Headache of Cervical Origin Anita Gross McMaster University Part 1 - - PDF document

11-03-24 1

Headache of Cervical Origin

Anita Gross McMaster University

HEADACHE CLASSIFICATION

Part 1

Headache Prevalence

Mechanical Headache

n Prevalence (44%) q Tension (38%) q Cervicogenic (2.5 - 4.1%)

Non-mechanical HA

q Migraine 10% q Chronic daily HA 3%

11-03-24 2 Headache “Red Flags”

n Sudden onset of a new severe H/A n Worsening pattern of pre-existing H/A in the

absence of obvious factors

n H/A associated with

q fever, neck stiffness, skin rash, q Hx of cancer HIV or other systemic illness q focal neurological signs other than aura

n Moderate to severe H/A triggered by cough,

exertion or bearing down

n New onset of a H/A during or

following pregnancy

Cervicogenic Headache

• A. Pain, referred from a source in the neck and perceived in one or

more regions of the head and/or face, fulfilling criteria C and D

• B. Clinical, laboratory and/or imaging evidence of a disorder or

lesion within the cervical spine or soft tissues of the neck known to be, or generally accepted as, a valid cause of headache

• C. Evidence that the pain can be attributed to the neck disorder or

lesion based on at least one of the following:

• 1. demonstration of clinical signs that implicate a source of pain

in the neck

• 2. abolition of headache following diagnostic blockade of a

cervical structure or its nerve supply using placebo- or other adequate controls

• D. Pain resolves within 3 months after successful treatment of the

causative disorder or lesion

• International Headache Society - 2004 -

Cervicogenic Headache

n Head pain due to mechanical strain of the upper

musculoskeletal cervical complex

n Major criteria q Symptoms and signs of neck involvement q Precipitation of comparable head pain by: n Neck movement n Awkward postures n External pressure over upper cervical spine on

symptomatic side

q Restriction of cervical movement q Ipsilateral neck, shoulder or arm pain.

• International Headache Society – 1988, p27 -

Sjaastad (1998)

11-03-24 3

Cervicogenic Headache

n Moderate criteria: q Confirmatory evidence by diagnostic blocks q Unilaterality of head pain (no side shift) (NB) q Head pain characteristics of: n Moderate to severe intensity n Non-throbbing, non-lancing pain n Episodes of varying duration n Fluctuating continuous pain.

Cervicogenic Headache

n Lesser criteria:

q Only marginal effect of idomethician, ergotomine and

sumatriptan

q 3:1 ratio females q Frequent past history of head trauma (50%) q Photophobia, phonophobia q Dizziness, vertigo, blurred vision q Difficulty swallowing (sign of longus coli deficiency) q Ipsilateral perioccular oedema.

Diagnostic Validity of criteria

n Cervicogenic Headache could be

differentiated from Migraine with:

q 100% sensitivity and specificity if 7 of the CGHA

criteria were present

n Cervicogenic Headache could be

differentiated from Tension with

q 100% sensitivity and 86.2% specificity if 7 of the

CGHA criteria were present.

Vincent et al 1999

11-03-24 4 Migraine Headache Classification

n Head pain due to intracranial neuro-vascular

dysfunction

n Characteristics

q Headache attacks lasting 4 - 72 hours q Unilateral but may “side shift” (NB) q Pulsating quality q Moderate to severe intensity (limits ADL) q Nausea & vomiting q Photophobia, phonophobia q May or may not be preceded by “aura”.

• International Headache Society – 1988, p26 -

Tension Headache Classification

n Head pain due to mechanical strain of the

upper cervical/cranial muscle complex

n Characteristics

q Headache lasting 30 min – 7 days q Pressing, tightening, non pulsating quality q Bilateral (NB) q Mild to moderate intensity (no ADL limit) q No or minor nausea, vomiting q Photophobia , phonophobia.

• International Headache Society – 1988, p26 -

Subjective Profile of Cervicogenic HA

n Area of pain n Quality of pain n Associated symptoms n Neurological signs n Temporal Pattern n Time and mode of onset n Precipitating & relieving

factors

n History of onset n Family history

11-03-24 5 Outcomes

Subjective Evaluation:

n HA severity n HA relief (time) n HA duration n HA frequency (#/month) n Drug consumption n Change in HA days per 4w n Change in mean HA severity in

4w

n Mean 4w HA relief score n Change in HA duration per day n Change in # of standard doses

• symptomatic drugs

n Headache Disability Index

(0 to 100)

Objective Evaluation:

n Neck Flexion-rotation test n IHS-classification

Headache Disability Index

n Reliability

q Internal consistency – r=0.89 Cronbach alpha

between subscale and total HDI

q Test-retest reliability n r=0.76 for functional score n r=0.83 for emotional score

n Validity

q Construct validity – HDI increased with HA

severity and frequency; HA classification or gender did not effect the score

Jarobson et al 1994 – Neruology 1994:44;837-842

The Flexion-Rotation Test and Active cervical mobility a Comparative Measurement Study in Cervicogenic Headache

Hall & Robinson 2004 – Manual Therapy 2004:9(4)

n Manual examination: q 24 subjects to be C1-2 dominant segment q 4 to be C2-3 dominant segment n Active Rotation ROM in neutral: q No significant difference symptomatic vs asymptomatic p>0.05 n Passive Rotation in flexion: q Difference of 17.1 degrees (towards painful side)

in symptomatic group p< 0.001

n Inverse relationship in the 24 C1-2 subjects between

rotation in flexion and H/A severity (Pearson correlation of r=-0.8. p<0.001)

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Headache of Cervical Origin

Anita Gross McMaster University

SPECIFIC ISOMETRIC MUSCLE TESTING

Part 2

Isometric Resisted Test – Flex/Ext

Flexion Extension

Rectus Capitus Anterior Minor Rectus Capitus Anterior Major RCP Min RCP Mj Superior Oblique Inferior Oblique

11-03-24 7 Isometric Resisted Test – SF/Rot

Left Rotation Right Side Flexion

CGH TREATMENT

Part 3

Management of Mechanical Headache

n I Pain control

q Manual therapy q Postural control

n II Recovery of mobility

q Self treatment - exercise q Manual therapy

n III Dynamic muscular control

q Longus coli / capitus q Lower fibers trapezius .

11-03-24 8 Manual Therapy

n Mobilizations n Mobilizations with

movement

n Mobilization using

Neuromuscular techniques (NMT)

n Manipulation n Soft tissue techniques n Manual traction

Therapeutic Exercise Craniocervical Flexion

Start with the pressure biofeedback inflated to 20 mm Hg Make sure your chin and forehead line up Nod your head keeping the big neck muscles soft and bringing the reading up to 22 mm Hg. Work up to 10 X 10 second

• holds. Then progress to

24,26,28 mm Hg.

Sets___ Reps___

11-03-24 9 Head Lift

Start with your head in neutral (chin and forehead lined up), do a chin nod and lift your head while maintaining your chin tucked. Hold for a count of 5 – 10 seconds and return smoothly with your chin still tucked.

Sets___ Reps___

Resisted Neck CC Flexion & Oblique Flexion

‘Set’ cervical spine, TA and scapulae then

• 4a. nod head forward
• 4b. nod head forward at

slight oblique angle

Sets___ Reps___

Resisted Neck Static dynamic strengthening

‘Set’ cervical spine, TA and scapulae then

• a. nod head
• b. step back maintaining

the head nod

Sets___ Reps___

11-03-24 10 Active Range - Neck

Start with your head in neutral then

• a. extend your head
• b. bend your head
• c. tilt your head
• d. turn your head

Sets___ Reps___

a. b. c. d.

Evidence of Benefit

n Moderate GRADE evidence

supports the use of C1-C2 self-SNAG exercise for acute cervicogenic headache at short and long term follow-up

Study or Subgroup 3.2.2 Chronic Cervicogenic H/A: Acute 4 w of treatment Hall 2007 Mean 31 SD 9 Total 16 Mean 51 SD 15 Total 16 IV, Random, 95% CI

• 1.58 [-2.38, -0.77]

Treatment Control

• Std. Mean Difference
• Std. Mean Difference

IV, Random, 95% CI

• 10
• 5

5 10 Favours experimental Favours control

Active Range - Shoulders

‘Set’ your cervical spine, TA & scapula

• a. clasp your hands behind your

back and squeeze your scapulae together

• b. hold your arms out in front of

you and reach forward feeling a stretch between your scapulae.

• c. reach your arms over head.

d & e. Lean into a wall corner to feel a stretch in the front of your chest – elbows first at shoulder then at eye level Hold for 20 seconds.

Sets___ Reps___

a. b. c. d. e.

11-03-24 11 Scapular Setting

• a. Single Arm
• b. Both Arms

Sets___ Reps___ Sets___ Reps___

‘Set’ your cervical spine, TA and scapulae, then extend your arm backward

Evidence of Benefit

n Low GRADE evidence

suggests eye-neck coordination exercises benefit chronic neck pain and function in the short term

Study or Subgroup 11.1.1 Chronic Neck Pain:<11 w of treatment Revel 1994 Mean

• 21.8

SD 25.2 Total 30 Mean

• 4.3

SD 19.6 Total 30 IV, Random, 95% CI

• 0.77 [-1.29, -0.24]

Treatment Control

• Std. Mean Difference
• Std. Mean Difference

IV, Random, 95% CI

• 10
• 5

5 10 Favours treatment Favours control

Education Advice Medicine

X Pamphlet

√ Video in ER

X Rest ? Pillow X Collar

• corticosteriod
• methelprednisolone
• analgesic ?
• antiinflammatory ?
• muscle relaxant ?

√ Activate ? Medication

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Physical Modalities

√ Laser Therapy (OA) √ Acupuncture ? PEMF ? TENS √ Intermittent Traction

Patient Wishes, Circumstance