Week 3: Cervicogenic Headache Flashcards
How prevalent are headaches?
- Lifetime prevalence 93-98%
- Very prevalent, very costly
What are cervicogenic headaches?
- Attributable to problems in the neck or upper cervical spine
- Affected by cervical movements
Where are cervicogenic headaches usually located
- Primarily occipital
- Radiate into head and face
- Unilateral
What percentage of headache sufferers c/o of neck pain associated w/ their headache?
70%
How prevalent are cervicogenic headaches?
- 14-18% of chronic headaches
- 15-20% of recurrent headaches
What is the anatomical basis for the pain pattern of cervicogenic headaches?
Afferents from CN V and spinal nerves C1-C3 go to the trigeminocervical nucleus
Clinical features for differential diagnosis
- Sex
- Lateralization
- Location
- Frequency
- Severity
- Duration
- Pain character
- Triggers
- Associated symptoms
Differential diagnosis for headaches based on sex (female:male)
- Cervicogenic: 50:50
- Migraine: 75:25
- Tension-type: 60:40
Differential diagnosis for headaches based on lateralization
- Cervicogenic: unilateral w/o sideshift
- Migraine: unilateral w/ sideshift
- Tension-type: diffuse bilateral
Differential diagnosis for headaches based on location
- Cervicogenic: occipital to frontoparietal and orbital
- Migraine: frontal, periorbital, temporal
- Tension-type: diffuse
Differential diagnosis for headaches based on frequency
- Cervicogenic: chronic, episodic
- Migraine: 1-4/month
- Tension-type: 1-30/month
Differential diagnosis for headaches based on severity
- Cervicogenic: moderate-severe
- Migraine: moderate-severe
- Tension-type: mild-moderate
Differential diagnosis for headaches based on duration
- Cervicogenic: 1 hr-weeks
- Migraine: 4-72 h
- Tension-type: days to weeks
Differential diagnosis for headaches based on pain character
- Cervicogenic: non-throbbing, nonlancinating, pain usually starts in the neck
- Migraine: throbbing, pulsating
- Tension-type: dull
Differential diagnosis for headaches based on triggers
- Cervicogenic: neck movement, posture, limit ROM, pressure over C0-C3
- Migraine: multiple, neck movement not typical
- Tension-type: multiple, neck movement not typical
Differential diagnosis for headaches based on associated symptoms
- Cervicogenic: usually absent or similar to migraine (but milder), decreased ROM
- Migraine: nausea, vomiting, visual changes, phonophobia, photophobia
- Tension-type: occasionally decreased appetite, phonophobia or photophobia
Possible signs of intracranial pathology
- Sudden onset of severe headache w/ increasing intensity
- Persistently unilateral headaches
- Wake the pt during night/early morning
- Generalized stiff neck/other signs of meningitis
- Systemic symptoms (weight loss, fever, malaise)
- Focal neurologic symptoms or signs
Pain distribution due to vascular issues
- Vertebral artery: unilateral in neck
- Internal carotid: unilateral in neck + temporal region
- Further questioning is needed for differential diagnosis
Concerning history for headache indicating cervical artery dysfunction
“I have pain in my neck and/or head UNLIKE ANYTHING I HAVE EVER HAD BEFORE.”
Major risk factors of cervical artery dysfunction
- Known hypertension
- Hypeercholsterolemia
- Hyperlipidemia
- Diabetes
- Smoker
- BMI >30
- Repeated/recent injury
- Upper cervical instability
5 D’s And 3 N’s
- Dizziness
- Drop attacks
- Diplopia (double vision)
- Dysarthria (motor speech disorder)
- Dysphagia (swallowing difficulties)
- Ataxia (lack of movement control)
- Nausea
- Numbness
- Nystagmus (repetitive, uncontrolled eye movement)
Other red flags indicating cervical arterial disease
- Altered taste
- Altered facial or peri-oral sensation
- Visual changes
- Unusual headaches/neck pain
- Facial numbness
- Tinnitus (ringing in ears)
- Gait disturbances
- Hoarseness
- Vomiting
- Memory loss
- Motor loss
Mean age of cervicogenic headache onset
42
Pain area for cervicogenic headache
- Posterior head and neck, possibly radiating shoulder or arm pain
- Primarily ipsilateral
What provokes cervicogenic headaches?
Sustained/awkward neck positions
Tests for cervicogenic headaches
- External pressure over upper cervical or occipital region (trigger points)
- Abnormal joint mobility testing
- cervical flexion-rotation test
- Cranial cervical flexion test
- Neck flexor muscle endurance test
How is the Cervical Flexion-Rotation Test (CFRT) conducted?
The neck is put in full flexion and then rotated to the right and left
Average normal rotation in CFRT
39 degrees
Average rotation with cervicogenic headache in CFRT
20 degrees
Positive CFRT
<32 degrees
Purpose of Cranial Cervical Flexor Test (CCFT)
Assess deep cervical flexor strength
Patient position for CCFT
Supine w/ occiput on the table
Procedure for CCFT
- Pt flexes cervical spine by tucking chin
- Pt should be able to generate 26-30 mmHg for 10 seconds
Purpose of neck flexor muscle endurance test
Assess deep cervical flexion strength
Patient position for neck flexor muscle endurance test
Hook lying with occiput on table
Procedure for neck flexor muscle endurance test
- Patient tucks chin and holds head up
- While maintaining flexion, raise head off table 2.5 cm
- Time stops when pt can’t hold head up and maintain chin tuck
Normal test for neck flexor muscle endurance test
> 38 seconds
Diagnostic cluster for cervicogenic headache (Jull, 2007)
- Decreased AROM cervical extension
- Palpable pain somewhere from OA to C3-4 joint dysfunctions
- Deep cervical flexor strength impairments w/ CCFT
Diagnostic cluster for cervicogenic headache (Zito, 2006)
- Palpably painful C1/C2 joint dysfunctions
- Pec minor muscle length shortened-
Evidence indicates what treatment is most effective for treating acute neck pain with headaches?
- Active mobility exercise
- Self-SNAG exercise
Evidence indicates what treatment is most effective for treating subacute neck pain with headaches?
- Cervical mob/manip
- Self-SNAG exercise
Evidence indicates what treatment is most effective for treating chronic neck pain with headaches?
- Cervical or cervicothoracic mob/manip
- Shoulder girdle and neck stretch/strength/endurance
