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Headache - Cervicogenic

(Also known as Headache, Cervical Headache, Neck Related Headache, Referred Pain from the Neck)
What is cervicogenic headache?
Cervicogenic headache is simply another name for a headache which originates from the neck and is one of the most common types of headache. It is important to note, however, that there are many types of headache of which cervicogenic is just one. Another common type is vascular (this includes migraines).
The spine (neck) comprises of many bones known as vertebrae. Each vertebra connects with the vertebra above and below via two types of joints: the facet joints on either side of the spine and the disc centrally.
During certain neck movements or sustained postures, stretching or compression force is placed on the joints, muscles, ligaments and nerves of the neck. This may cause damage to these structures if the forces are beyond what the tissues can withstand and can occur traumatically due to a specific incident or gradually over time. When this occurs pain may be referred to the head causing a headache. This condition is known as cervicogenic headache.
Cervicogenic headache typically occurs due to damage to one or more joints, muscles, ligaments or nerves of the top three vertebra of the neck. The pain associated with this condition is an example of referred pain (i.e. pain arising from a distant source – in this case the neck). This occurs because the nerves that supply the upper neck also supply the skin overlying the head, forehead, jaw line, back of the eyes and ears. As a result, pain arising from structures of the upper neck may refer pain to any of these regions causing a cervicogenic headache.
Although cervicogenic headache can occur at any age, it is commonly seen in patients between the ages of 20 and 60.

Causes of cervicogenic headache

Cervicogenic headache typically occurs due to activities placing excessive stress on the upper joints of the neck.  This may occur traumatically due to a specific incident (e.g. whiplash or heavy lifting) or more commonly, due to repetitive or prolonged activities such as prolonged slouching, poor posture, excessive bending or twisting of the neck or working at a computer.

Signs and symptoms of cervicogenic headache
Patients with this condition usually experience a gradual onset of neck pain and headache during the causative activity. However, it is also common for patients to experience pain and stiffness after the provocative activity, particularly upon waking the next morning. The pain associated with cervicogenic headache can sometimes last days, weeks or even months.
Cervicogenic headache usually presents as a constant dull ache, normally situated at the back of the head, although sometimes behind the eyes or temple region, and less commonly, on top of the head, forehead or ear region. Pain is usually felt on one side, but occasionally, both sides of the head and face may be affected.
Patients with this condition often experience neck pain, stiffness and difficulty turning their neck, in association with their head symptoms. Pain, pins and needles or numbness may also be felt in the upper back, shoulders, arms or hands, although this is less common. Occasionally patients may experience other symptoms, including: light-headedness, dizziness, nausea, tinnitus, decreased concentration, an inability to function normally, and depression.
Patients with cervicogenic headache typically experience an increase in symptoms during certain movements of the neck or sustained positions (e.g. driving or sitting at a computer in poor posture). Patients may also experience tenderness on firm palpation of the upper part of the neck just below the base of the skull along with muscle tightness in this region.

Diagnosis of cervicogenic headache

A thorough subjective and objective examination from a physician is usually sufficient to diagnose cervicogenic headache. Occasionally, investigations such as an X-ray, MRI or CT scan may be required to assist diagnosis.

Prognosis for cervicogenic headache
Most patients with this condition heal quickly and have a full recovery with appropriate physical therapy treatment. Recovery time varies from patient to patient depending on compliance with treatment and severity of injury. With ideal treatment, patients with minor cases of cervicogenic headache may be pain free in as little as a couple of days, although sometimes it may take 2 – 3 weeks. In severe or chronic cases a full recovery may take weeks to months.

Contributing factors to the development of cervicogenic headache

There are several factors which can predispose patients to developing cervicogenic headache. These need to be assessed and corrected where possible with direction from a physical therapist. Some of these factors include:
  • poor posture
  • neck and upper back stiffness
  • muscle imbalances
  • muscle weakness
  • muscle tightness
  • previous neck trauma (e.g. whiplash)
  • inappropriate desk setup
  • inappropriate pillow or sleeping postures
  • a sedentary lifestyle
  • a lifestyle comprising excessive slouching, bending forwards or shoulders forwards activities.
  • stress

Treatment for cervicogenic headache
Most cases of cervicogenic headache heal well with appropriate physical therapy. The success rate of treatment is largely dictated by patient compliance. One of the key components of treatment is that the patient rests sufficiently from any activity that increases their pain or ache until they are symptom free (a postural support or postural taping may be required). Activities which place large amounts of stress through the upper neck should also be minimized, these include: sitting, standing or lying in poor posture (slouching), head looking down activities, shoulders forward activities and lifting. Resting from aggravating activities allows the body to begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.
Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to lead to the condition becoming chronic. Immediate treatment for patients with cervicogenic headache is essential to ensure a speedy recovery. Once the condition is chronic, healing slows significantly resulting in markedly increased recovery times.
Patients with cervicogenic headache should perform early movement and postural exercises (often "chin tucks") to prevent stiffness from developing and to ensure the neck is functioning correctly. The treating physical therapist can advise which exercises are appropriate and when they should be commenced.
Patients with this condition should also pay particular attention to maintaining good posture as much as possible to minimize stress on the neck. This is particularly important when sitting or driving. Optimal sitting posture can be obtained by sitting tall on an appropriate chair, with your bottom in the back of the chair and a lumbar support (or a pillow or rolled up towel) in the small of your back. Your shoulders should be back and your chin should be tucked in slightly.

Physical therapy for cervicogenic headache
Physical therapy treatment for patients with this condition is vital to hasten the healing process, ensure an optimal outcome and decrease the likelihood of injury recurrence. Treatment may comprise:
  • joint mobilization
  • joint manipulation
  • soft tissue massage
  • dry needling
  • electrotherapy (e.g. ultrasound)
  • postural taping
  • postural bracing
  • the use of a lumbar roll for sitting
  • education
  • anti-inflammatory advice
  • activity modification advice
  • the use of an appropriate pillow for sleeping
  • ergonomic advice
  • exercises to improve flexibility, strength (particularly the deep cervical flexors) and posture
  • clinical Pilates
  • neural stretches

Other intervention for cervicogenic headache
Despite appropriate physical therapy management, a small percentage of patients with this condition fail to improve and may require other intervention. This may include pharmaceutical intervention, corticosteroid injection, investigations such as an X-ray, CT scan or MRI, or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the condition.