A cervicogenic headache is a headache that actually involves the neck. Through different treatment options, chiropractors are one of the better choices when it comes to treating this issue.
Who is most affected?
The mean age for cervicogenic headaches is in the 40’s, and the condition affects women more often than men at a rate of 4:1 (1,3). Cervicogenic headaches can be as debilitating as tension or migraine headaches, and a loss of cervical spine function compounds the problem. It is common in patients who have experienced trauma, especially a motor vehicle accident or an earlier concussion (4). The condition is particularly prevalent in weightlifters (10).
Cervicogenic headache patients typically have neck tenderness and stiffness. By definition, pain is typically on one side shift, but in some cases, the condition may present on both sides. Moderate to severe pain may begin in the neck and progressively affect areas in the head. Symptomatic episodes may last hours to days. The characteristic continuous, fluctuating pain is described as deep but generally not throbbing. Symptoms may be triggered or reproduced by sustained or awkward cervical spine postures (6).
Trigger points are prevalent in the upper trapezius, suboccipital, cervical and shoulder girdle musculature (7,59).
Cervicogenic headache patients often demonstrate a loss of strength in the deep neck flexors and over-activation of the SCM and upper trapezius muscles (8,9).
The most common cause of cervicogenic headaches are upper cervical spine restriction (12). Restrictions in motion in the upper cervical area is present in 63% of CGH patients and has good reliability (13). Lower cervical spine restrictions may also be a culprit, especially following trauma (14). Adjacent spinal regions should be assessed as limited upper thoracic mobility leads to substitution with excessive extension in the upper cervical spine (41).
Co-existent myofascial problems are consistently present (15). Palpation of trigger points in the suboccipital, SCM, upper trapezius, levator, scalenes, pectoral and temporalis muscles often reproduces or intensifies symptoms (4,17). There is a strong association of trapezius muscle tenderness to intensity and number of symptomatic headache days. (57) Upper crossed syndrome is also often present.
Do I need imaging?
Although radiography, advanced imaging, and lab tests may be needed to identify alternate diagnoses, these tests are non-confirmatory and of limited value for cervicogenic headache patients (18). MRI has shown no demonstrable anatomic difference between CGH patients and asymptomatic subjects (12).
Outcomes with Chiropractic:
A survey of 381 chiropractors found that over 80% of plans for recent onset headache (less than 3 months duration) required less than 10 visits scheduled at 1-2 visits per week for less than 8 total weeks (58)
One randomized controlled trial demonstrated that 6-8 of SMT sessions produced good outcomes (45)
A Spine Journal study found that spinal manipulation cuts the number of CGH symptomatic days in half, and the number of treatments has a linear dose response to improvement (55).
At Creekside, we typically combine SMT with myofascial release to provide the best outcomes for our patients. The combination of neural mobilization and soft tissue techniques induces significant improvement of pain and function (51).
Myofascial release and stretching may be needed in the suboccipital, SCM, upper trapezius, levator, scalenes, pectoral and temporalis muscles. Fascial adhesions in the connection between the suboccipital region and cervical dura may restrict normal upper cervical motion and may be released with IASTM.
Although some patients report palliative relief of CGH symptoms with NSAIDs, medical management of CGH is generally ineffective (34).
At Creekside Chiropractic & Performance Center, we are highly trained to treat this condition. We are the only inter-disciplinary clinic in Sheboygan county that provides chiropractic, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves. Voted Best Chiropractor in Sheboygan by the Sheboygan Press.
Evidence Based-Patient Centered-Outcome Focused
1. Stovner L., et al. , The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia, 2007. 27(3): p. 193–210
2. Bogduk N. The anatomical basis for cervicogenic headache. J Manipulative Physiol Ther. 1992;15:67-70
3. van Suijlekom HA, Lame I, Stomp-van den Berg SG, Kessels AG, Weber WE. Quality of life of patients with cervicogenic headache: a comparison with control subjects and patients with migraine or tension-type headache.Headache . 2003;43:1034-1041.
4. Treleaven J., Jull G., Atkinson L., Cervical musculoskeletal dysfunction in post-concussional headache. Cephalalgia, 1994. 14(4): p. 273–9; discussion 257.
5. Antonaci F., Sjaastad O., Cervicogenic headache: a real headache. Curr Neurol Neurosci Rep, 2011. 11(2): p. 149–55.
6. The Cervicogenic Headache International Study Group Diagnostic Criteria. (Modified from Biondi DM: Cervicogenic headache: mechanisms, evaluation, and treatment strategies. J Am Osteopath Assoc. 2000;100(9 Suppl):S7-14. Source: Sjaastad 0, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. Headache. 1998;38:442-445.)
7. Hall T, Robinson K. The flexion-rotation test and active cervical mobility—a comparative measurement study in cervicogenic headache. Man Ther. 2004;9:197-202.
8. Page P., Frank C.C., Lardner R., Assessment and treatment of muscle imbalance: The Janda Approach 2010, Champaign, IL: Human Kinetics.
9. Falla D.L., Jull G.A., Hodges P.W., Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test. Spine (Phila Pa 1976), 2004. 29(19): p. 2108–14
10. Rifat S.F., Moeller J.L., Diagnosis and management of headache in the weight-lifting athlete. Curr Sports Med Rep, 2003. 2(5): p. 272–5.
11. Hall T.M., et al. , Comparative analysis and diagnostic accuracy of the cervical flexion-rotation test. J Headache Pain, 2010. 11(5): p. 391–7
12. Coskun O, Ucler S, Karakurum B, Atasoy HT, Yildirum T, Ozkan S, et al. Magnetic resonance imaging of patients with cervicogenic headache. Cephalalgia. 2003;23:842-845.
13. Hall T., et al. , Reliability of manual examination and frequency of symptomatic cervical motion segment dysfunction in cervicogenic headache. Man Ther, 2010. 15(6): p. 542–6
14. Hong J.P., et al. , Clinical assessment of patients with cervicogenic headache: a preliminary study. Chang Gung Med J, 2010. 33(1): p. 58–66.
15. Jaeger B., Are “cervicogenic” headaches due to myofascial pain and cervical spine dysfunction? Cephalalgia, 1989. 9(3): p. 157–64.
17. Bansevicius D., Sjaastad O., Cervicogenic headache: the influence of mental load on pain level and EMG of shoulder-neck and facial muscles. Headache, 1996. 36(6): p. 372–8
18. Fredriksen TA, Fougner R, Tangerud A, Sjaastad O. Cervicogenic headache: radiological investigations concerning headneck. Cephalalgia. 1989;9:139-146.
19. Biondi, DM. Cervicogenic Headache: A Review of Diagnostic and Treatment Strategies. J Am Osteopath Assoc April 1, 2005 vol. 105 no. 4 suppl 16S-22S
20. Haas M., et al. , Dose response for chiropractic care of chronic cervicogenic headache and associated neck pain: a randomized pilot study. J Manipulative Physiol Ther, 2004. 27(9): p. 547–53.
21. Koes, BW, Bouter LM, et al. “Randomised Clinical Trial of Manipulative Therapy and Physiotherapy for Persistent Back and Neck Complaints: Results of One Year Follow Up.” British Medical Journal, Volume 304, Number 6827, March 7, 1992, Pages 601-605.
22. Boline PD, Kassak K, et al. “Spinal Manipulation vs. Amitriptyline for the Treatment of Chronic Tension-type Headaches: A Randomized Clinical Trial.” Journal of Manipulative and Physiological Therapeutics, Volume 18, Number 3, March/April 1995, Pages 148-154.
23. Nilsson N., A randomized controlled trial of the effect of spinal manipulation in the treatment of cervicogenic headache. J Manipulative Physiol Ther, 1995. 18(7): p. 435–40,
24. Schoensee S.K., et al. , The effect of mobilization on cervical headaches. J Orthop Sports Phys Ther, 1995. 21(4): p. 184–96,
25. Nilsson N., Christensen H.W., Hartvigsen J., The effect of spinal manipulation in the treatment of cervicogenic headache. J Manipulative Physiol Ther, 1997. 20(5): p. 326–30.
26. Gross A., et al. , Manipulation or mobilisation for neck pain: a Cochrane Review. Man Ther, 2010. 15(4): p. 315–33.
27. Biondi D. Physical treatments for headache: a structured review. Headache. 2005;45:1-9
28. Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002;27:1835-1843.
29. Andersen L.L., et al. , Effect of brief daily exercise on headache among adults - secondary analysis of a randomized controlled trial. Scand J Work Environ Health, 2011.
30. Ylinen J., Physical exercises and functional rehabilitation for the management of chronic neck pain. Eura Medicophys, 2007. 43(1): p. 119–32.
31. Randlov A., et al. , Intensive dynamic training for females with chronic neck/shoulder pain. A randomized controlled trial. Clin Rehabil, 1998. 12(3): p. 200–10
33. van Ettekoven H., Lucas C., Efficacy of physiotherapy including a craniocervical training programme for tension-type headache; a randomized clinical trial. Cephalalgia, 2006. 26(8): p. 983–91
34. Bogduk N., Govind J., Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. Lancet Neurol, 2009. 8(10): p. 959–68.
35. McCrory, Penzlen, Hasselblad, Gray. Duke Evidence Report (2001)
36. Racicki, S, Gerwin, S, DiClaudio, S, Reinmann, S, Donaldson, M. Conservative physical therapy management for the treatment of cervicogenic headache: a systematic review. JMPT Vol 21, Number 2, 2013 pp.113-124.
37. Domenech MA, Sizer PS, Dedrick GS, McGalliard MK, Brismee JM. "The Deep Neck Flexor Endurance Test: normative data scores in healthy adults." PM R. 2011 Feb. Web. 08/18/2012.
38. Harris KD, Heer DM, Roy TC, Santos DM, Whitman JM, Wainner RS. “Reliability of a measurement of neck flexor muscle endurance.” Physical Therapy 2005 Dec. Web. 08/18/2012.
39. Ashkenazi A. et al. Peripheral Nerve Blocks and Trigger Point Injections in Headache Management – A Systematic Review and Suggestions for Future Research. Headache: The Journal of Head and Face Pain. Volume 50, Issue 6, pages 943–952, June 2010
40. Blumenfeld A. et al. Expert Consensus Recommendations for the Performance of Peripheral Nerve Blocks for Headaches – A Narrative Review. Headache: The Journal of Head and Face Pain Volume 53, Issue 3, pages 437–446, March 2013
41. Liebenson C. Janda’s DNF Test & Neck “Packing”. www.craigliebenson.com/jandas-dnf-test/. Published 11/11/2011. Accessed 6/24/14
42. Espí-López Gemma V., Gómez-Conesa Antonia. Efficacy of Manual and Manipulative Therapy in the Perception of Pain and Cervical Motion in Patients With Tension-Type Headache: A Randomized, Controlled Clinical Trial. Journal of Chiropractic Medicine Volume 13, Issue 1, p1-80 March 2014
43. Enix, Dennis E., Frank Scali, and Matthew E. Pontell. “The Cervical Myodural Bridge, a Review of Literature and Clinical Implications.” The Journal of the Canadian Chiropractic Association 58.2 (2014): 184–192.
44. Scali F, Pontell ME, Nash LG, Enix DE. Investigation of meningomyovertebral structures within the upper cervical epidural space: a sheet plastination study with clinical implications. Spine J. 2015 Nov 1;15(11):2417-24.
45. Dunning JR, et al. Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: a multi-center randomized clinical trial. BMC Musculoskelet Disord. 2016 Feb 6;17(1):64
46. Silberstein SD, Lipton RB, Dalessio DJ. Overview, diagnosis, and classification. In: Silberstein SD, Lipton RB, Dalessio DJ, eds. Wolff’s Headache And Other Head Pain. 7th ed. Oxford, England: Oxford University Press; 2001:20
47. Dodick DW. Adv Stud Med. 2003; 3 (6C): S550-S555
48. Garcia JD, Arnold S, et al. Mobilization and Manipulation of the Cervical Spine in Patients with Cervicogenic Headache: Any Scientific Evidence? Front Neurol. 2016 Mar 21;7:40.
49. Varatharajan S, Ferguson B, Chrobak K, Shergill Y, Côté P, Wong JJ, Yu H, Shearer HM, Southerst D, Sutton D, Randhawa K, Jacobs C, Abdulla S, Woitzik E, Marchand AA, van der Velde G, Carroll LJ, Nordin M, Ammendolia C, Mior S, Ameis A, Stupar M, Taylor-Vaisey A. Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J. 2016 Jul;25(7):1971-99.
50. PalomequeDel-Cerro L, et al. A systematic review of the soft-tissue connections between neck muscles and dura mater: The myodural bridge. Spine (Phila Pa 1976).2017 Jan 1;42(1):49-54.
51. Ferragut-Garcías, Alejandro et al. Effectiveness of a Treatment Involving Soft Tissue Techniques and/or Neural Mobilization Techniques in the Management of Tension-Type Headache. Archives of Physical Medicine and Rehabilitation , Volume 98 , Issue 2 , 211 - 219.e2
52. Venne G. et al. Rectus Capitis Posterior Minor: Histological and Biomechanical Links to the Spinal Dura Mater. Spine 2017 Apr 15;42(8):E466-E473.
53. Hutson M., Ward A. Oxford Textbook of Musculoskeletal Medicine. Oxford University Press. Second Edition 2016. p.286
54. Malo-Urriés, Miguel et al. Immediate Effects of Upper Cervical Translatoric Mobilization on Cervical Mobility and Pressure Pain Threshold in Patients With Cervicogenic Headache: A Randomized Controlled Trial. JMPT, Volume 40, Issue 9, 649 – 658
55. Haas M. et al. Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial. Spine J. 2018 Feb 23. [Epub ahead of print]
56. Malo-Urriés, Miguel et al. Immediate Effects of Upper Cervical Translatoric Mobilization on Cervical Mobility and Pressure Pain Threshold in Patients With Cervicogenic Headache: A Randomized Controlled Trial. Journal of Manipulative & Physiological Therapeutics, Volume 40 , Issue 9 , 649 – 658
57. Lidegaard M et al. Association Between Trapezius Muscle Tenderness and Tension-Type Headache in Female Office Workers: A Cross-sectional Study. JMPT Volume 41, Issue 6, Pages 483–487
58. Moore C, Leaver A, Sibbritt D, Adams J. The management of common recurrent headaches by chiropractors: a descriptive analysis of a nationally representative survey. BMC Neurol. 2018;18(1):171. Published 2018 Oct 17. doi:10.1186/s12883-018-1173-6
59. Olivier B, Pramod A, Maleka D. Trigger Point Sensitivity Is a Differentiating Factor between Cervicogenic and Non-Cervicogenic Headaches: A Cross-Sectional, Descriptive Study. Physiother Can. 2018 Fall;70(4):323-329. doi: 10.3138/ptc.2017-38.