by Jennifer Ironside
The following outline discusses the most common clinically relevant information pertaining to cervicogenic headaches. Their description, diagnosis and management will be discussed with links to appropriate resources.
'Cervicogenic headache' is a term used to define headaches that arise from musculoskeletal dysfunctions in the cervical spine.1,2 More specifically, dysfunction is thought to lie within the joints, discs, ligaments, muscles, and/or dura of C0-C3. Typically these types of headaches are unilateral, often beginning at the neck or base of the skull and spreading into the oculo-fronto-temporal area.
Referral Patterns After Noxious Stimuli3
Referred pain pattern after noxious stimuli with percentages of patients who reported pain in area.3
Theory of Convergence
Although this theory of convergence is still the most widely accepted explanation for cervicogenic headaches, it has not been demonstrated in humans. All of the studies that support this theory have been conducted on animals.3
In 1988 the International Headache Society (IHS) published diagnostic criteria for headaches, including cervicogenic headache. In 2004 the IHS published a revised classification of headaches. Cervicogenic headache is considered a secondary headache and falls under the ICD-10 code of G44.841, with the key component being pain in the head or face that can be attributed from the neck dysfunction.
In 1998 the Cervicogenic Headache International Study Group (CHISG) published its own set of criteria that is more widely utilized in clinical practice than the IHS classification.
Distinguishing between Headache Types
The criteria put forward by the CHISG requires a diagnostic nerve block of the suspected cervical level for a diagnosis of cervicogenic headache to be given. For many patients it is not possible to receive this procedure. A manual examination of the upper cervical spine is a key tool many practitioners use to diagnosis cervicogenic headache.
General Examination for Cervical Spine1,4 with a focus on cervicogenic headache.
- Women are 4 times more likely to suffer from cervicogenic headache
- Cluster headaches more commonly seen in males
- Individuals with managerial and professional occupations seem to be more afflicted by cervicogenic headache
- Disc problems
- Degenerative joint changes
- No family tendency seen with cervicogenic headache
Time-line of Cervicogenic Headache
- Spontaneous, traumatic, or unknown start?
Specific Sites of Pain
Where does it start?
Sjaastad et. al.5 found that 90% of patients suffering from migraines report the pain starting in the forehead or temporal region where as 73% of cervicogenic headache patients report pain beginning at the neck and moving into the head
- Does it seem to move?
- Does it move in a predictable pattern?
Unilateral or Bilateral Symptoms?* Tension headaches are typically bilateral while cervicogenic headache are unilateral
- Does it switch sides?
- Migraines can switch sides, but cervicogenic headaches stay unilateral.
Constant or Intermittent
- What makes it better or worse?
- Is posture a component?
- Cervicogenic headaches are more likely to be triggered by a specific position than migraines.
Any other symptoms besides pain?
- Blurred vision
- Forward head
- Any asymmetry
Special Tests if Applicable
- Vertebral Artery insufficiency testing
- Upper cervical spine stability testing
- Cervical Spine ROM testing
- Gross movements
- Side Flexion
- Soft tissue
- Spinous processes
- Transverse processes
- Articular pillar
- Facet joints
Based on the findings from the examination a practitioner should be able to determine the source of a patient’s pain. If the patient is presenting with all of the criteria described earlier and a specific structure in the neck seems to be the cause then it is likely they are suffering from cervicogenic headaches.
Types of Management1,2,3
- Drug Therapies
- Botulium Toxin
- Local Anaesthetics
- Nerve Block
- Transcutaneous Electrical Nerve Stimulation (TENS)
- Manual Therapy (Manipulation and/or Mobilization)
- Physical Therapist or Chiropractic
- Self Administered
- Postural Reeducation
- Exercise Training
- Surgical Approach
- Biofeedback/Relaxation Training
When a physical therapist sees a patient suffering from cervicogenic headaches there are several tools that can be utilized to help relieve their symptoms. Mobilization and/or manipulation of the spine can help to ease pain and promote movement. Massage can be useful for relaxation and release of trigger points that may be referring pain to the head. Depending on the patient posture, postural reeducation may be another area for treatment focus. Proper alignment of the cervical spine can help to reduce strain on ligaments and muscles. Educating a patient on relaxation techniques, stretching, and the possible triggers for their headaches will help them to become independent in symptom management.
Web Based Resources
- Spinal Manipulation Institute: American Academy of Manipulative Therapy
- American Headache Society
- American Headache Society Committee for Headache Education
- National Headache Foundation
- International Headache Society
- Tension-Type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management.
- National Pain Foundation: Headache
- World Headache Alliance
- Chicago Institute of Neurosurgery and Neuroresearch
Recent Related Research
- Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache.
- Dose response and efficacy of spinal manipulation for chronic cervicogenic headache: A pilot randomized controlled trial.
- Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache
- Headache subsequent to whiplash.
- Influential variables associated with outcomes in patients with cervicogenic headache.
- Orthopaedic manual physical therapy including thrust manipulation and exercise in the management of a patient with cervicogenic headache: A case report.