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OS3 Exam II > Cervicogenic headache > Flashcards

Cervicogenic headache Flashcards

1
Q

Cervicogenic cephalgia (CHA)

A
  • 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
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2
Q

Cervicogenic cephalgia can be associated with

A

tendonitis of cervical muscles, trigger points and tender points, cervical joint inflammation
-pain may be alleviated by treatment of somatic dysfunction

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3
Q

Epidemiology of CHA

A
  • all ages
  • Females more common than males
  • common after neck trauma
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4
Q

Clinical course of CHA

A
  • 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
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5
Q

Risk Factors for CHA

A
  • 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
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6
Q

Suboccipital triangle muscles

A
  • 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
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7
Q

Myodural Bridge

A
  • 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
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8
Q

Sternocleidomastoid

A
  • unilateral contract–SB towards R away

- bilateral contract–Flexion of head and neck

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9
Q

Trapezius

A
  • connects the shoulder, thoracic spine, head and neck

- primary elevator and adductor of upper extremity

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10
Q

Semispinalis, splenius capitis, longissimus capitis

A
  • connect thoracic spine to head and neck

- collectively bilateral contraction–>extension

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11
Q

Splenius capitis and longissimus capitis unilateral contraction

A

SB/R same side

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12
Q

Semispinalis capitis unilateral contraction

A

Rotate away

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13
Q

Rotatores and multifidi unilateral contraction

A

-rotate away

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14
Q

Mltifidi

A

-traverse 1-3 spinal levels

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15
Q

Rotatores

A

connect successive vertebra

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16
Q

Intertransversarii

A
  • connect vertebra TP to TP
  • bilateral contraction–extension
  • unilateral contraction–SB same side
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17
Q

Tectospinal tract

A

coordinates eye and neck movements

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18
Q

Vestibular function

A

linked to neck motion

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19
Q

Neck motion is linked to

A

shoulder and upper back motion

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20
Q

Trigeminal Nerve

A
  • 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
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21
Q

Vagus Nerve

A
  • 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
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22
Q

Spinal accessory nerve

A
  • motor to trapezius and SCM

- some sensory afferents that may converge to TNC

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23
Q

C1-3

A
  • 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
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24
Q

Sensory nerves also converge with TNC

A

-pain signals project to trigeminal regions: ophthalmic, maxillary, and mandibular

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25
Q

Cervical Sympathetics

A
  • dense int he dura and along blood vessels

- superior cervical ganglia

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26
Q

Superior cervical ganglia

A
  • located anterior to C2
  • preganglionic fibers from T1-4
  • postganglionic fibers to vasculature and mucous membranes of head (middle ear, lacrimal gland, pupils)
27
Q

Activating sympathetics

A

-pupil dilation, less glandular secretions

28
Q

Activating parasympathetics

A

pupil constriction, copious secretions

29
Q

Greater and lesser occipital nerves

A
  • C1-3
  • innervate the posterior scalp
  • occipital neuralgia: trauma; entrapment of these nerves, upper cervical zygapophyseal joints, and C2
30
Q

C2 neuralgia

A
  • 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
31
Q

C3 neuralgia

A
  • somatic dysfunction here associated with whiplash injury

- transmits pain to frontotemporal and periorbital region

32
Q

Normal range for cranial rhythmic impulse

A

-10-14 cycles per minute

33
Q

Associated with a decreased rate and quality of the CRI

A
  • stress, depression, chronic fatigue, chronic infections

- chronic poisoning, compression of SBS

34
Q

Increase CRI

A

-vigorous activity, systemic overs, effective OMT of the craniosacral mechanism

35
Q

Cause of CHA is

A
  • cervical somatic dysfunction
  • often OA and AA dysfunction
  • 50% of whiplash patients with chronic pain have C2-3 joint pain
36
Q

Can be involved in cervical somatic dysfunction through TNC

A

CN V and Xi

37
Q

Upper cervical/suboccipital spasm induces

A

tension transmitted through modular bridge and elicits head pain

38
Q

C1 and 2 facets produce

A

pain in posterior auricular region via greater occipital nerve

39
Q

Organic disease through vagus nerve

A
  • viscerosomatic reflex

- sensitization of upper segments predisposed to dysfunctio

40
Q

have relieved cervicogenic pain

A
  • resolution of myofascial trigger points and botulinum toxin injections
  • indicates peripheral sensitization in soft tissues plays a role in CHA
41
Q

Higher in patients with CHA compared to migraine patients

A

proinflammatory cytokines and NO

-promotes hyperalgesia

42
Q

Indicates that the trigeminovascular system is not activated by CHA

A
  • lack of calcitonin gene-related peptide in symptomatic CHA patients
  • unlike migraine sufferers
43
Q

Differential Diagnosis of CHA

A
  • 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
44
Q

Different Diagnosis of CHA Red Flags

A
  • 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
45
Q

CHA Chief Complaint

A

moderate to severe deep, non-throbbing/non-lancinating pain

46
Q

CHA Precipitating factors

A

-neck movement, sustained head positioning, whiplash of other head and neck injury, inability to identify precipitating/aggravating/palliative factors

47
Q

CHA Location of Headache

A
  • occipital, frontal, temporal or orbital regions

- unilateral head or face pain without sideshift

48
Q

CHA Radiation

A
  • ipsilateral head, neck, shoulder and arm
  • non-radicular in nature generally
  • scalp paresthesias or dysesthesia
49
Q

CHA characteristics

A

-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

50
Q

CHA Associated symptoms

A
  • ipsilateral, diffuse arm/shoulder pain
  • nausea, phonophobia, photophobia, dizziness, ipsilateral “blurred vision”, difficulties swallowing, ipsilateral periorbital edema
51
Q

CHA Physical Exam

A
  • 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
52
Q

CHA Neuromusculoskeletal exam

A

-strength, sensory, DTRs, cerebellar testing, gross motion, specific motion patterns, segmental evaluation of pelvis to cervical spine for TART changes

53
Q

CHA ENT exam

A

-rule out infectious etiologies, lymphadenopathy (red flag)

54
Q

CHA Cardiac and respiratory evaluation

A
  • carotids for bruits

- pulmonary pathology that may be referring to shoulder

55
Q

CHA Lab/Imaging

A
  • blood tests for systemic pathology negative
  • C-spine radiographs, MRI, CT all negative
  • cervical disc bulging is non-specific
56
Q

CHA Evidence for OMM

A
  • 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
57
Q

CHA OMM Manual Medicine Risk vs. Benefit

A
  • 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
58
Q

Multidisciplinary Approach to treating CHA

A
  • manipulation, stretches, exercise, local injections, oral medications, stress reduction counseling, education on the disorder and causes
  • surgical consultation when conservative care fails
59
Q

OMM treatment for CHA

A

-soft tissue, myofascial release, articulatory, muscle energy, cranial, HVLA, counterstain, FPR, still’s

60
Q

CHA Treatment adjunct

A

analgesia
muscle relaxation
radio frequency neurolysis for refractor cases
cervical epidural steroids
psychological counseling (biofeedback, cognitive behavioral therapy (CBT)
-surgical

61
Q

CHA Analgesia

A
  • blockades of greater and lesser occipital nerves
  • non-narcotic or narcotic
  • antiepileptics: neuropathic pain
  • antidepressants: modulate pain, sleep
62
Q

CHA Muscle relaxation

A
  • muscle relaxants (baclofen, etc)
  • botulinum toxin A
  • trigger point injections
63
Q

CHA Surgical Treatment

A
  • 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
64
Q

CHA Patient education

A
  • posture
  • ergonomics
  • exercises: conditioning and neck stretches, strengthening neck flexors and extensors
  • reassurance

OS3 Exam II (10 decks)

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