www.drayerpt.com VOLUME 12,10, ISSUEISSUE 24
Cervicogenic Headaches: A Pain in the Neck
By Jessica Heath and Neal Goulet This study also indicated If you stick your neck out that CGH affects four times for someone, the saying suggests, more women than men. Neck then you’ve taken some risk. positions and specific occupa- In this technology-driven tions, such as hairdressing, car- age, we’re literally sticking our pentry and truck/tractor driv- necks out at the risk of causing ing, have been linked to CGH. very real headache pain. An Diagnosis of CGH can be article in Men’s Journal used tricky because it can resemble the term “the desk worker’s other headaches and can trig- malady,” while a BBC story ger other headaches, such as called it “text neck.” a migraine. “The problem is that we’re Doctors may look for the craning our heads forward over source of the pain by attempt- our screens,” according to the ing to use a nerve block. This BBC, “and it’s creating intense involves an injection into the pressure on the front and backs neck of an anesthetic that can of our necks.” What feels like a dull, achy pain in the head really has its roots help determine which nerve is That pressure can cause in the neck. causing the pain. pain that manifests as a Those suffering from headache. This pain actually spine, comprising seven bones Common causes of CGH headaches try many remedies. isn’t in the head but rather is more commonly known as the can be chronic: poor posture, Medication, massage and even “referred” from the neck. neck; “genic” means that the as noted above, or arthritis. botox injections have been used The technical term for this headache is generated in this They also can be traumatic: to address pain. Of course, is cervicogenic headache, or area, particularly the upper the result of sudden, forceful medication can only mask the CGH, which by one estimate three bones. In other words, movement of the skull and pain, not resolve its cause. One accounts for 15 to 20 percent what feels like a dull, achy pain neck as with whiplash caused study found that botox was of all headache disorders. in the head really has its roots by a car accident, a fall, or an no better than a placebo at The Journal of Manual and in the neck. athletic collision. providing pain relief. Manipulative Therapy noted: A “cervicogenic episode” Headaches that develop Most often, CGH results “Although the prevalence can last one hour to one week. three or more months after a from the joints of the neck of CGH is considerably lower Pain typically is on concussion, accord- being stiff, sore and inflamed. The adjacent nerves become than tension-type headache one side of the head, SCAN FOR VIDEO ing to one study, and migraine, patients with often correlating generally are not irritated and refer pain to CGH have a substantial quality- with the side of the caused by brain the neck, shoulder and head, of-life burden, comparable to neck where there is or head injury. including the face and behind patients with migraine and increased tightness. This suggests a an eye. tension-type headache.” Almost certainly, connection to the What the abdominal mus- The first part of “cervico- range of motion will cervical spine. cles do to support the low back, genic” refers to the cervical be compromised. Posture correction the deep neck flexor muscles to help reduce headaches. Continued on Page 2
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Continued from cover CERVICOGENIC do for the neck. This group of HEADACHE muscles is on the front of the ILLUSTRATED neck and helps with simple movements, including nodding 1 Atlanto-occipital joint: can refer and turning the head. pain to the supra-orbital region Over time, poor posture can 2 Atlanto-axial joint: can refer pain weaken the deep neck flexors, to the top of the head allowing the head to move for- 3 C2-3 Zygopophyseal joint and ward and changing the overall disc: can refer pain to the base alignment of the spine. This of the skull could cause chronic neck pain 4 Capsule, ligaments: can cause 5 5 if not corrected. local symptom referral. In cases of 1 1 cervical trauma, these structures Physical therapy and an can lead to instability of the above 2 2 ongoing exercise regiment, joints and lead to headaches according to the American 5 Suboccipital muscles: help stabi- Migraine Foundation, “often lize the upper cervical spine and 33 produce the best outcomes.” if tight can compress the upper cervical joints, causing pain Physical therapy as a treat- ment for headaches is a compre- Deep neck flexors: located anteri- 4 orly (front), these muscles stabilize hensive approach. The therapist the cervical spine and must be will conduct a detailed patient strong to reduce headaches history, including stressors, work history and postures, and recreational activities that may the mobility in the cervical and contribute to the pain and thoracic spine. other aggravating factors. As the treatment progresses, An initial assessment also it is important for the therapist will include palpation of the also to teach the patient good cervical muscles that are often postural stability and strength- painful and tight, range of ening exercises. motion assessment, cervical and The combination of manual TYPE OF HEADACHES CAUSE thoracic mobility testing, postur- therapy, postural education and al muscle stabilization strength strengthening has been found Cervicogenic Inflammation or mechanical dysfunction of the upper cervical joints, ligaments and muscles testing, and deep neck muscle to be effective in the treatment strength and endurance testing. of cervicogenic headaches. Often, early treatment will Tension Spasm or hypertonicity of the cervical or REFERENCES cranial musculature begin with postural education “Cervicogenic headache: the basics,” and modalities to relieve pain American Migraine Foundation website, accessed April 2016. and assist with compliance in Migraine Vascular, autonomic nervous system Hall, T., Briffa, K., and Hopper, D. maintaining good posture. “Clinical evaluation of cervicogenic headache: a clinical perspective.” Taping techniques can be used Journal of Manual and Manipulative to alleviate pain and to assist Therapy. 2008; 16(2): 73-80. Cluster Vascular, autonomic nervous system, increased with postural awareness. Page, P. “Cervicogenic headaches: an evidence-led approach to clinical man- levels of histamine Manual therapy (hands-on agement.” Int J Sports Phys Ther. treatment) also will be used. September 2011; 6(3): 254-266. Therapists may need to incor- Reavy David. “The real reason you have a headache.” Men’s Journal, July 27, porate techniques to decrease 2015, accessed on mensjournal.com Chronic paroxysmal Vascular, autonomic nervous system the tone of muscles (over-devel- April 2016. “The painful conditions you get from your hemicrania oped because of compensation) smart phone.” BBC Newsbeat, June 19, in the cervical spine or improve 2015, accessed on bbc.co.uk April 2016. Tempormandibular Inflammation or mechanical dysfunction of the temporomandibular joint and the masticatory muscles
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RESEARCH ABSTRACT Managing Cervicogenic Headaches with Conservative Treatment
By Kyle Baiocchi received no treatment. region; and a group that the management of cervicogenic received both manual therapy headaches, with results being METHODS INTRODUCTION and therapeutic exercise. maintained in the long term. Cervicogenic headaches are Participants ranging in age chronic or recurring in nature from 18 to 60 were included in RESULTS DISCUSSION and have been found to arise the study if they experienced a All treatment groups Cervicogenic headaches are from musculoskeletal dysfunction headache that was unilateral demonstrated a significant a common ailment suffered by of the cervical spine (neck). The (on one side) or unilateral dom- reduction in headache frequency adolescent and adult popula- lifetime prevalence of headaches inant (worse on one side than and intensity and neck pain tions. Physical therapists have in adults may be as high as 20 the other) and associated with immediately after treatment the potential to relieve symp- to 30 percent. neck pain. These symptoms and at 12 months compared toms of headaches and address Conservative treatment, such needed to be aggravated by neck with the control group. underlying musculoskeletal as physical therapy, often is recom- postures or movements and Seventy-two percent of impairments. mended as a first line of headache present for at least one week participants achieved a reduction In six weeks of conservative management. Treatment may over a period of two months of 50 percent or more and 42 therapy, the researchers achieved include manual therapy, exercise to 10 years. percent of participants reported positive long-term outcomes or a multimodal approach. The subjects were randomly 80 to 100 percent relief at the and provided patients with self- The purpose of this study assigned to one of four groups: 12-month follow-up, which management strategies of exer- was to assess the short- and a control group that received no rendered the findings clinically cises and postural awareness to long-term effectiveness of treatment; a group that received relevant. reduce the risk of recurrence. manual manipulative therapy; a This study found that con- manual therapy and a low-load REFERENCES group that received therapeutic servative treatment of combined exercise program, used alone or “A randomized controlled trial of exercise in combination and compared exercise using low-load endurance manual therapy and a specific and manipulative therapy for cervicogenic headache.” Jull, et al. Spine. September with a control group that exercises to the cervicoscapular exercise program were effective in 2002 1;27(17):1835-43.
SIGNS AND SYMPTOMS LOCATION OF PAIN PHYSICAL THERAPY TREATMENT OPTIONS
e Neck pain or stiffness Neck or base of head, can refer to any part Manual therapy, exercise, postural of head; may be one-sided or two-sided education and strengthening
Tight muscles in the cervical spine, light Bilateral (on both sides) Relaxation techniques, bio-feedback and and sound sensitivity exercises to lengthen short muscles
Aura (focal neurological, symptoms for Usually one-sided but may change sides Bio-feedback, education, manual therapy less than an hour, visual disturbances), for any associated mechanical dysfunction light and sound sensitivity, vomiting
d Usually recur over a period of time, usually One-sided behind the eye, above the eye Education regarding precipitating factors, same time each year. Nasal congestion, or on the head headache log, bio-feedback runny nose, facial sweating, eyelid edema, eye pain
Nasal congestion, runny nose, facial One-sided behind the eye, above the eye Education regarding precipitating factors, sweating, eyelid edema or on the head headache log, bio-feedback
Pain with jaw movement; bruxism, joint Face and temporal or on the head Manual therapy, exercises to address tenderness, popping, clicking dysfunctions, mouth appliances, education regarding posture and habits
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CASE STUDY Physical Therapy for Headaches
By Misty Seidenburg sitting postures but increased ease with doing laundry. PATIENT HISTORY The addition of cervical A 49-year-old female was retraction exercises to her pro- referred to physical therapy for gram immediately improved complaints of chronic cervical range of motion and headaches. She was referred to overhead reach with decreased therapy by her neurologist pain. To progress range of because of limited success with motion even further, manual pharmacological treatment. treatment addressed upper The patient, a stay-at- thoracic mobility. home mom, was responsible As the patient progressed, for all of the household chores scapular stabilization, deep neck and enjoyed playing computer flexor strengthening, and func- games for two hours per day. tional reaching exercises were Her headaches limited her added to address her remaining ability to complete some of impairments and self-reported her household tasks such as activity restrictions. laundry. She was unable to look She was unable to look at the computer or read for more than 30 SUMMARY at the computer or read for minutes without a headache occurring. more than 30 minutes without By the fourth week, the a headache occurring that patient’s headaches were occur- required migraine medication spine range of motion was The physical therapist ring seldom, requiring less to relieve the pain. significantly restricted with 30 hypothesized that she suffered medication to address her pain. At the time of evaluation, degrees of flexion (normal 80- from cervicogenic headaches. She was able to complete most 90); 10 degrees of extension of her home activities but the patient complained of TREATMENT (normal 70); 45 degrees of reported continued difficulty retro-orbital (behind the eye) Initial treatment consisted rotation bilateral (normal 90); with sitting for more than one headaches and suboccipital of postural correction; manual side bending right 15 degrees and hour at a time. (base of the head) tenderness. techniques including soft tissue side bending left 5 degrees (nor- The patient was progressed She also noted a history of massage to reduce muscle tone mal 20-35), with cervical pain with manual treatment to neck and thoracic stiffness that and tenderness along her upper and stiffness in all directions. address upper cervical mobility she attributed to stress. She trapezius and suboccipital Flexion and side bending and was seen for two additional rated her symptoms as 5-9 on a muscles; and kinesiotaping to also worsened the patient’s weeks to restore full functional scale of 0 (no pain) to 10 assist with pain relief by aiding headache. The patient was ten- cervical range of motion. At (worst pain ever felt). postural control. der to palpation along both the time of discharge, she had By the third visit, muscle ASSESSMENT upper trapezii and suboccipital achieved her range of motion tone and tenderness were Analysis of the patient’s musculature. Functional testing goals and returned to all reduced and cervical range posture revealed a forward revealed limited overhead previous activities of daily of motion was minimally head, rounded shoulders, and reach. Her head moved forward living without symptoms or improved. The patient reported increased thoracic kyphosis incorrectly when she reached need for medication. continued difficulty with sustained (rounded mid-back). Cervical overhead.
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