management of the cervicogenic patient · 3 scope of the problem headaches affect 66% of the...

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Management of the

Patient with Cervicogenic

Headaches

By: Julie McGee, PT, DTP, CEAS

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Welcome Introduction

Incidence of Cervicogenic Headaches

Patient presentation

Differential Diagnosis

What does the Research Say?

Patient Evaluation and Treatment

Conclusion

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Introduction Have worked in a variety of settings: Acute Rehab,

Worker’s Comp, Outpatient Orthopedics, Home Health.

B.S. from University of Massachusetts, Amherst.

MSPT & DPT from UCSF/SFSU Graduate program in

physical Therapy.

Performed ergonomic evaluations.

Worked at an onsite health clinic for a large tech

company.

Why Cervicogenic

Headaches?

Clinical work

Personal experience with cervicogenic headaches

Treating patients with head pain can be scary

Treating patients with had pain can be confusing

Neck pain

Shoulder pain

Objectives To understand the impact that cervicogenic headaches

(CGHA’s) have: number of population affected

impacts on quality of life

To be able to identify patients suffering from CGHA

To be able to provide effective treatment to those with

CGHA

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Scope of the problem Headaches affect 66% of the world’s population (NIH)

2.5%-4.1% are due to cervicogenic causes

20% of headache patients being seen in pain clinics had a

headache from cervicogenic causes. (Haldeman et. al.)

Those with cervicogenic headaches (CGHA) report a lower

quality of life compared to controls. The quality of life is

similar to those with migraines and tension type headaches.

Those with CGHA had the greatest loss of physical function

when compared to those suffering from other types of

headaches.

What is a cervicogenic

headache?

“Cervicogenic Headache is referred pain…perceived in the head from a source in the neck.” (American MigraneFoundation)


headache? “The trigeminal nucleus is a region of the upper cervical

spinal cord where sensory nerve fibers in the descending tract of the trigeminal nerve (trigeminal nucleus caudalis) are believed to interact with sensory nerve fibers from the upper cervical roots. This functional convergence of upper cervical and trigeminal sensory pathways allows the bidirectional referral of painful sensations between the neck and trigeminal sensory receptive fields of the face and head. A functional convergence of sensorimotor fibers in the spinal accessory nerve (CN XI) and upper cervical nerve roots ultimately converge with the descending tract of the trigeminal nerve and might also be responsible for the referral of cervical pain to the head.” (Biondi)

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Cervical Plexus


headache?

Often times upper cervical spine is implicated:

Head and neck extensors

Infrahyoid muscles (C1-3)

Rectus Capitus anterior and lateral (C1, C2)

Longus Capitus (C1-3 (C4))

Longus Colli (C2-6 (C7))

Levator Scapulae (C3-5)

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Dermatomes

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Typical Presentation:

Headache pattern

Often: Pain pattern that is supraorbital, or going over the top of the head

Typical Presentation:

Headache pattern

Typical Presentation Women affected more than men

Report a deep ache that can pulse or throb

May have crepitus

Limited cervical ROM, especially into flexion and extension

Posture: Forward head posture, or upper cervical spine extension

Dizziness that is instantaneous, not long lasting, not related to movement or head position

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Dizziness and CGHA CGHA

Quick onset and resolution

Not related to head or neck position

Benign paroxysmal positional

vertigo (BPPV):

dizziness lasting 30 seconds-

1 minute

related to changes in head position

Neurogenic dizziness:

lasting >1 minute

not related to changes in head position

Typical Presentation: Posture

Typical Presentation: Aggravating and Easing Factors

Aggravating factors:

Prolonged neck postures (i.e. driving, computer use)

Neck movements

Pressure on the back of the head

Easing factors:

Lying down

Change in neck position

Ice or analgesics

Sometimes can’t identify aggs and eases

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Red Flags

Sudden onset of a new, severe headache

Worsening of a pre-existing headache without obvious predisposing factors

Headache associated with fever, neck stiffness

Skin rash, especially with a history of cancer,

HIV, or other systemic illness

Red Flags continued Headache associated with focal neurological signs

Dysarthria, vertigo, tinnitus, double vision, other visual

disturbances, ataxia, personality changes, decreased level of consciousness, distal parathesias, and weakness

Moderate or severe headache triggered by coughing,

or bearing down

When in doubt: Go with your gut!

Differential Diagnosis Cranial tumors/space occupying lesions

Meningitis

Sub-arachnoid hemorrage

Migraine/vascular headache

Carotid or Vertebral artery dissection

Trigeminal neuralgia

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continued

May ask about onset of HA, fever, past neurological dx, history of cancer, history

of trauma


continued

Other non-cevicogenic causes of HA

Migraines: Those with CGHA often have more limitations

in cervical flexion and extension, as well as noticeable differences in cervical muscles tightness as compared to

those with Migraines.

(Clinical tests CGHA Zito, 2006)

Patient gets referred to your

clinic

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Subjective Questionnaires:

Neck Disability Index (NDI) (Vernon, 1991)

Headache Disability Inventory (Jacobsen, 1994)

Ask about onset

when/ how long going on

what

24 hour pattern

Subjective Aggravating factors: if patient is not able to identify

aggs, may ask about specific movements

Eases: If patient is not able to identify, may ask about specifics

Ask about medical history: History of cancer, history of

stroke/TBI, Car accidents, migraines, neck injuries

Can ask about stress levels and stress management

Ask about occupation and leisure activities

Examination Posture

ROM:

Cervical spine

upper and lower cervical ROM

may look at prolonged hold

Thoracic spine

Shoulder flexion and abduction ROM

Observe neck position

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Examination: Special Tests Upper cervical ligament stability

Sharp-Purser test: Assess the integrity of the cruciform or

transverse ligament of C1-2

Tectorial membrane test: Assess integrity of tectorial

membrane

Alar ligament stress test: Assess the integrity of the alar

ligament

Upper cervical ligament

stability When to perform:

history of trauma

rheumatoid arthritis

ankylosing spondylitis

focal neuro signs

before manipulation/ high grade mobilization

Positive findings:

increased laxity

focal neuro signs

Sharp-Purser Test

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Tectorial Membrane Test

Alar ligament stress test

Examination: Special Tests Vertebro-Basilar Insufficiency (VBI) / Cervical Arterial

Dysfunction (CAD)

Hold endrange AROM extension, right rotation and left rotation each for 10 seconds with 10 seconds rest in between positions

Monitor for dizziness, diploplia, dysarthria, nausea, level of alertness, parasthesias

Patient supine with head off of mat: hold PROM extension, right rotation and left rotation each for 10 seconds with 10 seconds rest in between positions

Monitor for dizziness, diploplia, dysarthria, nausea, level of alertness, parasthesias

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VBI/ CAD Testing: PROM

extension

VBI/ CAD Testing: AROM

rotation

VBI/ CAD Testing: AROM

extension and rotation

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extension


rotation


extension and rotation

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CAD/ VBI testing

When to perform:

before manipulation/ high grade mobilization

focal neuro signs

Positive findings:

focal neuro signs

Refer back to MD

Examination

Manual Examination:

Low evidence, but can be helpful in diagnosis

(Howard, 2015)

Cervical-Flexion rotation test

(Hall, 2008)

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TreatmentWhat does the research suggest?

Raciki et.al., 2013 Systematic review looking at conservative physical therapy

management of CGHA.

Searched CINAHL, ProQuest, PubMed, MEDLINE and SportDiscus

Inclusion criteria: RCT

Dx of CGHA using International Headache Society Classification

At least one:

baseline measurement

outcomes measure

an assessment of a conservative technique

Raciki et.al., 2013 Search yielded 6 RCT’s

Interventions:

Therapist-driven cervical manipulation and mobilization

self applied cervical mobilization

cervico-scapular strengthening

therapist driven thoracic manipulation

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Raciki et.al., 2013 5 of the 6 RCT’s suggested a reduction in pain and

disability, and improved function.

Conclusion: Mix of manual therapy ( manipulation,

STM) and exercise can be effective in treating patients with CGHA

Malo-Urries et. al., 2017 Purpose: evaluate immediate effects of upper cervical

translatoric spinal mobilization on cervical mobility and

pressure pain threshold

82 Volunteers randomly divided into treatment and

control groups

Treatment group received mobilization

Control group rested in the same position

No treatment

Malo-Urries et. al., 2017 Outcomes measured: Cervical mobility, pressure pain

thresholds, current headache intensity (VAS)

Treatment group showed significant increases in

cervical mobility and significant decrease in headache intensity

No significant difference in pressure pain thresholds

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Bodes-Pardo et. al., 2013 Pilot study

Measured the effects of manual therapy on active

trigger points on the sternocleidomastoid in the

treatment of CGHA

20 patients:

Treatment: manual pressure to trigger points and

stretching.

Control: longitudinal stroking of trigger points and

stretching

Bodes-Pardo et. al., 2013 Outcomes: headache intensity (VAS), neck pain

intensity, cervical range of motion, pressure pain

thresholds, deep cervical flexors motor performance

Measured at baseline and 1 week post treatment

Subjects in the treatment group:

Greater reduction of headache and neck pain

Improvements in motor control of the deep cervical

flexors, cervical active ROM and pressure pain thresholds

Dunning et. al., 2017 110 subjects with CGHA randomized into 2 groups:

Cervical and thoracic manipulation, mobilization and

exercise

Subjects completed 6-8 treatment sessions over 4 weeks

Outcome: Headache intensity (NPRS), headache

frequency, headache duration, disability (NDI),

medication intake

Measured at baseline, 1 week, 4 weeks, and 3 months

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Dunning et. al., 2017 Analyzed with a 2 way mixed model ANOVA

Those receiving manipulation

Reported significant reductions in headache intensity and disability at 3 months follow up

At each follow up reported shorter duration and less

frequent headaches

Had significantly greater percieved improvement at 1

week and 4 week follow up

Ylinen et. al. 2010 180 female office workers with chronic neck pain

Randomly assigned to one of three groups:

Strength group

Isometric, dynamic and stretching

Endurance Group

Dynamic muscle and stretching

Control group

Stretching only

Subjects performed a 12 month training program

Ylinen et. al. 2010

Pain assessed using VAS at baseline and a 12

months

At 12 months headache decreased

Strength group: 69%

Endurance group: 58%

Control group: 37%

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Jull et. al. 2002 RCT studying manipulative therapy and exercise in the

treatment of CGHA when used alone, in combination

and compared to a control group.

200 participants who met diagnostic criteria:

manipulative therapy

exercise therapy

combined therapy

control group

Jull et. al. 2002

Treatment period: 6 weeks

Follow up: post treatment, 3,6 and 12 months

Outcomes: change in HA frequency

HA intensity

HA duration

Jull et. al. 2002

Results: Exercise and Manipulative therapy group had significantly less HA

frequency and intensity

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Pharmacological

management?

May be helpful for some patients

Warning that patients with CGHA that only rely on pharmacological agents are at an increased

risk of dependency (Biondi, 2005)

What does this all mean?

Manual Therapy: Gr V or manipulation

Mobilizations

Contract/relax stretching

Soft tissue mobilization


Exercises: training postural stabilizers

self mobilization

stretching

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Ergonomics: getting the patient out of their position of discomfort

Treatment: Manual Therapy Soft tissue mobilization: suboccipitals, upper trapezius,

levator scapulae

Joint mobilization: P/A of C1 articluar pillar, A/P of occiput with C1 stabilized

Grade V, high velocity low amplitude/ manipulation

Contract/ relax stretching

STM to paraspinals and

suboccipitals

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STM to paraspinals and

suboccipitals

STM to upper trapezius

STM to upper trapezius

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STM to levator scapulae

STM to levator scapulae

Manual Therapy: Joint

Mobilization P/A of C1

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Manual Therapy: Joint

Mobilization A/P of Occiput

Manual Therapy: Contract/

Relax stretching

Manual Therapy: Contract/

Relax stretching

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Therapeutic Exercises Chin tucks

Scapular strengthening

Postural training

Pectoral stretching

Self mobilization

Core strengthening

Aerobic exercise

Therapeutic exercises:

chin tucks

Chin tucks with pneumatic

pressure feedback device

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Therapeutic exercise:

chin tucks


diaphragmatic breathing



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serratus anterior

Therapeutic Exercises: pelvic

tilts

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Therapeutic Exercises:

Postural Training

Therapeutic Exercises: prone on

exercise ball


quadriped progression

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Pectoral Stretching


Pectoral Stretching


Pectoral Stretching

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Therapeutic Exercises: Self

Mobilization

Therapeutic Exercises: Self

Mobilization


Aerobic Exercise

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Ergonomics Ergonomic evaluation

Refer to an ergonomic specialist

Advising patient on proper workplace setup

Ergonomics

Ergonomics

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In Conclusion CGHA can be treated by a physical therapist

Subjective and objective can help to identify patients

with CGHA

Mix of manual therapy and exercises can beneficial

Do not forget about ergonomics

Questions?

[email protected]

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