Cervicogenic headaches

Question 1

Types of HAs

Answer 1

• Sinus
• Migraine
• Tension
• Cluster
• Cervicogenic

Question 2

Sinus HA

Answer 2

Pain is usually behind forehead and or cheekbones

Question 3

Migraine HA

Answer 3

• 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

Question 4

Tension HAs

Answer 4

• Bilateral (Frontal and occipital region; can go into upper trap)
• Triggered by emotional stress
• Shorter lasting (30’ up to several days)

Question 5

Cluster HAs

Answer 5

• 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.

Question 6

Cervicogenic HA Classification

Answer 6

• 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

Question 7

____ Ratio of Femal to Male ratio for Cervicogenic HAs

Answer 7

4:1

Question 8

____ of subjects with (all types of) headaches have had previous cervical/thoracic pain

Answer 8

72-100%

Question 9

Medical Screening to rule out what?

Answer 9

Rule out:
* Fracture
* Ligamentous Instability
* Cervical Artery Insufficency (Refers similar to facets)

Question 10

Cervicogenic HAs - Subjective

Answer 10

• 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

Question 11

Cervicogenic HAs - Objective

Answer 11

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)

Question 12

People with cervicogenic heads most often have dysfunction with which spinal levels?

Answer 12

• Levels Occiput (C0) - C4
• Highest: Occiput - C1 and C1-C2 greatest dysfunction

Question 13

People with cervicogenic HAs will have the greatest limitations in motion where?

Answer 13

• Rotation!
• May also have some limitations with extension as well

Question 14

Assessment of C1-C2 mobility: Cervical Flexion-Rotation Test

Answer 14

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)

Question 15

What are the most aggravated muscles/referral points for Cervicogenic HAs?

Answer 15

• Suboccipitals: near ear
• Upper Trapezius: Ram like
• SCM: C around eye/eyebrow or circular on forehead

Question 16

Cervicogenic Irritability

Answer 16

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

Question 17

Cervicogenic HA interventions

Answer 17

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

Question 18

Patient Education - Cervicogenic HAs

Answer 18

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

Question 19

Patients should expect what improvements with interventions for cervicogenic HAs?

Answer 19

• Decrease in frequency, intensity and duration

Question 20

Manual Therapy and Motor coordination

Answer 20

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

Question 21

Self Mobilizations SNAGS - RCT

Answer 21

• 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

Question 22

____ decreases headaches in the long term when provided as the sole line of treatment

Answer 22

Self SNAGS