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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 every manual therapist agrees that manipulation is an essential component for 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)

Neck Flexion test

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 for 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)

Deep neck flexor endurance test

From a supine hook-lying position, the patient performs chin retraction 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 headache, the combination of neural mobilization and soft tissue techniques induces significant improvement of pain and function. (24) Here’s how that’s performed:

Suboccipital Nerve Floss

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 reproduction of pain or neurologic symptoms. To improve available ROM, this maneuver may be preceded 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 symptom 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 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. 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 & rehab for cervicogenic headache. Now it’s time to make sure 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.  

Check out a sample of ChiroUp’s Cervicogenic Headache condition report in the link attached.

You can create customizable reports like the one attached for 99 different conditions in a matter of seconds. Have you built a report yet? Visit our Plans & Pricing page to see how you can get started for free.

A must-have for any evidence-based chiropractor. Being able to give my patients a write up of their condition and provide them with videos/written instructions of home exercises is a game-changer. Every treatment recommendation and condition report is supported through good, peer-reviewed RCT and Systematic Reviews, not anecdotal case reports or pilot studies. ChiroUp is a must for any clinic that values patient education.”

– ChiroUp Subscriber

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  2. 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
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  1. 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
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About the Author

Dr. Tim Bertelsman

Dr. Tim Bertelsman


Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as past president of the executive board.

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