Managing Cervicogenic Headaches: Assessment and Treatment Tips

Headaches affect almost half of the population. Up to one-fourth of all headaches are referred from the cervical spine and are classified as "cervicogenic" (1,2). Cervicogenic headache can be as debilitating as migraine headaches, and a loss of cervical spine function compounds the problem. 

Chiropractors generally enjoy treating cervicogenic headache patients. Our primary tool of cervical SMT is a highly effective treatment, as demonstrated by multiple studies. (3-16) However, the successful long-term resolution of CGH patients often requires a multifaceted approach, including more than isolated SMT. 

This week’s blog provides three invaluable tools and a video tutorial to help you assess and manage this problem more quickly and thoroughly.

The Chief Complaint

Cervicogenic headache (CGH) patients present with neck tenderness and stiffness. By definition, CGH is unilateral without side shift, but in some cases, the condition may present bilaterally.  Moderate to severe pain may begin in the cervical spine and progressively affect the occipital, temporal, frontal, or supraorbital regions. In some instances, pain may refer to the ipsilateral arm. (17) 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. (18)

The Solutions

Most manual therapist agrees that manipulation is an essential component of managing CGH. However, as mentioned earlier, the successful long-term resolution of CGH patients often requires a multifaceted approach that includes more than isolated SMT. So here are three ancillary tools to help you assess and manage this problem more quickly and completely.

1. Assessment: Deep Neck Flexors

Upper cervical joint dysfunction is a key finding in CGH patients. In many cases, this dysfunction is secondary to chronic muscular imbalance and sustained poor posture. Loss of strength in the deep neck flexors and over-activation of the SCM and upper trapezius is a common finding in CGH patients. (19,20) Janda recommends screening for neck flexor weakness with the Neck Flexion Test. (19)

In this test, the supine patient is asked to lift their head several inches off of the table to look at their toes. The clinician observes a "normal" movement pattern - initiated with a chin tuck and smooth reversal of the cervical lordosis. An "abnormal" screen would result in the chin moving forward into protraction from overcompensation by the SCM. The normal firing pattern for this movement is longus capitus, longus colli, SCM, and finally, anterior scalenes. Abnormal movement patterns suggest weakness of the deep neck flexors.

The Deep neck flexor endurance test is another valuable tool to screen for weakness. (21,22)

From a supine hook-lying position, the patient performs chin retraction and then lifts their head an inch off the table. The clinician places their flat hand on the table below the patient’s occiput. If the patient’s head begins to lower or their anterior neck skin folds separate, they are reminded to “tuck your chin and hold your head up.” The test is timed until the patient’s head touches the clinician’s hand for more than one second. The average endurance for men is about 40 seconds and 30 for women. Those with neck pain average closer to 20 seconds. Low times suggest neck flexor weakness with a predisposition to over-utilize the SCM, platysma, and hyoid, resulting in a forward head posture and neck pain. 

2. Treatment: Nerve Flossing

The greater occipital nerve is frequently implicated in CGH, particularly in traumatic whiplash cases. Recent research has shown that “The obliquus capitis inferior remains relatively immobile during traumatic events, like whiplash injuries, placing strain as a tethering point on the greater occipital nerve.” (23)  This trauma may lead to irritation, inflammation, and loss of neuroplasticity, i.e., adhesions.

 In patients with cervicogenic tension-type headaches, the combination of neural mobilization and soft tissue techniques induces a significant improvement in pain and function. (24) Here’s how that’s performed:

Adhesions along the course of the nerve may develop secondary to any traumatic or inflammatory process. "Nerve flossing" may help release adhesions and restore normal neurodynamics. Begin with the patient lying supine, headpiece slightly extended. Have the patient bring their fingertips to their clavicles. Firmly grasp the patient's head and move their neck into full flexion while maintaining a chin tuck. Ask the patient to fully extend their arms, wrists, and fingers while you simultaneously move their head and neck into full extension. Return to the start position and slowly repeat ten flossing cycles. Stop if there is a reproduction of pain or neurologic symptoms. To improve available ROM, this maneuver may be preceded by contract-relax stretching of the suboccipitals.

3. ADL Advice: Workstation

Routine daily activities involving workstations and cell phones can be potent postural trainers to guarantee a flexor-dominated (forward/ head, forward/shoulder) posture. While manipulation is an effective tool for resolving the symptoms of this postural fault, it’s no match for the cause. Thirty seconds of HVLA three times per week rarely wins the long-term war against eight-plus hours of ongoing postural stress. Lasting improvement necessitates a plan to minimize cumulative trauma.

In addition to equipping our patients with corrective exercises, we must seek to eliminate the habits, hobbies, activities, and postures that perpetuate postural imbalance; and workstations are at the top of that list. Make sure your patients understand the essentials of an ergonomically friendly workstation:

Workstation Ergonomics

• Monitors should be visible without leaning or straining, and the top line of the type should be 15 degrees below eye level.

• Use audio equipment that keeps you from bending your neck (i.e., Bluetooth, speakerphones, headsets).

• Keep your shoulders relaxed, and elbows bent to 90 degrees.

• Wrists should not be bent while at the keyboard, and forearms and wrists should not be leaning on a hard edge.

• Keep frequently used objects, like your telephone, close to your body to prevent excessive reaching.

• Take a 10-second break every 20 minutes. Micro activities include walking, stretching, or moving your head in a "plus sign" fashion.

• Periodically, perform the "Brugger relief position" -Position your body at a chair's edge, feet pointed outward. Weight should be on your legs, and your abdomen should be relaxed. Tilt your pelvis forward, lift your sternum, arch your back, drop your arms, and roll out your palms while squeezing your shoulders together. Take a few deep, cleansing breaths.

We’ve broken down the assessment, management, and rehab for cervicogenic headaches. Now, it’s time to ensure that your patients are equipped with the education they need to stay compliant and active in their recovery.

That’s precisely what ChiroUp’s condition-specific reports are designed to do.

You can create customizable reports like the attached for 100+ different conditions in seconds. Have you built a report yet? Visit our Plans & Pricing page to see how you can get started for free.

• References

  Stovner LJ, Hagen K, Jensen R, Katsarava Z, Lipton RB, Scher AI, Steiner TJ, Zwart JA. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. 2007 Mar;27(3):193-210. Link

  Racicki S, Gerwin S, DiClaudio S, Reinmann S, Donaldson M. Conservative physical therapy management for the treatment of cervicogenic headache: a systematic review. Journal of manual & manipulative therapy. 2013 May 1;21(2):113-24. Link

  Nilsson N. A randomized controlled trial of the effect of spinal manipulation in the treatment of cervicogenic headache. Journal of manipulative and physiological therapeutics. 1995 Sep;18(7):435-40. Link

  Schoensee SK, Jensen G, Nicholson G, Gossman M, Katholi C. The effect of mobilization on cervical headaches. Journal of Orthopaedic & Sports Physical Therapy. 1995 Apr;21(4):184-96. Link

  Nilsson N, Christensen HW, Hartvigsen J. The effect of spinal manipulation in the treatment of cervicogenic headache. Journal of manipulative and physiological therapeutics. 1997 Jun;20(5):326-30. Link

  Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002 Sep 1;27(17):1835-43. Link

  McCrory, Penzlen, Hasselblad, Gray. Duke Evidence Report (2001) 

  Antonia GC. 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. 2014 Mar 1;13(1):4-13. Link

  Dunning JR, Butts R, Mourad F, Young I, Fernandez-de-las Peñas C, Hagins M, Stanislawski T, Donley J, Buck D, Hooks TR, Cleland JA. Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: a multi-center randomized clinical trial. BMC musculoskeletal disorders. 2016 Dec;17(1):64.

  Link

  Garcia JD, Arnold S, Tetley K, Voight K, Frank RA. Mobilization and manipulation of the cervical spine in patients with cervicogenic headache: any scientific evidence?. Frontiers in neurology. 2016 Mar 21;7:40. Link

  Varatharajan S, Ferguson B, Chrobak K, Shergill Y, Cote P, Wong JJ, Yu H, Shearer HM, Southerst D, Sutton D, Randhawa K. 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. European spine journal. 2016 Jul 1;25(7):1971-99. Link

  Malo-Urriés M, Tricás-Moreno JM, Estébanez-de-Miguel E, Hidalgo-García C, Carrasco-Uribarren A, Cabanillas-Barea S. 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 and physiological therapeutics. 2017 Nov 1;40(9):649-58. Link

  Haas M, Bronfort G, Evans R, Schulz C, Vavrek D, Takaki L, Hanson L, Leininger B, Neradilek MB. Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial. The Spine Journal. 2018 Oct 1;18(10):1741-54. Link

  Malo-Urriés M, Tricás-Moreno JM, Estébanez-de-Miguel E, Hidalgo-García C, Carrasco-Uribarren A, Cabanillas-Barea S. 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 and physiological therapeutics. 2017 Nov 1;40(9):649-58. Link

  Koes BW, Bouter LM, Van Mameren H, Essers AH, Verstegen GM, Hofhuizen DM, Houben JP, Knipschild PG. Randomised clinical trial of manipulative therapy and physiotherapy for persistent back and neck complaints: results of one year follow up. Bmj. 1992 Mar 7;304(6827):601-5. Link

  Boline PD, Kassak K, Bronfort G, Nelson C, Anderson AV. Spinal manipulation vs. amitriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial. Journal of Manipulative and Physiological Therapeutics. 1995;18(3):148-54. Link

  Antonaci F, Sjaastad O. Cervicogenic headache: a real headache. Current neurology and neuroscience reports. 2011 Apr 1;11(2):149-55. Link

  Biondi DM. Cervicogenic headache: a review of diagnostic and treatment strategies. The Journal of the American Osteopathic Association. 2005 Apr 1;105(4_suppl):16S-22S. Link

  Page P., Frank C.C., Lardner R., Assessment and treatment of muscle imbalance: The Janda Approach 2010, Champaign, IL: Human Kinetics.

  Falla DL, Jull GA, Hodges PW. Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test. Spine. 2004 Oct 1;29(19):2108-14. Link

  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 1;3(2):105-10. Link

  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 1;85(12):1349-55. Link

  Scherer SS, Schiraldi L, Sapino G, Cambiaso-Daniel J, Gualdi A, Peled ZM, Hagan R, Pietramaggiori G. The Greater Occipital Nerve and Obliquus Capitis Inferior Muscle: Anatomical Interactions and Implications for Occipital Pain Syndromes. Plastic and reconstructive surgery. 2019 Sep 1;144(3):730-6. Link

  Ferragut-Garcías A, Plaza-Manzano G, Rodríguez-Blanco C, Velasco-Roldán O, Pecos-Martín D, Oliva-Pascual-Vaca J, Llabrés-Bennasar B, Oliva-Pascual-Vaca Á. Effectiveness of a treatment involving soft tissue techniques and/or neural mobilization techniques in the management of tension-type headache: a randomized controlled trial. Archives of physical medicine and rehabilitation. 2017 Feb 1;98(2):211-9. Link