Cervicogenic Headache

Many of us will be able to relate to the discomfort and disability experienced from having a headache. The constant pounding, the inability to concentrate and sleep and more importantly the severe impact it can have on every day functional activities.

More than 10 million people in the UK have experienced symptoms of a headache at some time or other, making it one of the most common health complaints seen by General practitioners. Most headaches aren’t serious and can be treated with medication, physiotherapy and lifestyle changes. But what do we really know about the science behind headaches?

In general terms a headache is a pain that occurs in the head and upper neck region of the body. It can affect a small portion of the head, such as the eyes or temples, or it can affect the entire head. The pain may be sharp or dull, and may come along with a variety of other symptoms like light sensitivity or nausea. Whatever the specifics may be, headaches are extremely common.

Headaches have many different causes but can generally be split into two types:

  1. Primary headaches are a result of abnormali ties in the brain or head. These include tension headaches, cluster headaches, and migraine which are all fairly common.
  2. Secondary headaches are caused by a disease or medical condition. These include inflammatory disorders and injuries to the head and neck and require careful and accurate diagnosis.

Cervicogenic headache is classified as a secondary headache.
Classifying what type of headache you have can be vitally important, as it will help your physiotherapist to determine the best course of treatment for you. Not bothering to identify the type of headache you have, and more importantly its cause, could be a costly mistake. It’s really a matter of being safe rather than sorry!

What is the cause of a cervicogenic headache and how is it diagnosed?
Cervicogenic headache (CGH) is usually characterized by pain that is referred to the head from the cervical spine (the neck region). Clinical studies have shown that pain from the upper
cervical joints and muscles can often refer pain into the head. Strangely, if these pain sensitive structures become irritated we can often feel pain that is more prominent in the head than it is in the neck.

Medical experts believe that the reason neck pain can cause a headache is due to the ‘convergence’ (the coming together) of sensory nerve fibres from the neck and sensory nerve fibres from the trigeminal nerve (the nerve that supply’s the sensation of the face and scalp). This convergence effectively makes it very difficult for the brain to interpret where exactly the pain is coming from and effectively transmits signals related to what we typically feel when we have a headache. This is why it is often called referred pain.

A whiplash injury or poor sitting posture is one common cause of this type of headache. Arthritis can be a contributing factor. There are as many as 20 muscles in the neck region as well and a dysfunction in how these muscle work collectively in controlling head and neck movement can often cause significant problems.

Some other facts regarding CGH:

  • In the general population, around 1% or 2% suffer from cervicogenic headaches.
  • About 20% of those who have chronic headaches are diagnosed as having the cervicogenic type
  • About 4 times as many women than men suffer from this type of headache
  • The frequency and severity of a cervicogenic headache can vary greatly, but those who suffer from this type of headache often experience it on an almost daily basis.

With a cervicogenic headache, pain will often start of in the neck region first, whereas it normally starts in the head with Migraine’s and tension-type headache sufferers. Cervicogenic headaches are also side- specific and do not fluctuate from side to side like a migraine headache can.

“The presence of relevant physical signs in the musculoskeletal system is fundamental to the diagnosis of cervicogenic headache” (Classification Committee of the International Headache Society 1988).

How can Physiotherapy Assessment and Treatment help?
A patient’s history and clinical presentation is vital in helping your physiotherapist to know whether their symptoms are consistent with cervicogenic headache. They will often ask you questions such as the location, severity, frequency and duration of you headache symptoms. What movements and postures typically bring on a headache episode and what you can do to make things easier.

Two recent studies by Jull et al. (2) and Amiri et al. (3) have reported three measures that collectively have 100% sensitivity and 94% specificity in distinguishing cervicogenic headaches from migraine or tension- type headaches. The three measures are reduced range of motion of the cervical spine, especially for extension; the presence of painful joint dysfunction in the upper cervical joints (C0-3); and impairment in muscle function, specifically a lack of endurance in the deep flexors of the neck.

At Richmond Physiotherapy our team of highly experienced physiotherapists have been trained to recognize these findings and employ appropriate manual therapy techniques to the cervical spine and associated soft tissue structures to regain range of motion and restore normal joint mechanics to the cervical spine along with instructing patients in a specific and evidence based exercise program that addresses the deep neck flexors and the stabilising muscles of the scapular area. This will also help to stimulate the process of healing and repair by facilitating normal movement and loading stresses around the symptomatic joints. Studies have documented a 76% success rate with a combination of these treatment interventions, whereby patients reported a more than 50% decrease in headache frequency and 35% achieved complete resolution of symptoms following seven weeks of treatment (4)

Medication for Cervicogenic Headache:
Medication alone seldom serves as an adequate treatment for cervicogenic headache although medication can sometimes provide a measure of relief. When medication is prescribed, it typically is an antidepressant, and anti-inflammatory, an analgesic, or an antiepileptic drug. It takes an expert to determine the type of medication best suited and your physiotherapist will be able to both guide you and liaise with your GP.

Medication-Induced Headaches:
Medication-induced headaches are more common that you may think and are caused by taking painkillers for migraines or headaches too regularly. In fact it is now recognized as the third most common cause of headache. By taking medication such as codeine, ibuprofen, paracetemol and Triptans (more specifically used for migraines) too frequently, your body becomes used to the effects of the drugs. A “rebound” or withdrawal headache may then develop if you do not take another one. As a result, you may end up getting stuck in a vicious cycle of having to rely on taking medication every day in order to keep the headache at bay.

What can I do to help prevent headaches?

  • Maintain a good sitting posture
  • Avoid prolonged periods of sitting or static postures in general
  • Ask your employer about having an appropriate workstation assessment
  • Avoid getting overtired to the point of exhaustion
  • Keep yourself well hydrated throughout the day
  • Exercise regularly to stimulate the circulation of blood to the head and to maintain neuro-musculoskeletal flexibility.
  • Try not to sleep on your stomach. ither sleep on your side with your head supported so that it is level with your spine, or on your back with a small pillow or rolled up towel supporting your neck rather than your head.

(1) Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Headache Classification Committee of the International Headache Society; Cephalalgia 1988;8; 7:1.
(2) Jull G, Amiri M, Bullock-Saxton J, et al. Cervical musculoskeletal impairment in frequent intermittent headache. Part 1: Subjects with single headaches. Cephalalgia 2007;27:793-802.
(3) Amiri M, Jull G, Bullock-Saxton J et al. Cervical musculoskeltal impairment in frequent intermittent headache. Part 2: subjects with multiple headaches. Cephalagia 2007;27:891-898.
(4) Jull G, Trott P, Potter H, et al. A Randomised controlled trial of exercise and manipulative therapy for cervicogenic headaches. Spine 2002; 27: 1835-43.

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