial rotatory subluxation Neurope-diatrics 200435134ndash138

98 Corluy L Pison L Lauweryns P Samson I Westhov-ens R An unusual non-traumatic atlantoaxial subluxation inan adult patient Griselrsquos syndrome Clin Rheumatol 200423182ndash183

99 Guleryuz A Bagdatoglu C Duce MN Talas DUCelikbas H Koksel T Griselrsquos syndrome J Clin Neurosci2002981ndash84

100 Okada Y Fukasawa N Tomomasa T Inoue YMorikawa A Atlanto-axial subluxation (Griselrsquos syndrome)associated with mumps Pediatr Int 200244192ndash194

101 Gourin CG Kaper B Abdu WA Donegan JO Non-traumatic atlanto-axial subluxation after retropharyngealcellulitis Griselrsquos syndrome Am J Otolaryngol 20022360ndash65

102 Akpinar G Tekkok IH Sumer M Griselrsquos syndromea case of potentially lethal spinal cord injury in the adult BrJ Neurosurg 200216592ndash596

103 Goel VK Clausen JD Prediction of load sharingamong spinal components of a C5ndashC6 motion segment usingthe finite-element approach Spine 199823684ndash691

104 Winkelstein BA Nightengale RW Richardson WJMyers BS The cervical facet capsule and its role in whiplashinjury Spine 2000251238ndash1246

105 Vishteh AG Crawford NR Melton MS Spetzler RFSonntag WKH Dickman CA Stability of the craniovertebraljunction after unilateral occipital condyle resection a biome-chanical study J Neurosurg (Spine 1) 19999091ndash98

106 Clausen JD Goel VK Traynelis VC Scifert J Unc-inate processes and Luschka joints influence the biomechan-ics of cervical spine quantification using a finite elementmodel of the C5ndashC6 segment J Orthop Res 199715342ndash347

107 Kotani Y McNulty PS Abumi K Cunningham BWKaneda K McAfee PC The role of anteromedial foraminot-omy and the uncovertebral joints in the stability of the cervicalspine Spine 1998231559ndash1565

108 Sizer PS Phelps V Brismee JM Differential diagno-sis of local cervical syndrome versus cervical brachial syn-drome Pain Pract 2001121ndash35

109 Krueger BR Okazaki H Vertebral-basilar distribu-tion infarction following chiropractic cervical manipulationMayo Clin Proc 198055322ndash332

110 Haldeman S Kohlbeck FJ McGregor M Risk fac-tors and precipitating neck movements causing vertebrobasilarartery dissection after cervical trauma and spinal manipula-tion Spine 199924785ndash794

111 Haldeman S Kohlbeck FJ McGregor M Unpredict-ability of cerebrovascular ischemia associated with cervicalspine manipulation therapy a review of sixty-four cases aftercervical spine manipulation Spine 20022749ndash55

112 Shimizu T Shimada H Shiradura K Scapulo-humeral reflex (Shimizu) its clinical significance and testingmaneuver Spine 1993182182ndash2190

113 Sjaastad O Bovim G Cervicogenic headache Thedifferentiation from common migraine An overview FunctNeurol 1991693ndash100

114 Skliut IA Likhachev SA Skliut MI Cervical-ocularreflex in healthy humans Aviakosm Ekolog Med 19993346ndash48


115 Skliut IA Likhachev SA Skliut MI The role of cer-vical proprioceptive afferentation in compensatory mecha-nisms of vestibular dysfunction 1 Passive cervico-ocularreflex in unilateral labyrinthine lesion Vestn Otorinolaringol1999234ndash38

116 Bronstein AM Plastic changes in the human cervi-coocular reflex Ann N Y Acad Sci 1992656708ndash715

117 Conley MS Stone MH Nimmons M Dudley GAResistance training and human cervical muscle recruitmentplasticity J App Physiol 1997832105ndash2111

118 Berg HE Berggren G Tesch PA Dynamic neckstrength training effect of pain and function Arch Phys MedRehabil 199475661ndash665

119 Highland TR Dreisinger TE Vie LL Russel GSChanges in isometric strength and range of motion of theisolated cervical spine after eight weeks of clinical rehabilita-tion Spine 19926S77ndashS82

120 Hong CZ Hsueh TC Difference in pain relief aftertrigger point injections in myofascial pain patients with andwithout fibromyalgia Arch Phys Med Rehabil 1996771161ndash1166

121 Dwyer A Aprill C Bogduk N Cervical zygapophy-seal joint pain patterns I a study in normal volunteers Spine199015453ndash457

122 Imai S Konttinen YT Tokunaga Y et al An ultra-structural study of calcitonin gene-related peptide-immunore-active nerve fibers innervating the rat posterior longitudinalligament Spine 1997221941ndash1947

123 Kang JD Stefanovic-Racic M McIntyre LAGeorgescu HI Evans CH Toward a biochemical understand-ing of human intervertebral disc degeneration and herniationContributions of nitric oxide interleukins prostaglandin E2and matrix metalloproteinases Spine 1997221065ndash1073

124 Kallakuri S Singh A Chen CY Cavanaugh JMDemonstration of substance P calcitonin gene-related peptideand protein gene product 95 containing nerve fibers in humancervical facet joint capsules Spine 2004291182ndash1186

125 Huang RC Shapiro GS Lim M Sandhu HS LutzGE Herzog RJ Cervical epidural abscess after epidural ste-roid injection Spine 200429E7ndashE9

126 McDonald GJ Lord SM Bogduk N Long-term fol-low-up of patients treated with cervical radiofrequency neu-rotomy for chronic neck pain Neurosurgery 19994561ndash67

127 Royal M Wienecke G Movva V et al (224) Retro-spective study of efficacy of radiofrequency neurolysis for facetarthropathy Pain Med 20012249ndash250

128 Barnsley L Bogduk N Medial branch blocks arespecific for the diagnosis of cervical zygapophyseal joint painReg Anesth 199318343ndash350

129 Grubb S Kelly C Cervical discography clinicalimplications from 12 years of experience Spine 2000251832ndash1839

130 Kaube H Katsarava Z Przywara S Drepper J Ell-rich J Diener HC Acute migraine headache possible sensiti-zation of neurons in the spinal trigeminal nucleus Neurology2002581234ndash1238

131 Humphreys BK Kenin S Hubbard BB Cramer GDInvestigation of connective tissue attachments to the cervicalspinal dura mater Clin Anat 200316152ndash159

132 Lieberman R Dreyfuss P Baker R Fluoroscopicallyguided interlaminar cervical epidural injections Arch PhysMed Rehabil 2003841568ndash1569

133 Jull G Trott P Potter H et al A randomized con-trolled trial of exercise and manipulative therapy for cervico-genic headache Spine 2002271835ndash1843

134 Falla DL Jull GA Hodges PW Patients with neckpain demonstrate reduced electromyographic activity of thedeep cervical flexor muscles during performance of the cran-iocervical flexion test Spine 2004292108ndash2114

135 Jull G Kristjansson E DallrsquoAlba P Impairment inthe cervical flexors a comparison of whiplash and insidiousonset neck pain patients Man Ther 2004989ndash94

136 Falla D Jull G Hodges PW Feedforward activity ofthe cervical flexor muscles during voluntary arm movementsis delayed in chronic neck pain Exp Brain Res 200415743ndash48

137 Garfin SR Rydevik B Lind B Massie J Spinal nerveroot compression Spine 1995201810ndash1820

138 Hanai F Matsui N Hongo N Changes in responsesof wide dynamic range neurons in the spinal dorsal horn afterdorsal root or dorsal root ganglion compression Spine1996211408ndash1414

139 Howe JF Calvin WH Loeser JD Impulses reflectedfrom dorsal root ganglia and from focal nerve injuries BrainRes 1976116139ndash144

140 Wall PD Devor M Sensory afferent impulses origi-nate from dorsal root ganglia as well as from the periphery innormal and nerve injured rats Pain 198317321ndash339

141 Weinstein JM Mechanism of spinal pain the dorsalroot ganglion and its role as a mediator of low back painSpine 198611999ndash1001

142 Howe JF Loeser JD Calvin WH Mechanosensitiv-ity of dorsal root ganglia and chronically injured axons aphysiological basis for the radicular pain of nerve root com-pression Pain 1977325ndash41

143 Cavanaugh JM Yamashita T Ozaktay AC King AIAn Inflammation Model of Low Back Pain Proceedings ofthe International Society for the Study of the Lumbar SpineBoston MA International Society for the Study of the LumbarSpine 199046

144 Olmarker K Rydevik B Nordborg C Autologousnucleus pulposus induces neuro-physiological and histologicalchanges in porcine cauda equina nerve roots Spine 1993181425ndash1432


Review questions1 Uncinate processes are found on which compo-

nent of the cervical vertebraa Caudal-lateral C1 vertebral bodyb Cranial-lateral C2 vertebral bodyc Caudal-lateral C2 vertebral bodyd Cranial-lateral C3 vertebral body

2 All of the following cervical motion segmentsdemonstrate four synovial joints EXCEPT fora C0C1b C1C2c C2C3d C3C4

3 Which upper cervical joint system demonstrates abiconvex joint surface relationship whose discon-gruencies are filled with meniscoid structuresa C0C1b C1C2c C2C3d C3C4

4 The upper cervical continuation of the lower cer-vical ligamentum flavum is thea Anterior atlantoaxial membraneb Nuchal ligamentc Posterior atlantoaxial membraned Transverse ligament of atlas

5 The greatest range of motion observed in any cer-vical segment is found ata C0C1b C1C2c C2C3d C3C4

6 Occipital numbness suggests a lesion of all of thefollowing roots EXCEPT fora C1b C2c C3d C4

7 Severe unilateral retro-orbital headaches that aremore frequent in males and apparently triggeredby melatonin and cortisol secretion abnormalitiesand subsequent circadian rhythm disturbances inthe inferior hypothalamus are classified asa Cluster headacheb Exertional headachec Migraine headached Tension headache

8 Unilateral moderate to severe headaches thatemerge from vascular changes in the rostral brain-

stem (including midbrain pons and periaqueduc-tal gray matter) and more often in femalesthrobbing and accompanied by nausea vomitingand photo- andor phonophobia are classified asa Cluster headacheb Exertional headachec Migraine headached Tension headache

9 If a patient looks down during full cervical rota-tion one should suspecta Lower cervical extension limitationb Lower cervical flexion limitationc Upper cervical extension limitationd Upper cervical flexion limitation

10 Which of the following movements maximizesupper cervical flexiona Full cervical extensionb Full cervical flexionc Full cervical protractiond Full cervical retraction

11 If your patientrsquos upper cervical symptoms are mostprovoked with full cervical protraction and (L)sidenodding then you would suspect whichlesiona Lesion of the ventral capsule C0C1b Lesion of the dorsal capsule C0C1c Lesion of the ventral capsule C1C2d Lesion of the dorsal capsule C1C2

12 If your patientrsquos (R) upper cervical symptoms aremost provoked with full (R) cervical rotation (R)sidebending and extension then you would firstsuspect which lesiona Lesion of the (L) C2C3 uncovertebral jointb Lesion of the (L) C2C3 zygaophyseal jointc Lesion of the (R) C2C3 uncovertebral jointd Lesion of the (R) C2C3 zygaophyseal joint

13 After deciding to test your patientrsquos upper cervicalligaments you stabilize the patientrsquos C2 segmentand attempt to sidenod the patientrsquos head afterproviding minimal traction to the cranium Whichligament are you testinga Alar ligamentsb Ligamentum flavumc Tectorial membraned Transverse ligament of atlas

14 All of the following symptoms are considered amajor component of cervicomedullary syndromeEXCEPT or


a DeKleyn and Nieuwenehuyse testsb Diplopliac LrsquoErmittersquos signd Scapulohumeral reflex

15 Movement of the eyes in a caudal direction whilekeeping the head directed forward emphasizes theactivity of which muscle group in the cervicalspinea Longus colib Rectus capitusc Semispinalis capitusd Upper trapezius

16 Your patient complains of occipital lancinatingpain and constant unilateral or bilateral suboccip-ital pain that is provoked with protraction andcontralateral rotation In addition the patientreports absolute decreased sensation over theocciput and no complaints of pain with ValsalvaWhich affliction do you suspecta C1C2 joint arthropathyb C2 DRG entrapment between the C1 and C2

dorsal laminar arches

c C2 DRG entrapment under the epistrophicligament

d C2 ventral ramus entrapment

Legend for Review Questions

1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c

256 bull

sizer jr et al

The complex architecture of the upper cervical artic-ular system affords considerable mobility

5

This in con-cert with the considerable weight of the cranium and itscontents renders the muscles ligaments tendons andjoints to injury predilection Mechanical cervical spinepathology produces painful and limited cervical move-ment as a consequence of dysfunction in the musclesand C0 to C2 articulations Additionally affliction inthe C2C3 intervertebral disc zygapophyseal joints(ZAJ) andor uncovertebral joints (UVJ)

6

can contrib-ute to the clinical presentation complicated by thehypomobile adaptation

7ndash9

andor hypermobilityin-stability

7

of the upper cervical spine in the context ofaging Finally the clinician is challenged with under-standing the role of systemic disease

10ndash13

or trauma

14ndash20

in the patientrsquos upper cervical clinical picture

PATHOANATOMY

The upper cervical spinal motion segments are distinc-tively different on several accounts from segments in thelower cervical spine and each architectural componentof the upper cervical spine contributes to the structuraldistinctions observed in this spine region The atlas (C1Figure 1) is typified by an absent vertebral body where

its bony ring serves as an intercalated ldquorelay centerrdquobetween the occiput and C2 The C1 lateral masses inaccompaniment with the anterior and posterior archesborder the triangular spinal foramen that accommodatesthe brainstem The posterior arch found caudal to theocciput lacks a spinous process and is difficult to pal-pate because of its depth beneath the dorsal skin of theneck The long C1 transverse processes have transverseforamina that accommodate the vertebral arteries whichcontinue on to course through grooves on the posteriorlateral masses These grooves or occasional tunnelsaccommodate the vertebral arteries as they loop for asecond time in the upper cervical region Bony adapta-tions can be witnessed in this region that can producevertebrobasilar insufficiency (VBI) as a consequence ofvertebral artery function compromise

21

This conditionis especially observed in females who exhibit architec-tural differences in the previously described grooves

22

The cranial articular surfaces of C1 are large andconcave in both the frontal and parasagittal planes Thisshape complements the kidney-bean-shaped articularsurfaces of the occiput that are oriented ventromedialto dorsolateral 50

infin

to 60

infin

from the frontal plane Theseellipsoid C0C1 joints permit the considerable flexionextension as well as small amount of sidebending thatare required of the head in function

The most prevalent feature of the axis (or C2) is thedens which is the asparagus-shaped projection thatemerges from the front of the C2 bony segment Thisdens or odontoid process serves as a pivot aroundwhich C1 and the head turn (Figure 2)

23

and is highlyprone to deformity an architectural feature with whichclinicians must be aware before incorporating manualtechniques to the upper cervical spine The dens mayvary in its orientation in the cervical space as well asthe depth and orientation of the tip and dorsal notchwhich serve as a barrier to vertical disarticulation of theC1 vertebra Axial separation is prevented between C1and C2 because of the strong constraint by the trans-verse ligament positioned behind a normally configureddens Any deformity to the dens (such as that found inDowns syndrome)

24

could potentially reduce upper cer-vical stability produce excessive separation and meritavoiding any therapeutic cervical traction maneuvers Inaddition a gap which can be appreciated on sagittalview X-ray between the dens and the anterior arch ofC1 is full of cartilage and should not exceed 3 mm evenduring cervical flexion or extension Otherwise onemay suspect atlantodental dislocation or lesions of theligaments articular capsules or facet joints

Figure 1

The atlas (C1) 1 Facet for the dens 2 anterior tubercle3 posterior tubercle 4 transverse foramen 5 groove for thevertebral artery 6 cartilage over superior articular facet(Reprinted from Racz GB Anderson SR Sizer PS Phelps V Atlan-tooccipital and atlantoaxial injections in the treatment of head-ache and neck pain In Waldman S ed

Interventional PainManagement

2

nd

edn pp 295ndash305 2000 with permission fromElsevier)


bull 257



23


23


Figure 2



2

nd


(a)

(b)

Figure 3



Management


258 bull

sizer jr et al


25




2627


28


29

Figure 4



Management


Figure 5





bull 259


30


31


32


3334


35


3637


3536



38



39


40


39


41


BIOMECHANICS


infin

to 35

infin


infin


infin


260 bull

sizer jr et al


4243


infin

total)

3242

whereas 40

infin

to 45

infin


54244




2745



2745


46


Figure 6



Management


Figure 7





bull 261



2747ndash49

EXAMINATION

History


50


9


51


952


53ndash57



58


59


60


5461


61


662


63ndash65


666




67ndash70


262 bull

sizer jr et al


71


72ndash75


7677


7879


80


7981ndash84



85


86


87


88


89


2939



90


Inspection



























































SUMMARY

















































































































































































1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c


bull 257



23


23


Figure 2



2

nd


(a)

(b)

Figure 3



Management


258 bull

sizer jr et al


25




2627


28


29

Figure 4



Management


Figure 5





bull 259


30


31


32


3334


35


3637


3536



38



39


40


39


41


BIOMECHANICS


infin

to 35

infin


infin


infin


260 bull

sizer jr et al


4243


infin

total)

3242

whereas 40

infin

to 45

infin


54244




2745



2745


46


Figure 6



Management


Figure 7





bull 261



2747ndash49

EXAMINATION

History


50


9


51


952


53ndash57



58


59


60


5461


61


662


63ndash65


666




67ndash70


262 bull

sizer jr et al


71


72ndash75


7677


7879


80


7981ndash84



85


86


87


88


89


2939



90


Inspection



























































SUMMARY

















































































































































































1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c

258 bull

sizer jr et al


25




2627


28


29

Figure 4



Management


Figure 5





bull 259


30


31


32


3334


35


3637


3536



38



39


40


39


41


BIOMECHANICS


infin

to 35

infin


infin


infin


260 bull

sizer jr et al


4243


infin

total)

3242

whereas 40

infin

to 45

infin


54244




2745



2745


46


Figure 6



Management


Figure 7





bull 261



2747ndash49

EXAMINATION

History


50


9


51


952


53ndash57



58


59


60


5461


61


662


63ndash65


666




67ndash70


262 bull

sizer jr et al


71


72ndash75


7677


7879


80


7981ndash84



85


86


87


88


89


2939



90


Inspection



























































SUMMARY

















































































































































































1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c


bull 259


30


31


32


3334


35


3637


3536



38



39


40


39


41


BIOMECHANICS


infin

to 35

infin


infin


infin


260 bull

sizer jr et al


4243


infin

total)

3242

whereas 40

infin

to 45

infin


54244




2745



2745


46


Figure 6



Management


Figure 7





bull 261



2747ndash49

EXAMINATION

History


50


9


51


952


53ndash57



58


59


60


5461


61


662


63ndash65


666




67ndash70


262 bull

sizer jr et al


71


72ndash75


7677


7879


80


7981ndash84



85


86


87


88


89


2939



90


Inspection



























































SUMMARY

















































































































































































1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c

260 bull

sizer jr et al


4243


infin

total)

3242

whereas 40

infin

to 45

infin


54244




2745



2745


46


Figure 6



Management


Figure 7





bull 261



2747ndash49

EXAMINATION

History


50


9


51


952


53ndash57



58


59


60


5461


61


662


63ndash65


666




67ndash70


262 bull

sizer jr et al


71


72ndash75


7677


7879


80


7981ndash84



85


86


87


88


89


2939



90


Inspection



























































SUMMARY

















































































































































































1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c


bull 261



2747ndash49

EXAMINATION

History


50


9


51


952


53ndash57



58


59


60


5461


61


662


63ndash65


666




67ndash70


262 bull

sizer jr et al


71


72ndash75


7677


7879


80


7981ndash84



85


86


87


88


89


2939



90


Inspection



























































SUMMARY

















































































































































































1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c

262 bull

sizer jr et al


71


72ndash75


7677


7879


80


7981ndash84



85


86


87


88


89


2939



90


Inspection



























































SUMMARY

















































































































































































1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c


























































SUMMARY

















































































































































































1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c















































SUMMARY

















































































































































































1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c




































SUMMARY

















































































































































































1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c





























SUMMARY

















































































































































































1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c

















SUMMARY

















































































































































































1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c







SUMMARY

















































































































































































1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c





































































































































































1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c
































































































































1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c




























































































1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c

























































1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c


























1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c









1 d2 a3 b4 c5 b6 d7 a8 c9 c

10 d11 a12 d13 a14 a15 a16 c

Documents

Diagnosis and Management of Cervicogenic Headache