Spine - ICF Classification: Neck Pain with Headaches (Cervicogenic Headache)

Symptoms

• Primary complaint

  • Noncontinuous unilat neck pain w referred headache

  • Unilat headache w onset preceded by neck pain (no side shift - stays on one side)

  • Headache precipitated or aggravated by neck movements or sustained positions

• Head pain characteristics

  • Mod-severe non-throbbing, non-lancinating pain usually starting in neck

  • Episodes vary duration w fluctuating continuous pain

• Associated symptoms

  • Ipsilat neck, shoulder, or arm pain

  • Suboccipital neck pain

  • Cervicogenic dizziness and lightheadedness may be present

    • Commonly occurs w whiplash-associated disorders

• Other features (occasionally present)

  • Nausea

  • Phonophobia and photophobia

  • Ipsilat blurred vision

  • Difficulties swallowing

  • Ipsilateral periocular edema

  • Females

• Notable characteristic

  • Headache pain elicited by external pressure over upper cervical or occipital region on the symptomatic side

  • Only marginal response or lack of response to typical headache medications (indomethacin, ergotamine, sumatriptan)

Key examination findings

• Limited rotation (C1-2)

• Pain w upper cervical palpation

• Positive flexion-rotation test (Craniovertebral rot passive intervertebral motion test in full cervical forward bending)

• Hypomobility on upglide/downglide testing

• Tender suboccipital musculature

Muscle performance impairments

• Under activation of longus coli and longus capitis

• Overactivation of superficial neck flexors (ant scalene & SCM)

• Deep neck extensor weakness

• Suboccipital muscle tightness

• Scapular stabilizer weakness

• Levator scap and upper trap tightness

Postural impairments

• FHP

  • Shortens the suboccipitals and lengthens deep neck flexors —> compress suboccipital region

• Scapular protraction/elevation

  • Weak lower and middle traps and weak serratus ant

  • Tight upper traps and levator scap

• Increased upper cervical extension

  • Compensatory for FHP

  • Narrows suboccipital space

  • Pressure at the base of the skull

• Decreased lower cervical flexion

  • Deep neck flexors are weak

  • Increased shear forces at C5-7

Cervicogenic headaches vs other types

• Migraines

  • CGH do not tend to switch sides

  • CGH start in the neck while migraines start in the head

  • CGH pts have less CROM flex/ext

  • Higher incidence of dysfunctions of upper 3 cerv joints

  • Tightness of upper traps, levator scap, suboccipital extensor muscles

• Tension-type

  • Tension type headaches present w myofascial trigger points of the head, face, jaw, and neck

Diagnostic tests

• Identification of CGH through cluster findings in

  • Restricted cervical movement w manual examination of C0-C3 (facet joint hypomobility and tenderness to palpation)

  • Impairment in the craniocervical flexion test

  • Restricted cervical ROM, especially in extension and rot

• Craniocervical flexion test, cervical torsion test

• Diagnostic criteria

  • A. Any headache fulfilling criterion C

  • B. Clinical and/or imaging evidence of a disorder or lesion within the cerv spine or soft tissues of neck, known to be able to cause headache

  • C. Evidence of causation demonstrated by at least two of the following:

    • 1. Headache has developed in temporal relation to the onset of the cervical disorder or appearance of the lesion

    • 2. Headache has significantly improved or resolved in parallel w improvement in or resolution of the cervical disorder or lesion

    • 3. Cervical range of motion is reduced, and headache is made significantly worse by provocative maneuvers

    • 4. Headache is abolished following diagnostic blockage of a cervical structure or its nerve supply

  • D. Not better accounted for by another ICHD-3 diagnosis

Interventions

• Cervical and thoracic manipulation/mobilization

• Exercises for improving strength, endurance, and coordination of neck and postural muscles

• Joint position sense, eye, and balance training

  • Specifically targets cervicogenic dizziness

• Postural education

Cervical manipulations

• Cervical spine upglide/downglide

• PA mobilization

• Isometric manipulation

Exercises

• Strength training for deep neck flexors

  • Longus capitis and longus coli

  • Use of pressure biofeedback to assist w training

• Strength training for muscles surrounding scapula

  • Lower trap, serratus anterior

  • Work on holding scapular adduction and retraction postural positions

• Postural instruction and training of deep neck rotator muscles

• Muscle-lengthening exercises

Balance training

• Standing balance

  • Narrow base of support

  • Foam pad

• Tandem standing

• Single leg standing

• Progress to include

  • Joint position sense training

  • Eye movement coordination

Joint position sense training

• Joint position sense error

  • Ability to accurately return your head to a predefined target after neck movement

• Pts w cervicogenic headaches typically have less proprioception and more joint position sense error

• Joint position sense training

  • Have pt practice tracing pictorial patterns and performing controlled movements