PHTY 3210 Block 3 Lecture 3 Cervicogenic headache:

A symptom of a disorder located in articular, neural, muscular or other soft tissues of the neck. Mechanism: Convergence of afferents of upper three cervical nerves and trigeminal nerve on common neurons in the trigeminocervical nucleus. Cervicogenic headache is a term to represent a potential spectrum of pain sources and pathologies in the upper cervical structures. No one structure, pathology or pathophysiological process is responsible for headache. Sources of headache are structures innervated by upper 3 nerves - joints, ligaments of upper 3 cervical segments - their anterior and posterior muscles - S.C.M. and upper trapezius - dura mater upper spinal cord and posterior cranial fossa - the upper three cervical nerves - upper part of the vertebral artery. Prevalence Cervicogenic headache: 1 month prevalence of 2.5% (Nilsson 1995) Migraine: 1 month prevalence of 4.0% Tension headache: 1 month prevalence of 48.0% (Rasmusson et al 1991)

The diagnostic criteria for cervicogenic headache (Sjaastad et al 1998)

Major criteria of cervicogenic headache 1. Symptoms and signs of neck involvement i. Precipitation of comparable head pain by: - neck movement or sustained awkward head postures, and/or - external pressure over the upper cervical or occipital region on the symptomatic side ii. Restriction of range of motion in the neck iii. Ipsilateral neck, shoulder or arm pain (One or more of the points 1 (i to iii) should be present) 2. Confirmatory evidence by diagnostic blocks 3. Unilaterality of head pain, without sideshift 4. Head pain characteristics i. moderate-severe, non-throbbing and non-lancinating pain, usually starting in the neck ii. episodes of varying duration iii. fluctuating continuous pain (None of the single points in 4 are obligatory) Other characteristics of some importance

5. i. Only marginal effects or lack of effect of idomethician ii. Only marginal effect or lack of effect of ergotomine and sumatriptan iii. Female sex iv. Not infrequent history of head or indirect neck trauma, usually of more than medium severity (None of the single points in 5 are obligatory) Other features of lesser importance 6. Various attack-related phenomena, only occasionally present, and/or moderately expressed when present i. Nausea ii. Phonophobia and photophobia iii. Dizziness iv. Ipsilateral blurred vision v. Difficulties on swallowing vi. Ipsilateral oedema, mostly in the periocular area

Diagnostic criteria migraine (IHS 1988)

Headache attacks lasting 4-72 hours Unilateral Pulsating quality Moderate to severe intensity (limits daily activity) Aggravated by physical activity Nausea or vomiting Photophobia, phonophobia Other causes of headache ruled out

Migraine with aura aura precedes headache and lasts approx 60mins

Diagnostic criteria tension headache (IHS 1988)

headache lasting 30 mins to 7 days pressing, tightening, non pulsating quality bilateral mild to moderate intensity (may inhibit, not prohibit activity) not aggravated by physical activity no nausea, vomiting photophobia or phonophobia is present other headache forms ruled out

Order of subjective examination for a headache patient Length of history Temporal pattern History of onset Area of pain Aggravating features Relieving features Medication General health Other headaches Family history

Nature of pain Onset of headache

Physical impairments in Cervicogenic headache subjects

Articular system: Painful cervical joint dysfunction a primary feature of cervicogenic headache Restriction of active range of movement is a feature of cervicogenic headache and not a feature of headaches of other causes Manual Examination Dysfunction will be present in the upper cervical joints (C0-3) Muscle System New evidence of motor control problems in the neck flexor synergy, suggesting decreased supporting capacity of the deep neck flexors (Jull et al 1999). Deficits in upper cervical and cervical strength and endurance (Watson and Trott 1993, Treleaven et al 1994). Muscle length, inconclusive, tightness not necessarily a strong feature of cervicogenic headache subjects (Treleaven et al 1994, Jull et al 1999) Postural form Forward Head Posture is the most commonly described postural abnormality in cervicogenic headache subjects. There is inconclusive evidence of its presence and significance. (Watson and Trott 1993, Griegal-Morris et al 1992, Treleaven et al 1994, Haughie et al 1995) Neural structures Neural allodynia can be present in cervicogenic headache subjects (Sjaastad et al 1998) Nerve compression (vascular, mechanical) can be associated with headache (rare) Neural mechanosensitivity (10% incidence in 200 cervicogenic headache subjects) Physical Criteria, Cervicogenic Headache Articular system ROM Segmental joint dysfunction Neuromotor control (cervical flexors) Length Strength Tenderness (low specifity) 4 4 4 4 4 Neural mechanosensitivity

Muscle system

Postural form Neural structures

Treatment of Cervicogenic Headache Evidence base for efficacy of physiotherapy management (Jull et al 2001) Articular dysfunction: Manipulative therapy and therapeutic exercise to restore muscle control of cervical segments. Muscle system: Re-education of neuromuscular control DNF and flexor synergy (retrain the craniocervical action with the pressure biofeedback unit to achieve holding capacity at 28 or 30 mmHg without any dominant activity in the --superficial neck flexors) Scapular control (retrain action of the lower trapezius and serratus anterior, in relative isolation in the first instance, incorporating exercises into postural control and functional activities) Postural re-education (correct the pelvic position to upright neutral position, add in control of scapular position) Muscle lengthening exercises if necessary Co-contraction exercises; upright correct sitting posture, using rotation for cocontraction of neck flexors and extensor for joint support. Note 10-20% MVC. Re-ed of movement patterns; cervical extension pattern, prone resting on elbows, sitting Effective home program is essential Neural system Treat joint dysfunction first to assess effect on neural system. - Gentle treatment of neural system. Note may have to modify positions for deep neck flexor and lower trapezius retraining if neural system is sensitised Ergonomics: work practices; work environment, a most important component of treatment. Patient must practice postural control preventatively.

Bogduk, N. 1995. Anatomy and physiology of headache. Biomedicine and Pharmacotherapy 49:435-445 Jull, G. 1998. Characterization of cervicogenic headache. Physical Therapy Reviews 3 Jull, G., Barrett, C., Magee, R., Ho, P. 1999. Further characterisation of muscle dysfunction in cervical headache. Cephalalgia 19:179-185 Jull, G. A. 1997. The management of cervicogenic headache. Manual Therapy 2:182-190 Nilsson, N., Christensen, H. W., Hartvigsen, J. 1997. The effect of spinal manipulation in the treatment of cervicogenic headache. Journal of Manipulative and Physiological Therapeutics 20:326-330 Sjaastad, O., Fredriksen, T. A., Pfaffenrath, V. 1998a. Cervicogenic headache: Diagnostic criteria. Headache 38:442-445 Sjaastad, O., Fredriksen, T. A., Stolt-Nielsen, A., Salvesen, R., Jansen, J., Pareja, J. A., Poughias, L., Knuszewski, P., Inan, L. 1997. Cervicogenic headache: A clinical review with a special emphasis on therapy. Functional Neurology 12:305-317 Sjaastad, O., Salvesen, R., Jansen, J., Fredriksen, T. A. 1998b. Cervicogenic headache. A critical view on pathogenesis. Functional Neurology 13:71-74

Treleaven, J., Jull, G., Atkinson, L. 1994. Cervical musculoskeletal dysfunction in postconcussional headache. Cephalalgia 14:273-279 Watson, D. H., Trott, P. H. 1993. Cervical headache: an investigation of natural head posture and upper cervical flexor muscle performance. Cephalalgia 13:272-84; discussion 232 Zwart, J. A. 1997. Neck mobility in different headache disorders. Headache 37:6-11