Olivia Stanwood
My philosophy is that physiotherapy offers patient-centered, evidence-based therapeutic treatment that uses an active approach to rehabilitation. In other words, a patient and their therapist work tog...
Cervicogenic Headaches
CERVICOGENIC HEADACHE…WHAT DOES THAT MEAN?
Cervicogenic headache is a fancy way of saying a headache that is caused by the cervical spine, aka the neck (cervico- = cervical spine = neck, -genic = produced by). The International Headache Society (IHS) defines a cervicogenic headache as a:
“Headache caused by a disorder of the cervical spine and its component bony, disc and/or soft tissue elements, usually but not invariably accompanied by neck pain.”
So, the headache is produced as a result of a dysfunction in the neck, be it the joints, muscles, discs and ligaments, or any combination of these. Since the problem originates in the neck itself, there is often some amount of neck pain associated with the headache (but not always!). The IHS describes some specific criteria to determine if a headache is considered “cervicogenic” or not. This includes various tests and a history that identify a problem in the cervical spine, and show a correlation between the onset and symptom fluctuation of the headache and the neck problem (ICHD-3 2018).
A typical cervicogenic headache may feel like a deep aching type pain typically on one side of the head, often in a “C” shape going up around the ear. There is often associated neck pain or stiffness as well. The headache may be triggered by things like specific neck movements (eg. Turning to look at your blind spot while driving), or prolonged neck postures (eg. Hours spent on the computer). Since these headaches are in fact due to a neck problem, the duration can be very variable and episodic depending on the specific problem present, and thus each person will experience their headache slightly differently.
A close cousin of the cervicogenic headache is a tension-type headache, which is very similar and sometimes hard to differentiate from the cervicogenic. Tension-type headaches get their name from the sensation of tension or pressure one feels around their head, as if they were wearing a headband that is much too tight. This type is more associated with muscular structures in the neck.
HOW DOES MY NECK CAUSE PAIN IN MY HEAD?
The simple answer is: the nerves. Now let’s get into some more juicy details…
The back portion of your head is innervated by two nerves that come directly from the upper portion of your neck (the greater and lesser occipital nerves). The top portion of your head and your face are innervated by the trigeminal nerve.
Fibers of this nerve go from your face, deep into your skull into the brainstem, and then down the spinal cord to about the level of C3 (the third vertebrae in your neck). Through this region of the spinal cord, we have the trigeminocervical nucleus – a section of densely-packed nerve tissue where the trigeminal and spinal nerves converge and share information. Because of this “mixing pot” of information, sometimes the brain struggles to identify where exactly the information is coming from. For example: if there is a dysfunction in a neck joint and the person turns their head, there is a signal going from the joint into the “mixing pot” where it gets mixed with many other signals happening at the same time, the brain interprets it as coming from the trigeminal nerve and thus the pain is felt in the face. This is the main mechanism by which current research explains how the neck can refer pain to the face and head (Biondi 2005).
HOW DO WE DIAGNOSE A CERVICOGENIC HEADACHE?
Headache is a common reason for medical consultation, and is included in the top 10 most disabling conditions according to the World Health Organization (WHO 2016). There are 14 different categories of headaches currently identified (ICHD-3 2018). So, how do we figure out when someone is presenting with a cervicogenic headache in the clinic? The first step is always to consider the possibility of a serious pathology such as a blood circulation problem, a cancer, a fracture of the skull, or an injury to the brain itself. Once these possibilities have been ruled out, a series of clinical tests can be used to differentiate a cervicogenic headache from other common types of headaches like migraine, tension-type headaches, or concussions (Howard et al. 2015, Luedtke et al. 2016). Firstly, the subjective information provided by the patient is analyzed. This includes answers to questions like when did the headaches start? How did they start (ie. Was there a trauma or not)? What makes the headache worse? Then the physical exam begins with an evaluation of the patient’s posture, range of motion and strength of the neck and upper back, and manual techniques to explore the various structures in the neck (Luedtke et al. 2016). Through all of these tests the therapist seeks to understand how the neck moves and what may be provoking the headache. A detailed examination is essential to inform how to most appropriately treat the headache. Cervicogenic headaches tend to respond very well to physical therapy treatment including manual therapy techniques, where as other types of headaches (such as migraine) do not (Jull et al. 2002, Chaibi & Russell 2012, Varatharajan et al. 2016).
HOW TO MAKE IT GO AWAY
We have identified that headache is cervicogenic…now what? Now it is time to treat it! The first line of treatment for cervicogenic headaches is physiotherapy. This includes 3 main aspects:
1. Understanding aggravating factors and making lifestyle adjustments to avoid them
Headaches are notorious for being difficult to treat since there are so many factors that play a role: stress, fatigue, sleep deprivation, nutrition, caffeine withdrawal, hormonal changes, sensory stimuli (light, sound, odors), trauma, medications... The first thing to do is to understand which of these factors influence the headache, and then create a plan to mitigate the influence. For example, if prolonged sitting has been identified as a provocative factor, adjustments to have an ergonomic setup at the work station may be beneficial.
2. Exercise therapy
The therapist will create an exercise program that targets the specific impairments identified during the examination. Typically, this includes 3-4 exercises to work on the cervical dysfunction directly, and thus helps eliminate the root cause of the pain. The program may include exercises for range of motion in the neck and/or upper back, strength of the neck and posture muscles, and stress management or relaxation strategies as needed (Jull et al. 2002, Biondi 2005, Chaibi & Russell 2012, Gross et al. 2015, Varatharajan et al. 2016). The patient is asked to practice this program at home in order to maximize benefits and to empower them by providing a sense of control over the situation.
3. Manual therapy
The last piece of the puzzle is manual therapy. Manual therapy techniques have been recommended to help reduce symptom intensity and frequency both acutely and in the long term (Jull et al. 2002, Biondi 2002, Chaibi & Russell 2012, Varatharajan et al. 2016). The exact techniques used will depend on the findings of the examination. This aspect of treatment should be seen as an adjunct that may help manage symptoms, but should not be emphasized more than #1 and #2.
Due to the complex nature of headaches and the potential heavy burden they have on one’s quality of life, both the therapist and patient need to have patience during the recovery process. We cannot expect the entire problem to be solved in one session. Usually, multiple sessions are required to fully address any provocative factors, and to improve on the underlying biomechanical issues. Each case is unique, and thus the exact treatment approach and techniques used must be tailored to the individual in order to be effective.
References
International Headache Society. https://ihs-headache.org/en/
International Headache Society. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018 Jan;38(1):1-211.
World Health Organization. Headache Disorders. 2016 April. https://www.who.int/news-room/fact-sheets/detail/headache-disorders
Biondi M. Cervicogenic headache: a review of diagnostic and treatment strategies. J Am Osteopath Assoc. 2005 Apr;105(4 Suppl 2):16S-22S
Chaibi A, Russell MB. Manual therapies for cervicogenic headache: a systematic review. J Headache Pain. 2012;13:351-359.
Gross A, Kay TM, Paquin JP, Blanchette S, Lalonde P, Christie T, Dupont G, Graham N, Burnie SJ, Gelley G, Goldsmith CH, Forget M, Hoving JL, Bronfort G, Santaguida PL, Cervical Overview Group. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2015 Jan;1(1):CD004250
Howard PD, Behrns W, Martino MD, DiMambro A, McIntyre K, Shurer C. Manual examination in the diagnosis of cervicogenic headache: a systematic literature review. J Man Manip Ther. 2015;23(4):210-218.
Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002 Sep;27(17):1835-43.
Luedtke K, Boissonnault W, Caspersen N, Castien R, Chaibi A, Falla D, Fernandez-de-Las-Penas C, Hall T, Hirsvang JR, Horre T, Hurley D, Jull G, Kroll LS, Madsen BK, Mallwitz J, Miller C, Schafer B, Schottker-Koniger T, Starke W, von Piekartz H, Watson D, Westerhuis P, May A. International consensus on the most useful physical examination tests used by physiotherapists for patients with headache: A Delphi study. Man Ther. 2016 Jun;23:17-24.
Varatharajan S, Ferguson B, Chrobak K, Shergill Y, Cote P, Wong J, Yu H, Shearer HM, Southerst D, Sutton D, Randhawa K, Jacobs C, Abdulla S, Woitzik E, Marchand AA, van der Velde G, Carroll LJ, Nordin M, Ammendolia C, Mior S, Ameis A, Stupar M, Taylor-Vaisey A. Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the OPTIMa Collaboration. Eur Spine J. 2016 Jul;25(7):1971-99.
