In part one of this post, we looked at differentiating between cervicogenic headaches, migraines and tension-type headaches. To review, there are differences which may help with diagnosis and treatment planning:
- Cervicogenic headaches (CGH) are usually unilateral, whereas migraines or tension-type headaches can sideshift or be bilaterally diffuse.1
- The duration of cervicogenic headaches tends to be shorter, and can be triggered by neck movements or sustained postures.
- Unlike migraines or tension-type headaches, cervicogenic headaches tend not to be associated with phonophobia, photophobia or nausea.
Patients with cervicogenic headaches often present with both head and neck symptoms, and frequently have concurrent TMJ issues (it’s good practice to ask TMJ patients if they have headache issues, and vice versa). There may also be radicular, shoulder or arm pain present.
In a paper by Jull et al. looking to differentiate between cervicogenic headaches and tension-type or migraine headaches, some findings were specific to cervicogenic headaches (and not found in migraine or tension-type headaches):
- Decreased cervical spine range of motion, especially active extension,
- Pain with palpation of OA – C3/C4 joints,
- Poor deep neck flexor coordination and endurance.2
In his 2006 paper, Zito also found a number of characteristics specific to cervicogenic headaches:
- Pain and/or hypomobility on palpation of C1/C2,
- Gross decrease in range of motion throughout the cervical spine, especially flexion/extension,
- Pectoralis minor muscle shortening.3
Weak deep neck flexors and overactive superficial neck flexors, particularly sternocleidmastoid and the scalenes, have been positively associated with cervicogenic headaches (Jull et al. 2005). Normative endurance of the deep neck flexors has been established at >38 seconds, whereas the average endurance for patients with cervicogenic headaches was found to be 24 seconds. Similar to Zito in 2006, Jull in 2007 found the cervicogenic headache group had significantly greater activation of the superficial vs. deep neck flexors.
In Bronfort’s 2004 Cochrane review, he found “both neck exercise (low intensity, endurance training) and spinal manipulation are effective in the short term and the long term”.4 There have been several case reports looking at the efficacy of combining manual therapy (joint manipulation, mobilization) with an exercise program targeting endurance of the deep neck flexors and periscapular stability, all of which showed good outcomes in terms of statistically significant differences on the Neck Disability Index, headache frequency, duration and intensity. Most interesting was the 2002 paper by Jull et al., ‘A Randomised Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache’, which split the patients into four groups:
- Manual Therapy (low and high velocity mobilizations to the cervical spine),
- Exercise (Deep Neck Flexor training, Scapular stability work, Postural re-education, including neutral spine and scapular retraction),
- Combination of Manual Therapy and Exercise,
The Manual Therapy, Exercise and Combination groups all had statistically significant decreases in neck pain, headache frequency and intensity at follow-up at 7 weeks and 12 months, ranging from 50% better to complete resolution. Medication use decreased in all groups (except the control group) and in the combination group medication use decreased by an impressive 93%, underlying the efficacy and importance of physical therapy in the treatment of cervicogenic headaches.
Below, watch a video of Supine Deep Neck Flexor Training on Blood Pressure Cuff from the MedBridge’s Home Exercise Library.
- Hall T, Briffa K , Hopper D; ‘Clinical Evaluation of Cervicogenic Headache: A Clinical Perspective’ J Man Manip Ther. 2008; 16(2): 73–80.
- Jull G, Amiri M, Bullock-Saxton J, Darnell R, Lander C ; ‘Cervical musculoskeletal impairment in frequent intermittent headache. Part 1: Subjects with single headaches’ Cephalgia 2007; 27:793–802
- Zito G, Jull G, Story I. Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache. Man Ther. 2006;11:118–129
- Bronfort G, Nilsson N, Haas M, et al. Non-invasive physical treatments for chronic/recurrent headache. Cochrane Database Syst Rev. 2004;(3)
- Jull G, Trott P, Potter H, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002;27:1835–1843