Cervicogenic headache Flashcards
Cervicogenic cephalgia (CHA)
- pain referred to the head unilaterally from cervical dysfunction
- characterized in the presence of somatic dysfunction: muscle spasm, decreased ROM, pain on palpation and movement, pain relieved with rest
Cervicogenic cephalgia can be associated with
tendonitis of cervical muscles, trigger points and tender points, cervical joint inflammation
-pain may be alleviated by treatment of somatic dysfunction
Epidemiology of CHA
- all ages
- Females more common than males
- common after neck trauma
Clinical course of CHA
- lacks regular pattern, affects quality of life, recurrent and episodic
- most CHA associated with whiplash resolve in 1 year
- whiplash patients with prior injuries to neck, pre-existing headache or neck pain may lead to chronic CHA
Risk Factors for CHA
- head and neck trauma
- compensatory cervical somatic dysfunction: thoracic, lumbar, pelvic, shoulder, leg length or costal dysfunctions
- provocative factors: sustained neck postures or movements; stress
Suboccipital triangle muscles
- level the occiput and temporal bones to the horizon
- optimize functioning of visual and vestibular systems
- obliquus capitis superior (SB same side)
- obliquus capitis inferior (R same side)
- rectus capitis posterior major (bilateral contraction–>extension; unilateral contraction–>SB/R same side
Myodural Bridge
- fascia and tendon of rectus capitis posterior minor with surrounding perivascular sheaths
- form the posterior OA membrane and directly fuse with the spinal dura between C1-2 and C2-3
- direct anatomic link between the musculoskeletal system and dura mater
- cervical dura sensory nerves sensitive to stretch from strain and prolonged contraction of posterior sub occipital muscles
- possible mechanism for eliciting pain in the occipital region
Sternocleidomastoid
- unilateral contract–SB towards R away
- bilateral contract–Flexion of head and neck
Trapezius
- connects the shoulder, thoracic spine, head and neck
- primary elevator and adductor of upper extremity
Semispinalis, splenius capitis, longissimus capitis
- connect thoracic spine to head and neck
- collectively bilateral contraction–>extension
Splenius capitis and longissimus capitis unilateral contraction
SB/R same side
Semispinalis capitis unilateral contraction
Rotate away
Rotatores and multifidi unilateral contraction
-rotate away
Mltifidi
-traverse 1-3 spinal levels
Rotatores
connect successive vertebra
Intertransversarii
- connect vertebra TP to TP
- bilateral contraction–extension
- unilateral contraction–SB same side
Tectospinal tract
coordinates eye and neck movements
Vestibular function
linked to neck motion
Neck motion is linked to
shoulder and upper back motion
Trigeminal Nerve
- innervates cranial and facial structures, blood vessels, dura mater
- sensory and motor
- tracts that descend into the upper cervical spine–trigeminal nucleus caudalis (TNC)–descends as low as C4
Vagus Nerve
- referral from visceral origin through vagus
- converge with the upper cervical segments
- thought to increase efferent motor to spinal neurons–>increased muscle tension (viscerosomatic reflex
Spinal accessory nerve
- motor to trapezius and SCM
- some sensory afferents that may converge to TNC
C1-3
- innervates the zygapophyseal joints, uncovertebral joints, discs, cervical muscles, ligaments, vertebral artery, cervical spinal dura, posterior scalp, lower layer of tantrum cerebelli
- afferents from these structures converge with TNC int he cord
Sensory nerves also converge with TNC
-pain signals project to trigeminal regions: ophthalmic, maxillary, and mandibular
Cervical Sympathetics
- dense int he dura and along blood vessels
- superior cervical ganglia
Superior cervical ganglia
- located anterior to C2
- preganglionic fibers from T1-4
- postganglionic fibers to vasculature and mucous membranes of head (middle ear, lacrimal gland, pupils)
Activating sympathetics
-pupil dilation, less glandular secretions
Activating parasympathetics
pupil constriction, copious secretions
Greater and lesser occipital nerves
- C1-3
- innervate the posterior scalp
- occipital neuralgia: trauma; entrapment of these nerves, upper cervical zygapophyseal joints, and C2
C2 neuralgia
- deep dull pain radiates from occiput to parietal/temporal/frontal/periorbital
- paroxysmal sharp/shock pain superimposed over constant pain
- ipsilateral eye lacrimation and conjunctival injection common
C3 neuralgia
- somatic dysfunction here associated with whiplash injury
- transmits pain to frontotemporal and periorbital region
Normal range for cranial rhythmic impulse
-10-14 cycles per minute
Associated with a decreased rate and quality of the CRI
- stress, depression, chronic fatigue, chronic infections
- chronic poisoning, compression of SBS
Increase CRI
-vigorous activity, systemic overs, effective OMT of the craniosacral mechanism
Cause of CHA is
- cervical somatic dysfunction
- often OA and AA dysfunction
- 50% of whiplash patients with chronic pain have C2-3 joint pain
Can be involved in cervical somatic dysfunction through TNC
CN V and Xi
Upper cervical/suboccipital spasm induces
tension transmitted through modular bridge and elicits head pain
C1 and 2 facets produce
pain in posterior auricular region via greater occipital nerve
Organic disease through vagus nerve
- viscerosomatic reflex
- sensitization of upper segments predisposed to dysfunctio
have relieved cervicogenic pain
- resolution of myofascial trigger points and botulinum toxin injections
- indicates peripheral sensitization in soft tissues plays a role in CHA
Higher in patients with CHA compared to migraine patients
proinflammatory cytokines and NO
-promotes hyperalgesia
Indicates that the trigeminovascular system is not activated by CHA
- lack of calcitonin gene-related peptide in symptomatic CHA patients
- unlike migraine sufferers
Differential Diagnosis of CHA
- occipital neuralgia
- migraine with and without aura
- tension-type headaches
- mixed-type headaches
- cervical spondylosis; greater occipital nerve compression/inflammation; herniated disc; idiopathic intracranial HTN; rheumatoid arthritis; trauma; tumors
Different Diagnosis of CHA Red Flags
- AV malformations
- cerebral aneurysm
- chiari malformations
- glaucoma
- infections
- posterior fossa tumors
- hemorrhage
- vasculitis
- vertebral artery dissection
- constant/worsening
- wakes a patient up at night or is worse in the AM
CHA Chief Complaint
moderate to severe deep, non-throbbing/non-lancinating pain
CHA Precipitating factors
-neck movement, sustained head positioning, whiplash of other head and neck injury, inability to identify precipitating/aggravating/palliative factors
CHA Location of Headache
- occipital, frontal, temporal or orbital regions
- unilateral head or face pain without sideshift
CHA Radiation
- ipsilateral head, neck, shoulder and arm
- non-radicular in nature generally
- scalp paresthesias or dysesthesia
CHA characteristics
-mechanical precipitation of attacks, intermittent attacks of pain lasting hours to days, variable duration, pain starts in neck, viselike, dull or aching, lack of response to medical management only
CHA Associated symptoms
- ipsilateral, diffuse arm/shoulder pain
- nausea, phonophobia, photophobia, dizziness, ipsilateral “blurred vision”, difficulties swallowing, ipsilateral periorbital edema
CHA Physical Exam
- upper cervical (OA/AA, C2-4) tissue texture changes, suboccipital muscle tensiona and stiffness in mobility
- asymmetry of head and neck position with shoulders
- restriction of cervical rotation (active and passive motion), restriction of motion AA (C1-2)
- pain induced by motion, palpation; myofascial trigger points
- Suboccipital, C2-4 tenderness
- suboccipital, cervical or shoulder girdle pain referred to ipsilateral head
CHA Neuromusculoskeletal exam
-strength, sensory, DTRs, cerebellar testing, gross motion, specific motion patterns, segmental evaluation of pelvis to cervical spine for TART changes
CHA ENT exam
-rule out infectious etiologies, lymphadenopathy (red flag)
CHA Cardiac and respiratory evaluation
- carotids for bruits
- pulmonary pathology that may be referring to shoulder
CHA Lab/Imaging
- blood tests for systemic pathology negative
- C-spine radiographs, MRI, CT all negative
- cervical disc bulging is non-specific
CHA Evidence for OMM
- manipulation decreases joint afferent stimulus to cord–decreases efferent motor to paraspinal muscle–releases strain on connective tissue and joints
- manipulation + physical conditioning exercises effect to relieve moderate to severe pain in all ages and genders (Grade A evidence)
- ongoing exercise and physical conditioning programs beneficial for long term prevention and control of symptoms
CHA OMM Manual Medicine Risk vs. Benefit
- no reported complications with cervical mobilization procedures to treat somatic dysfunction of CHA (MFR, ME, functional techniques
- decrease in pain frequency, intensity, duration (grade A evidence)
- improved functionality in ADLs and at work
- decreased reliance on analgesics and other medications
Multidisciplinary Approach to treating CHA
- manipulation, stretches, exercise, local injections, oral medications, stress reduction counseling, education on the disorder and causes
- surgical consultation when conservative care fails
OMM treatment for CHA
-soft tissue, myofascial release, articulatory, muscle energy, cranial, HVLA, counterstain, FPR, still’s
CHA Treatment adjunct
analgesia
muscle relaxation
radio frequency neurolysis for refractor cases
cervical epidural steroids
psychological counseling (biofeedback, cognitive behavioral therapy (CBT)
-surgical
CHA Analgesia
- blockades of greater and lesser occipital nerves
- non-narcotic or narcotic
- antiepileptics: neuropathic pain
- antidepressants: modulate pain, sleep
CHA Muscle relaxation
- muscle relaxants (baclofen, etc)
- botulinum toxin A
- trigger point injections
CHA Surgical Treatment
- relief of nerve entrapments
- transection of greater occipital nerve
- implantation of nerve stimulators
- neurectomy, dorsal rhizotomy
- microvascular decompression of nerve roots or peripheral nerves as a last resort
CHA Patient education
- posture
- ergonomics
- exercises: conditioning and neck stretches, strengthening neck flexors and extensors
- reassurance
