Cervicogenic headaches Flashcards
Types of HAs
- Sinus
- Migraine
- Tension
- Cluster
- Cervicogenic
Sinus HA
Pain is usually behind forehead and or cheekbones
Migraine HA
- Unilateral but may shift sides
Associated with:
* Aura
* Nausea
* Photo or phono phobia
* Vomitting
* Throbbing
- Long lasting (24-72 hours)
- May be triggered by foods, smells, light, exertion, stress
Tension HAs
- Bilateral (Frontal and occipital region; can go into upper trap)
- Triggered by emotional stress
- Shorter lasting (30’ up to several days)
Cluster HAs
- Unilateral (Orbital, supraorbital or temporal)
Associated with:
* Eye tearing
* nasal stiffness
* facial sweating
* ptosis (drooping of eyelid)
- Short duration: 2-15 minutes
- Triggered by stress, alcohol, tobacco, etc.
Cervicogenic HA Classification
- Pain primarily in neck and occipital region but may project to forehead and around eye
- Pain triggered/aggravated by neck movements or sustained postures
One or more of the following:
* Limitation of PROM - especially rotation (usually upper cervical)
* Neck muscle tenderness and tone (Usually TrP tenderness of Suboccipitals, Upper Trap, Levator, SCM
* Active trigger points in the muscles above that refer into head
____ Ratio of Femal to Male ratio for Cervicogenic HAs
4:1
____ of subjects with (all types of) headaches have had previous cervical/thoracic pain
72-100%
Medical Screening to rule out what?
Rule out:
* Fracture
* Ligamentous Instability
* Cervical Artery Insufficency (Refers similar to facets)
Cervicogenic HAs - Subjective
- Commonly Hx of trauma (MVA)
- Unilateral neck/suboccipital pain with associated headache symptoms aggravated with movement
- Referral of symptoms into the head (temporal region most common)
- “Mechanical nature to their pain”: Specific movements or sustained postures aggravate condition
- Intermittent and fluctuates with specific activity
- Lying down (unloading of spine) relieves symptoms
Cervicogenic HAs - Objective
AROM Assessment in Sitting
* Restricted motion and/or pain esp. with overpressure ESPECIALLY WITH ROTATION (upper cervical involvement)
PROM Assessment in Supine:
* Restriction of motion with ISOLATED UPPER CERVICAL ASSESSMENT (Occiput-C1 OR C1-C2 motion)
Joint Mobility:
* Suboccipital traction alleviates symptoms
* Hypomobility of Occiput-C1 or C1-C2 mobility assessment (Cervical Flex/Rot assessment)
Soft Tissue Mobility/Flexibility
* Tenderness and flexibility deficits of suboccipital muscles, upper trapezius or SCM
Motor Coordination:
* Altered motor coordination and proprioceptive awareness
– Deep neck flexors, neck extension and lower trap activation/endurance
– Neck Joint Position Error Testing (JPET)
People with cervicogenic heads most often have dysfunction with which spinal levels?
- Levels Occiput (C0) - C4
- Highest: Occiput - C1 and C1-C2 greatest dysfunction
People with cervicogenic HAs will have the greatest limitations in motion where?
- Rotation!
- May also have some limitations with extension as well
Assessment of C1-C2 mobility: Cervical Flexion-Rotation Test
Significant Difference in C1-C2 ROM
- Control/Migraine Aura: Avg 39 degrees
- Cervicogenic HAs: Avg 20 degrees
Positive test is less than 32 degrees
Very reliable (98.3% agreement); Kappa - Excellent (0.81)
What are the most aggravated muscles/referral points for Cervicogenic HAs?
- Suboccipitals: near ear
- Upper Trapezius: Ram like
- SCM: C around eye/eyebrow or circular on forehead
Cervicogenic Irritability
High:
* Pain before end ranges of rotation during cervical flex/rotation test
* Minimal pressure palpation/mobility assessment produces pain
Moderate:
* Pain at end ranges of rotation during cervical flex/rotation test
* Moderate pressure palpation or mobility assessment produces pain
Low:
* Pain with overpressure into end ranges of rotation during cervical flex/rotation test
* Maximal pressure palpation mobility assessment produces pain
Cervicogenic HA interventions
Patient Education
Manual Techniques
* Manual-STM
– Soft tissue clearing along the suboccipitals
– Upper trapezius and levator scap
* Suboccipital release/Stretch
* Upper cervical mobilization techniques
– C1-C2 Muscle Energy/Contract-Relax Stretching (MET)
– Upper Cervical Rotation Distraction Non-Thrust Mobilization
– General thoracic and cervical mobilizations
Self- joint and soft tissue Mobilizations/ Stretching:
- Upper cervical SNAGs
- Motor coordination exercises
Patient Education - Cervicogenic HAs
Acute or Chronic
- Reassurance of what it is not(fractures, etc.) - Cognitive
* Address person’s attitudes and behaviors – Behavioral (STRESS, sleeping, posture, etc)
* Use words that Heal! (not harm)
If trauma (MVA), tissues need time to heal (4-6 weeks)
- During healing, do not stress tissues too much
- When they do heal, motion/stretching is good. Address FAB
If chronic,
- address “tissue sensitivity”, not “tissue damage”
- Graded exercise
Pain coping strategies:
- Diaphragmatic breathing
- Imagery
Work to identify triggers
Posture plays a role
Patients should expect what improvements with interventions for cervicogenic HAs?
- Decrease in frequency, intensity and duration
Manual Therapy and Motor coordination
Multi factorial: Address:
* Soft tissue tone of the suboccipital and upper trap and SCM
* Joint restrictions of the upper cervical region
* Motor control of the deep cervical stabilizers
Self Mobilizations SNAGS - RCT
- Cervicogenic HA individuals
- 12 week HEP:
– C1-2 Self Snag
– Placebo Self Snag - Increase in Flexion-rotation test ROM of 15 degrees
- Decrease in HA severity index at 4 and 12 month follow up
____ decreases headaches in the long term when provided as the sole line of treatment
Self SNAGS
