Cervicogenic headache: diagnostic criteria. The Cervicogenic Headache International Study Group

11. Cervicogenic headache and occipital neuralgia

INTRODUCTION

Cervicogenic headache (CEH) and occipital neuralgia (ON) are headaches originating in the occiput and that radiate to the vertex. Because of the intimate relationship between structures based in the occiput and those in the upper cervical region, there is significant overlap between the presentation of CEH and ON. Diagnosis starts with a headache history to assess for diagnostic criteria formulated by the International Headache Society. Physical examination evaluates range of motion of the neck and the presence of tender areas or pressure points.

METHODS

The literature for the diagnosis and treatment of CEH and ON was searched from 2015 through August 2022, retrieved, and summarized.

RESULTS

Conservative treatment includes pain education and self-care, analgesic medication, physical therapy (such as reducing secondary muscle tension and improving posture), the use of TENS (transcutaneous electrical nerve stimulation), or a combination of the aforementioned treatments. Injection at various anatomical locations with local anesthetic with or without corticosteroids can provide pain relief for a short period. Deep cervical plexus block can result in improved pain for less than 6 months. In both CEH and ON, an occipital nerve block can provide important diagnostic information and improve pain in some patients, with PRF providing greater long-term pain control. Radiofrequency ablation of the cervical facet joints can result in improvement for over 1 year. Occipital nerve stimulation (ONS) should be considered for the treatment of refractory ON.

CONCLUSION

The treatment of CEH preferentially consists of radiofrequency treatment of the facet joints, while for ON, pulsed radiofrequency of the occipital nerves is indicated. For refractory cases, ONS may be considered.

A Review on Osteopathic Manipulation in Patients With Headache

Headaches are a common neurological disorder, significantly impacting patients' quality of life. Traditional treatments include pharmacological and nonpharmacological approaches. Osteopathic manipulative treatment (OMT) is a holistic, hands-on technique used by osteopathic physicians to alleviate pain and improve function by addressing musculoskeletal dysfunctions. This review aims to evaluate the effectiveness of osteopathic manipulation in managing headaches, focusing on the different types of headaches, the specific techniques used, and the overall outcomes reported in clinical studies. A comprehensive literature search was conducted across multiple databases, including PubMed, Google Scholar, and MEDLINE, to identify relevant studies published in the past two decades. Inclusion criteria were studies involving adult patients diagnosed with headaches and treated with OMT. Both randomized controlled trials (RCTs) and observational studies were included. The review identified 15 studies meeting the inclusion criteria. Evidence suggests that OMT can be beneficial in reducing the frequency, intensity, and duration of headaches, particularly tension-type headaches (TTHs) and migraines. Techniques such as myofascial release, cranial osteopathy, and muscle energy techniques were commonly employed. Many studies reported significant improvements in patients' quality of life and functional status post-treatment. However, the heterogeneity in study designs, sample sizes, and outcome measures warrants cautious interpretation of the results. Osteopathic manipulation shows promise as a complementary approach for managing headaches, with positive effects on pain relief and functional improvement. Further large-scale, high-quality RCTs are needed to confirm these findings and to establish standardized treatment protocols. Integrating OMT into multidisciplinary headache management strategies could potentially enhance patient outcomes and reduce reliance on pharmacological interventions.

Mulligan manual therapy added to exercise improves headache frequency, intensity and disability more than exercise alone in people with cervicogenic headache: a randomised trial

QUESTION

What is the effect of a 4-week regimen of Mulligan manual therapy (MMT) plus exercise compared with exercise alone for managing cervicogenic headache? Is MMT plus exercise more effective than sham MMT plus exercise? Are any benefits maintained at 26 weeks of follow-up?

DESIGN

A three-armed, parallel-group, randomised clinical trial with concealed allocation, blinded assessment of some outcomes and intention-to-treat analysis.

PARTICIPANTS

Ninety-nine people with cervicogenic headache as per International Classification of Headache Disorders (ICHD-3).

INTERVENTIONS

Participants were randomly allocated to 4 weeks of: MMT with exercise, sham MMT with exercise or exercise alone.

OUTCOME MEASURES

The primary outcome was headache frequency. Secondary outcomes were headache intensity, headache duration, medication intake, headache-related disability, upper cervical rotation range of motion, pressure pain thresholds and patient satisfaction. Outcome measures were collected at baseline and at 4, 13 and 26 weeks.

RESULTS

MMT plus exercise reduced headache frequency more than exercise alone immediately after the intervention (MD between groups in change from baseline: 2 days/month, 95% CI 2 to 3) and this effect was still evident at 26 weeks (MD 4 days, 95% CI 3 to 4). There were also benefits across all time points in several secondary outcomes: headache intensity, headache duration, headache-related disability, upper cervical rotation and patient satisfaction. Pressure pain thresholds showed benefits at all time points at the zygapophyseal joint and suboccipital areas but not at the upper trapezius. The outcomes in the sham MMT with exercise group were very similar to those of the exercise alone group.

CONCLUSIONS

In people with cervicogenic headache, adding MMT to exercise improved: headache frequency, intensity and duration; headache-related disability; upper cervical rotation; and patient satisfaction. These benefits were not due to placebo effects.

TRIAL REGISTRATION

CTRI/2019/06/019506.

The utilization of dry needling and an upper extremity exercise program for individuals with cervicogenic headaches: A pilot study

OBJECTIVE

To investigate whether a combination of dry-needling treatments and upper extremity neuromuscular reeducation exercises can significantly improve neck pain and/or headache-related disability, joint position error, cervical range of motion, and pain pressure threshold in individuals suffering from cervicogenic headache (CGH).

METHODS

This study is a quasi-experimental design. Seven participants met the inclusion criteria and received dry needling to three muscles that reproduced the participant's headache symptoms and completed the Neck Disability Index (NDI), Headache Disability Inventory (HDI), Visual Analog Scale (VAS), and Numeric Pain Rating Scale (NPRS). Participants performed an exercise regimen designed to address strength and mobility of cervical and scapulothoracic musculature.

RESULTS

There were significant improvements seen in cervical range of motion and neck pain-related disability (NDI) during the 4-week treatment period.

CONCLUSION

Dry needling and neuromuscular re-education (NMR) exercises could be effective components of treatment for individuals suffering from CGH to reduce disability and pain.

Cervicogenic Headaches: A Literature Review and Proposed Multifaceted Approach to Diagnosis and Management

Cervicogenic headaches are a secondary headache disorder attributable to cervical spine dysfunction resulting in head pain with or without neck pain. Diagnosis of this condition has been complicated by varied clinical presentations, causations, and differing diagnostic criteria. In this article, we aim to clarify the approach to diagnosing cervicogenic headaches by providing an overview of cervicogenic headaches, clinical case examples, and a practical diagnostic algorithm based on the most current criteria. A standardized approach will aid in confirmation of the diagnosis of cervicogenic headaches and facilitate further research into this condition.

Dry needling in the management of chronic tension-type headache associated with levator scapulae syndrome: A case report

Key Clinical Message

The use of DN to the muscular trigger points and distal periosteal enthesis of the levator scapulae may be a useful adjunct intervention within a multi-modal plan of care for the management of work-related chronic tension-type headaches associated with LSS.

Abstract

Chronic tension-type headaches (CTTH) have a lifetime prevalence of 42% and account for more lost workdays than migraine headaches. Dry needling (DN) is being increasingly used by physical therapists in the management of CTTH; however, to date, the supporting evidence is limited. The purpose of this case report was to describe how three sessions of DN targeting myofascial trigger points in the levator scapulae (LS) muscle and its distal enthesis was used to treat a 63-year-old male patient who presented with work-related CTTH associated with levator scapulae syndrome (LSS). The patient was treated for five visits over the course of 2 months. At discharge and 6-month follow-up, the patient reported full resolution of symptoms. Self-report outcomes included the numeric pain rating scale and the Neck Disability Index. The use of DN to the LS muscle and its distal enthesis may be a valuable addition to a multi-modal plan of care in the treatment of work-related CTTH associated with LSS.

The effect of neck-specific exercise and prescribed physical activity on headache and dizziness in individuals with cervical radiculopathy: Further analyses of a randomized study with a 1-year follow-up

OBJECTIVE

To evaluate the effect of neck-specific exercise (NSE) compared to prescribed physical activity (PPA) on headache and dizziness in individuals with cervical radiculopathy (CR). Also, to investigate associations between headache or dizziness and pain, neck muscle endurance (NME), neck mobility, physical activity, and fear avoidance beliefs.

METHODS

Individuals randomized to either NSE or PPA were selected to a headache subgroup (n = 59) and/or a dizziness subgroup (n = 73). Data were evaluated, according to headache and/or dizziness outcomes at baseline and at 3, 6, and 12-month follow-ups.

RESULTS

No significant between-group differences were found between NSE and PPA in either subgroup. In the headache subgroup, significant within-group improvements were seen at all follow-ups for NSE (p < .001) and from baseline to 3 (p = .037) and 12 (p = .003) months for PPA. For dizziness, significant within-group improvements were seen from baseline to 3 months for NSE (p = .021) and from baseline to 3 (p = .001) and 6 (p = .044) months for PPA. Multiple regression models showed significant associations at baseline between headache intensity and neck pain (adjusted R-square = 0.35, p < .001), and for dizziness with neck pain and dorsal NME (adjusted R-square = 0.34, p < .001).

CONCLUSION

NSE and PPA show similar improvements in headache intensity and dizziness in individuals with CR. Headache intensity is associated with neck pain, and dizziness with neck pain and dorsal NME, highlighting the importance of these factors when evaluating headache and dizziness.

Reliability and measurement properties of upper cervical flexion-extension range of motion testing in people with cervicogenic headache and asymptomatic controls

OBJECTIVE

The objective was to determine reliability of sagittal plane range of motion (ROM) assessment in a healthy population and in people with cervicogenic headache (CGH).

METHODS

Upper cervical flexion/extension ROM was measured using an iPhone magnetometer sensor and retraction/protraction ROM measured by linear displacement. Two independent raters evaluated these movements in 33 subjects with CGH and 33 age and gender matched asymptomatic healthy controls on two occasions. Measurement procedures were standardized; and the order of testing randomized. Reliability, standard error of measurement (SEM) and minimum detectable change (MDC) were calculated.

RESULTS

Subjects comprised 30 females and 36 males. The iPhone method demonstrated high reliability (ICC >0.82) with SEM values ranging from 0.62 to 1.0 and MDC values ranging from 1.70 to 4.81 respectively. Evaluation of linear displacement demonstrated moderate reliability (ICC >64). with SEM values ranging from 0.38 to 1.91 and MDC values ranging from 1.05 to 1.63 respectively. Compared to healthy controls, upper cervical flexion, retraction and protraction ROM was significantly less in the CGH group with mean difference of 6.50°, 1.52 cm and 2.34 cm respectively.

DISCUSSION

Upper cervical spine sagittal plane ROM can be measured with moderate to high reliability and was found to be more restricted in people with CGH.

Comparative effectiveness of cervical vs thoracic spinal-thrust manipulation for care of cervicogenic headache: A randomized controlled trial

BACKGROUND

There is ample evidence supporting the use of different manipulative therapy techniques for Cervicogenic Headache (CgH). However, no technique can be singled as the best available treatment for patients with CgH. Therefore, the objective of the study is to find and compare the clinical effects of cervical spine over thoracic spine manipulation and conventional physiotherapy in patients with CgH.

DESIGN, SETTING, AND PARTICIPANTS

It is a prospective, randomized controlled study conducted between July 2020 and January 2023 at the University hospital. N = 96 eligible patients with CgH were selected based on selection criteria and they were divided into cervical spine manipulation (CSM; n = 32), thoracic spine manipulation (TSM; n = 32) and conventional physiotherapy (CPT; n = 32) groups, and received the respective treatment for four weeks. Primary (CgH frequency) and secondary CgH pain intensity, CgH disability, neck pain frequency, neck pain intensity, neck pain threshold, cervical flexion rotation test (CFRT), neck disability index (NDI) and quality of life (QoL) scores were measured. The effects of treatment at various intervals were analyzed using a 3 × 4 linear mixed model analysis (LMM), with treatment group (cervical spine manipulation, thoracic spine manipulation, and conventional physiotherapy) and time intervals (baseline, 4 weeks, 8 weeks, and 6 months), and the statistical significance level was set at P < 0.05.

RESULTS

The reports of the CSM, TSM and CPT groups were compared between the groups. Four weeks following treatment CSM group showed more significant changes in primary (CgH frequency) and secondary (CgH pain intensity, CgH disability, neck pain frequency, pain intensity, pain threshold, CFRT, NDI and QoL) than the TSM and CPT groups (p = 0.001). The same gradual improvement was seen in the CSM group when compared to TSM and CPT groups (p = 0.001) in the above variables at 8 weeks and 6 months follow-up.

CONCLUSION

The reports of the current randomized clinical study found that CSM resulted in significantly better improvements in pain parameters (intensity, frequency and threshold) functional disability and quality of life in patients with CgH than thoracic spine manipulation and conventional physiotherapy.

TRIAL REGISTRATION

Clinical trial registration: CTRI/2020/06/026092 trial was registered prospectively on 24/06/2020.

Cervicogenic headache - How to recognize and treat

Cervicogenic headache, described almost 100 years ago, only had its clinical awakening at the end of the century with the work of Professor Sjaastad. Its classic definition is the induction of trigeminal symptoms from cervical disorders, thanks to trigeminocervical convergence mechanisms. For this reason, it can manifest several features typical of migraine, leading to diagnostic errors. Classically, subjects complain of fixed unilateral headaches, with cervical onset and trigeminal irradiation, associated with reduced neck mobility and flexion strength. The headache is mild to moderate, described as pulsatile or compressive, accompanied by nausea, vomiting, photophobia, phonophobia, and may present autonomic symptoms and dizziness. The pain duration varies from one day to weeks, and its frequency is unpredictable. A history of whiplash injury is common. The differential diagnosis encompasses migraine and tension-type headache. Management includes physiotherapy rehabilitation, anesthetic blocks, and selectively surgical procedures. In this article, all these aspects were extensively covered.

Physical Therapist Interventions to Reduce Headache Intensity, Frequency, and Duration in Patients With Cervicogenic Headache: A Systematic Review and Network Meta-Analysis

OBJECTIVE

The aim of this study was to assess the efficacy of physical therapist interventions on the intensity, frequency, and duration of headaches, as well as on the quality of life of patients with cervicogenic headache.

METHODS

The following databases were searched up to October 2022: Physiotherapy Evidence Database, Web of Science, Pubmed, and Cochrane Library. Randomized controlled trials assessing the effect of physical therapist interventions on adults with cervicogenic headache were included. Quality appraisal was conducted using the Cochrane risk of bias 2.0 tool and the Confidence in Network Meta-analysis web app. Synthesis methods were conducted in accordance with the Cochrane Handbook.

RESULTS

Of the 28 identified reports, 23 were included in the quantitative synthesis. Manipulation plus dry needling was the highest-ranked intervention to reduce the short-term headache intensity (mean difference [MD] = -4.87; 95% CI = -8.51 to -1.24) and frequency (MD = -3.09; 95% CI = -4.93 to -1.25) when compared to a control intervention. Other high-ranked and clinically effective interventions (when compared to a control intervention) were muscle-energy technique plus exercise (MD = 4.37; 95% CI = -8.01 to -0.74), as well as soft tissue techniques plus exercise (MD = -3.01; 95% CI = -5.1 to -0.92) to reduce short-term headache intensity, and dry needling plus exercise (MD = -2.92; 95% CI = -4.73 to -1.11) to reduce short-term headache frequency. These results were based on a low certainty of evidence.

CONCLUSION

The 4 most highly ranked interventions can be considered in clinical practice. However, no conclusive recommendation can be made due to the low certainty of evidence.

IMPACT

Combined interventions such as spinal joint manipulation plus dry needling and muscle-energy technique or soft tissue techniques or dry needling plus exercises seem to be the best interventions to reduce short-term cervicogenic headache intensity and/or frequency.

The Magnitude of Physical and Sensory Impairments in Post-traumatic and Non-traumatic Cervicogenic Headaches: A Comparative Study

Background Cervicogenic headaches can significantly deteriorate the quality of life of patients and decrease their productivity. Few studies have been conducted to assess the magnitude of physical impairments among patients with non-traumatic and post-traumatic cervicogenic headaches. Therefore, this study was conducted to examine and compare the magnitude of cervical physical impairments among patients with post-traumatic cervicogenic headaches in contrast to patients with non-traumatic cervicogenic headaches, migraine, and a group of sex- and age-matched controls who did not have headaches. Methodology This was a comparative study. A total of 104 patients and 30 sex- and age-matched controls were included. The patients were stratified into three groups: post-traumatic cervicogenic headaches (n = 42), non-traumatic cervicogenic headaches (n = 30), and migraines (n = 32). The cervical active range of motion and proprioception were assessed using a goniometer, the craniovertebral angle was measured while the heads of the subjects rested in a comfortable position, the strength of the cervical flexors and extensors was assessed using a hand-held dynamometer, and endurance of the short cervical flexors was assessed while the subjects were in a supine position with no pillow. Skin roll tests were performed in the trapezius and mandibular areas, and pain was measured using the McGill Pain Questionnaire-Short Form. Results Patients in the post-traumatic cervicogenic headache group reported a significantly higher number of headache days (p < 0.001) compared to the controls, patients with migraines, and those with non-traumatic cervicogenic headaches. Patients with post-traumatic cervicogenic headaches showed a significant reduction in total rotation, flexion and extension, lateral bending, and craniovertebral angle compared to the controls, patients with migraines, and those with non-traumatic cervicogenic headaches. On the other hand, the controls endured significantly longer and had stronger neck flexors and extensors compared to the patients in the migraine, non-traumatic, and post-traumatic cervicogenic headache groups, respectively. Patients with post-traumatic cervicogenic headaches significantly reported higher affective and total pain compared to the controls and patients in the migraine group. Conclusions Patients with post-traumatic cervicogenic headaches had significant deficits in the cervical active range of motion in the different planes, endurance, and strength of cervical flexors and extensors compared to the controls and patients with migraine and non-traumatic cervicogenic headaches. Similarly, patients with post-traumatic cervicogenic headaches reported higher affective pain compared to the controls and patients with migraines. The results of this study indicated that patients with post-traumatic cervicogenic headaches have significantly higher physical impairments compared to patients with non-traumatic cervicogenic headaches. These differences warrant caution when combining data from patients with non-traumatic and post-traumatic cervicogenic headaches.

Relationship between echogenicity of deep cervical muscles and pain laterality in subjects suffering from cervicogenic headache

OBJECTIVE

This study investigated the deep upper cervical muscles echogenicity in cervicogenic headache (CGH) patients.

METHODS

The echogenicity of longus capitis (LCAP), rectus capitis posterior major (RCPM), and obliquus capitis superior (OCS) muscles was measured by ultrasonography and analyzed by Image J software in 17 CGH patients matched with 17 healthy subjects.

RESULTS

The echogenicity of all muscles in the CGH group was higher than that in healthy subjects. The echogenicity of the LCAP muscle on the right side was significantly different between the CGH and healthy subjects (p< 0.05), but there was no difference in the echogenicity of RCPM and OCS muscles between the groups (p> 0.05). Additionally, the echogenicity differences did not match with the pain side in CGH patients (p> 0.05).

CONCLUSION

Only the deep anterior muscle (LCAP) echogenicity affected by CGH and fatty infiltration occurred in this muscle. Hence, anterior muscle dysfunction is important in CGH diagnosis and treatment.

Cervicogenic headache

INTRODUCTION

Cervicogenic headache, first proposed as a distinct headache in 1983, is a secondary headache to a primary cervical musculoskeletal disorder. Research into physical impairments was integral to clinical diagnosis and to develop and test research informed conservative management as the first line approach.

PURPOSE

This narrative presents an overview of the body of cervicogenic headache research from our laboratory which was undertaken in the context of a broad program of research into neck pain disorders.

IMPLICATIONS

Early research validated manual examination of the upper cervical segments against anaesthetic nerve blocks, which was vital to clinical diagnosis of cervicogenic headache. Further studies identified reduced cervical motion, altered motor control of the neck flexors, reduced strength of flexor and extensor muscles, and occasional presentation of mechanosensitivity of the upper cervical dura. Single measures are variable and not reliable in diagnosis. We proved that a pattern of reduced motion, upper cervical joint signs and impaired deep neck flexor function accurately identified cervicogenic headache and differentiated it from migraine and tension-type headache. The pattern was validated against placebo controlled diagnostic nerve blocks. A large multicentre clinical trial determined that a combined program of manipulative therapy and motor control exercise is effective in the management of cervicogenic headache and outcomes are maintained in the long term. More specific research into cervical related sensorimotor controlled is warranted in cervicogenic headache. Further adequately powered clinical trials of current research informed multimodal programs are advocated to further strengthen the evidence base for conservative management of cervicogenic headache.

Individual perceptions on the relationship between migraine and neck pain

BACKGROUND

Despite neck pain being a common complaint for people with migraine, little is known about how individuals perceive the relationship between their migraine and neck pain. Exploring their beliefs and perceptions could provide valuable understanding to improve overall management and reduce the burden of migraine and neck pain.

OBJECTIVES

To investigate individual perspectives on how migraine and neck pain relate.

METHODS

A retrospective qualitative study was performed. Seventy participants (mean age 39.2, 60 female) were recruited via community and social media advertisements, and interviewed by an experienced physiotherapist using a semi-structured interview framework. An Inductive thematic analysis was used to analyse the responses.

RESULTS

Five themes were identified from the interviews: (i) the timing of neck pain and migraine, (ii) causality beliefs, (iii) burden of neck pain and migraine, (iv) experiences with treatment and (v) mismatched perspectives. Diverse views emerged, revealing links between the first two themes of timing and causality, showing increased burden in those suffering from both neck pain and migraine, and providing insights into apparently ineffective or even aggravating treatments.

CONCLUSIONS

Valuable insights for clinicians emerged. Due to the complex relationship, clinicians should discuss the aetiology of neck pain in migraine with patients. For some individuals, neck treatment may not produce long-term relief and may even aggravate migraine, but the value of short-term relief in a chronic condition must be considered individually. Clinicians are ideally placed to have discussions with patients individually to tailor individual decisions about management.

Effectiveness of therapeutic exercise for the management of cervicogenic headache: A systematic review

OBJECTIVE

The main aim of this systematic review is to evaluate the effectiveness of therapeutic exercise for managing pain and disability in patients with cervicogenic headache (CEH).

METHODS

A protocol for this systematic review was published in PROSPERO (CRD42019122703). PRISMA and AMSTAR2 standards were followed. Based on an extensive systematic search in five databases (EMBASE, MEDLINE, CINHAL, PsychInfo and SportDISCUS) and the CENTRAL trial register, two reviewers carefully and independently assessed, selected results, collected data, rated the risk of bias (RoB) of included studies with the Cochrane risk of bias tool, synthesized the available evidence, and rated it using GRADE methodology.

RESULTS

A total of 12 manuscripts, reporting on 11 studies were included. Most studies showed a high risk of bias (63,63%). Additionally, a great deal of heterogeneity was observed regarding interventions, comparisons, and outcomes and thus, results could not be synthesized in meta-analyses. The quality of the evidence was found to be from low to very low. Significant differences with large effect sizes were found when comparing multimodal exercise vs. control groups on headache outcomes (SMD = 0.73; 95%CI [0.31, 1.14] for headache intensity and SMD = 0.98; 95%CI [0.56, 1.41], for headache frequency).

CONCLUSIONS

Findings indicate that therapeutic exercise may be effective to achieve clinically relevant reductions in headache intensity and frequency as well as disability for patients suffering from cervicogenic headache. However, more high-quality research is needed to gain confidence in this finding and possibly determine optimal types and dosage of therapeutic exercise.

Neck Pain Disability on Headache Impact and the Association between Sleep Disturbance and Neck Pain in Migraine

Neck pain (NP) is a prevalent symptom among migraine patients, but its disability on headache impact and the contributing factors for comorbid NP are poorly understood. This study aimed to investigate NP disability on the impact of headaches among migraineurs and factors linked to comorbid NP, including sleep-related variables. This cross-sectional study was conducted at a university hospital headache center, for headache patients at their first visits. Included in the study were 295 patients with migraines (217 females; 39.0  ±  10.8 years; 101 chronic migraine). Information on NP, history of physician-diagnosed cervical spine or disc disorders, detailed parameters of headache, and sleep and mood variables were collected. Logistic analysis of the severe impact of headache and contributing factors for NP were performed. NP was present in 153 participants (51.9%) with migraine, with high NP disability observed in 28 patients, and 125 patients had low NP disability. In multivariable analysis, NP disability, medication days per month, severe disability of migraine, and excessive daytime sleepiness were significant predictors for severe impact of headache. Thirty-seven patients with physician-diagnosed cervical spine or disc disorders were excluded from the NP analysis. Higher monthly headache days, female gender, and a high likelihood of obstructive sleep apnea were positively correlated with the presence of NP among migraineurs in multivariable analysis. Overall, the study highlights the potential impact of sleep-related variables and monthly headache days on NP in these patients. The high disability of NP was also associated with severe impact of headache.

Headache and orofacial pain: A traffic-light prognosis-based management approach for the musculoskeletal practice

Introduction

Headache (HA) is one of the most prevalent disabling conditions worldwide and is classified as either primary or secondary. Orofacial pain (OFP) is a frequent pain perceived in the face and/or the oral cavity and is generally distinct from a headache, according to anatomical definitions. Based on the up-to-date classification of the International Headache Society, out of more than 300 specific types of HA only two are directly attributed to the musculoskeletal system: The cervicogenic HA and HA attributed to temporomandibular disorders. Because patients with HA and/or OFP frequently seek help in the musculoskeletal practice, a clear and tailored prognosis-based classification system is required to achieve better clinical outcomes.

Purpose

The aim of perspective article is to suggest a practical traffic-light prognosis-based classification system to improve the management of patients with HA and/or OFP in the musculoskeletal practice. This classification system is based on the best available scientific knowledge based on the unique set-up and clinical reasoning process of musculoskeletal practitioners.

Implications

Implementation of this traffic-light classification system will improve clinical outcomes by helping practitioners invest their time in treating patients with significant involvement of the musculoskeletal system in their clinical presentation and avoid treating patients that are not likely to respond to a musculoskeletal based intervention. Furthermore, this framework incorporates medical screening for dangerous medical conditions, and profiling the psychosocial aspects of each patient; thus follows the biopsychosocial rehabilitation paradigm.

Global trends in research on cervicogenic headache: a bibliometric analysis

Background

There has been a marked increase in cervicogenic headaches in recent years, significantly affecting sufferers' daily lives and work. While several treatments exist for this type of headache, their long-term effects could be improved, and additional data from large clinical samples are needed. This study aims to systematically examine the current state of research in cervicogenic headaches through a bibliometric analysis, identify areas of current interest, and provide insight into potential future research directions.

Methods

This article examines research trends in the field of cervicogenic headache through a bibliometric analysis of scholarly articles in the field of cervicogenic headache over the past four decades. The bibliometric analysis method employed included searching the Web of Science database using topics related to cervicogenic headaches. Inclusion criteria were limited to articles and review papers on cervicogenic headaches published between 1982 and 2022. The retrieved dataset was then analyzed using R software and VOSviewer to identify the major research areas, countries and institutions, the most influential authors, journals and keywords, co-citations in the literature, and co-authorship networks.

Results

This study analyzed 866 articles published between 1982 and 2022, involving 2,688 authors and generating 1,499 unique author keywords. Neuroscience and neurology were the primary focus, with participation from 47 countries, primarily led by the United States, which has the most published articles (n = 207), connections (n = 29), and citations (n = 5,238). In the cervicogenic headache study, which involved 602 institutions, the University of Queensland received the most significant number of citations (n = 876), and Cephalalgia was the journal with the most published articles and received the most local citations (n = 82) and highest growth (n = 36). Two hundred sixty-nine journals have published articles on cervicogenic headaches. Among researchers studying cervicogenic headache, Sjaastad O had the most published articles (n = 51) and citations (n = 22). The most commonly occurring keyword was "cervicogenic headache." Except for the fourth most impactful paper, as determined by the Local Citation Score, which analyzed clinical treatments, all the top documents emphasized investigating the diagnostic mechanisms of cervicogenic headache. The most commonly occurring keyword was "cervicogenic headache."

Conclusion

This study used bibliometric analysis to provide a comprehensive overview of the current research on cervicogenic headaches. The findings highlight several areas of research interest, including the need for further investigation into the diagnosis and treatment of cervicogenic headaches, the impact of lifestyle factors on cervicogenic headaches, and the development of new interventions to improve patient outcomes. By identifying these gaps in the literature, this study provides a foundation for guiding future research to improve the diagnosis and treatment of cervicogenic headaches.

The effectiveness of manual and exercise therapy on headache intensity and frequency among patients with cervicogenic headache: a systematic review and meta-analysis

BACKGROUND

Cervicogenic headache is a secondary headache, and manual therapy is one of the most common treatment choices for this and other types of headache. Nonetheless, recent guidelines on the management of cervicogenic headache underlined the lack of trials comparing manual and exercise therapy to sham or no-treatment controls. The main objective of this systematic review and meta-analysis was to assess the effectiveness of different forms of manual and exercise therapy in people living with cervicogenic headache, when compared to other treatments, sham, or no treatment controls.

METHODS

Following the PRISMA guidelines, the literature search was conducted until January 2022 on MEDLINE, CENTRAL, DOAJ, and PEDro. Randomized controlled trials assessing the effects of manual or exercise therapy on patients with cervicogenic headache with headache intensity or frequency as primary outcome measures were included. Study selection, data extraction and Risk of Bias (RoB) assessment were done in duplicate. GRADE was used to assess the quality of the evidence.

RESULTS

Twenty studies were included in the review, with a total of 1439 patients. Common interventions were spinal manipulation, trigger point therapy, spinal mobilization, scapulo-thoracic and cranio-cervical exercises. Meta-analysis was only possible for six manual therapy trials with sham comparators. Data pooling showed moderate-to-large effects in favour of manual therapy for headache frequency and intensity at short-term, small-to-moderate for disability at short-term, small-to-moderate for headache intensity and small for headache frequency at long-term. A sensitivity meta-analysis of low-RoB trials showed small effects in favor of manual therapy in reducing headache intensity, frequency and disability at short and long-term. Both trials included in the sensitivity meta-analysis studied spinal manipulation as the intervention of interest. GRADE assessment showed moderate quality of evidence.

CONCLUSION

The evidence suggests that manual and exercise therapy may reduce headache intensity, frequency and disability at short and long-term in people living with cervicogenic headache, but the overall RoB in most included trials was high. However, a sensitivity meta-analysis on low-RoB trials showed moderate-quality evidence supporting the use of spinal manipulation compared to sham interventions. More high-quality trials are necessary to make stronger recommendations, ideally based on methodological recommendations that enhance comparability between studies. Trial registration The protocol for this meta-analysis was pre-registered on PROSPERO under the registration number CRD42021249277.

Neural Basis of Etiopathogenesis and Treatment of Cervicogenic Orofacial Pain

(1) Background and Objectives: The aim of this narrative review was to analyze the neuroanatomical and neurophysiological basis of cervicogenic pain in cervico-cranial pain syndromes, focusing particularly on cervico-orofacial syndromes as a background for the proper diagnosis and non-surgical treatment. Relevant literature on the topic from past 120 years has been surveyed. (2) Material and Methods: We surveyed all original papers, reviews, or short communications published in the English, Spanish, Czech or Slovak languages from 1900 to 2020 in major journals. (3) Results: The cervicogenic headache originates from the spinal trigeminal nucleus where axons from the C₁–C₃ cervical spinal nerves and three branches of the trigeminal nerve converge (trigeminocervical convergence) at the interneurons that mediate cranio-cervical nociceptive interactions. The role of the temporomandibular joint in the broad clinical picture is also important. Despite abundant available experimental and clinical data, cervicogenic orofacial pain may be challenging to diagnose and treat. Crucial non-surgical therapeutic approach is the orthopedic manual therapy focused on correction of body posture, proper alignment of cervical vertebra and restoration of normal function of temporomandibular joint and occlusion. In addition, two novel concepts for the functional synthesis of cervico-cranial interactions are the tricentric concept of mouth sensorimotor control and the concept of a cervicogenic origin of bruxism. (4) Conclusions: Understanding the basis of neuroanatomical and neurophysiological neuromuscular relations enables an effective therapeutic approach based principally on orthopedic manual and dental occlusal treatment.

The effectiveness of Sustained Natural Apophyseal Glide on Flexion Rotation Test, pain intensity, and functionality in subjects with Cervicogenic Headache: A Systematic Review of Randomized Trials

OBJECTIVE

To determine the effect of sustained natural apophyseal glide (SNAG) on Flexion Rotation Test, pain intensity, and functionality in subjects with Cervicogenic Headache (CH).

METHODS

The research was conducted on five computerized databases PubMed/Medline, Web of Science, PEDro, Lilacs, and Cochrane Library (CENTRAL), using the keywords combination: (sustained natural apophyseal glide OR SNAG OR joint mobilization OR Mulligan) AND (cervicogenic headache) according to PRISMA guidelines. The methodological quality of the included studies was analyzed using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Eight articles fulfilled the eligibility criteria and were included in the review. The selected studies had a methodological quality of 6.6/10 on the PEDro scale and included a total of 357 participants. The SNAG significantly improved pain, Flexion Rotation Test and reduced functional symptoms.

CONCLUSION

The available evidence suggests that SNAG may be a relevant intervention for CH.

Prevalence and characteristics of ponticulus posticus and its association with cervicogenic headache and migraine: A lateral cephalometric study

Background

Ponticulus posticus (PP) (arcuate foramen) is an abnormal bony bridge in the posterior arch of the atlas, which could possibly cause certain complications such as headache. Our goal was to assess the prevalence and size of PP on lateral cephalometric radiographs and its relationships with cervicogenic headache and migraine.

Materials and Methods

This cross-sectional study was a descriptive-analytical type and was performed in Isfahan Azad Dental University. Lateral cephalometric radiographs of 150 patients referred to the radiology department were selected to assess the prevalence and size of the anomaly. A checklist was prepared to evaluate cervicogenic headache and migraine among patients.

Results

Our sample consisted of 97 females and 53 males with an age range between 5 and 56 years. The prevalence of PP was 21.3% (12% complete and 9.3% incomplete), and an insignificant difference was noted between the prevalence of complete and incomplete foramen (P > 0.05). The prevalence of foramen was higher in women (59.4%), but it was not significant. The mean width of complete foramen was 6.40 mm, and the mean heights in individuals with complete and incomplete foramen were 4.71 and 4.84 mm, respectively. Among patients with the anomaly, 43.8% had cervicogenic headache and 9.4% had migraine. There was a significant association between the presence of foramen and both types of headaches (P < 0.05). However, there was no significant correlation between the shape of anomaly and the presence of cervicogenic headache and migraine (P > 0.05).

Conclusion

Our study showed a high prevalence of PP and its significant association with cervicogenic headache and migraine.

Computed tomography-guided radiofrequency ablation of cervical intervertebral discs for the treatment of refractory cervicogenic headache: A retrospective chart review

OBJECTIVE

To evaluate the feasibility and efficacy of computed tomography (CT)-guided radiofrequency ablation (RFA) of cervical intervertebral discs for the treatment of discogenic cervicogenic headache (CEH).

BACKGROUND

Some patients with CEH experience no obvious therapeutic effect after conventional therapy, particularly patients with refractory CEH originating from abnormal cervical intervertebral discs. Treatment for this type of CEH remains poorly characterized.

METHODS

Using a single intervention arm, pretest/posttest design, we retrospectively analyzed the data of patients who underwent CT-guided RFA of cervical intervertebral discs for CEH at the Pain Medicine Center of Zhejiang Provincial People's Hospital from January 2017 to April 2021. If conservative treatment failed in patients with discogenic CEH, we classified the patients as having refractory CEH and performed RFA of cervical intervertebral discs. We used a numeric rating scale (NRS) to assess pain intensity for 6 months. We also compared therapeutic outcome of patients with different characteristics.

RESULTS

A total of 44 patients who underwent CT-guided RFA of cervical intervertebral discs were enrolled and 41 of them were analyzed in the present study. The preoperative median (25th, 75th) NRS score was 4 (4, 5), and it was significantly reduced to 1 (0, 4) 6 months after RFA (p < 0.001). The number of patients with ≥50% of their pain relieved after 6 months was 28 of 41 (68%). No serious treatment-related complications occurred in this study. Compared with single-level RFA, multi-level RFA shows greater effects on pain intensity reduction (p = 0.032) and pain relief rate (p = 0.047) of patients.

CONCLUSION

In patients who have discogenic CEH, CT-guided RFA of the cervical intervertebral discs appears to be a promising treatment with no serious complications.

Reproduction and resolution of familiar head pain with upper cervical spine sustained joint mobilization may help identify cervicogenic headaches: a case-control study

BACKGROUND

The relative value of clinical tests toward identifying cervicogenic headache (CGH) remains under investigated. Whilst certain physical examination findings have been associated with CGH, consensus on which findings provide the strongest association remains elusive.

OBJECTIVES

To determine which cervical musculoskeletal assessment procedures used in CGH are positively associated with CGH.

DESIGN

Single blind observational study.

METHODS

Four selected musculoskeletal assessment procedures of the cervical spine, craniocervical flexion test, cervical flexion-rotation test, cervical retraction range of motion and reproduction and resolution of familiar head pain with upper cervical spine sustained joint mobilization, were applied to 20 headache and 20 controls. Inclusion criteria for the headache group met the International Headache Society criteria for CGH except positive diagnostic blocks.

RESULTS

Upper cervical spine sustained joint mobilization testing associated with reproduction and resolution of familiar head pain was strongly associated with CGH (Odds Ratio = 36, p < 0.01). This was 78% sensitive and 90% specific in identifying CGH. Other physical tests were not statistically associated with CGH.

CONCLUSIONS

Reproduction and resolution of familiar head pain with upper cervical spine sustained joint mobilization is effective in differentiating those with CGH from control participants. Other cervical measures did not clearly identify CGH in this study.

Effectiveness of sustained natural apophyseal glides in females with cervicogenic headache: A randomized controlled trial

BACKGROUND

Cervicogenic headache (CGH) is a common condition that results in significant disability. To treat this dysfunction, Mulligan described sustained natural apophyseal glides (SNAGs) as a manual therapy approach. However, only inconclusive short-term evidence exists for treating CGH with SNAGs.

OBJECTIVE

The present study aims to investigate the effect of SNAGs in the treatment of CGH.

METHODS

Fourty female patients ranging from 20 to 40 years with CGH were randomly assigned to two groups: 20 in a treatment group and 20 in a control group. SNAGs were applied to the treatment group while the control group received placebo treatment. Both groups received their respective treatment for 20 minutes, alternately three times per week, for a total of 12 times in four weeks. The outcome measures were the Neck Disability Index (NDI) and the Visual Analogue Scale (VAS). Participants were assessed at baseline and at the end of each week. The data was analyzed using SPSS version 20. Independent t-testing was used to reveal changes between groups. One-way ANOVA was used to determine changes within groups. The level of significance was P< 0.05.

RESULTS

Twenty participants (100%) in the treatment group and 17 (85%) in the control group had a history of headache aggravation with active movements or passive head positioning. There was no significant difference at baseline (p> 0.05), indicating that both groups were homogeneous at the time of recruitment. The p value (p< 0.05) showed a significant difference in pain and level of disability at three and four weeks (p< 0.05) in patients treated with SNAGs. However, the cervical range of motion (ROM) showed a statistically significant improvement in flexion and extension in the treatment group (p< 0.05) while there was no significant improvement in side flexion and rotation ROM in both groups (p> 0.05).

CONCLUSION

This study found that SNAGs were effective in reducing pain and neck disability and improved ROM in females with CGH.

The temporal behaviour of migraine related neck pain does not inform on the origin of neck pain: An observational study

BACKGROUND

Clinicians seek to identify associations between pain behaviours to understand if symptoms are related or separate conditions. This study determined whether the temporal behaviour of migraine related neck pain related to i) the presence of cervical musculoskeletal function or ii) migraine hypersensitivity.

METHODS

Cross-sectional study of migraineurs with neck pain (n = 110). Participants reported daily for one month via an online survey, on migraine and other headaches, neck symptoms, location of onset and self-identified triggers. Allodynia Symptom Checklist (ASC12), Pressure pain thresholds (PPTs), and presence or absence of cervical musculoskeletal dysfunction were also assessed.

RESULTS

The temporal behaviours of neck pain in 92 participants (46 migraine only, 46 migraine plus another headache) were categorised as: i) ictal only (n = 42), ii) ictal and infrequent interictal (n = 26), iii) ictal and frequent interictal (n = 17), and iv) undecipherable (n = 7). Cervical musculoskeletal dysfunction was present in 43%. Temporal behaviours of neck pain were not associated with cervical musculoskeletal dysfunction (p = 1.00 and 0.21), nor related to ASC12, PPTs, headache triggers, neck pain, nor region of symptom onset, whether migraine only or migraine and another headache was reported (p = 0.29 to 0.97).

CONCLUSION

Individuals with migraine present with varied behaviours of neck pain in relation to the headache. As temporal behaviour is not informative, a physical examination is needed to negate or confirm a cervical source of neck pain in migraine.

Assessment of the head, cervical spine, thoracic spine and shoulder girdle postures in people with and without chronic headache

Background/Aims

Cervical dysfunction is one of the common symptoms of chronic headaches. This study was conducted to assess the posture of the head, cervical and thoracic spine and the shoulder girdle in people with and without cervicogenic and migraine headaches.

Methods

The postural angles of the head, cervical and thoracic spine and the shoulder girdle in frontal and sagittal planes, as well as thoracic spine curvature, were measured on 90 people who were split into three groups: 20 people with cervicogenic headache, 20 people with migraine and 50 people as the control group.

Results

There were significant differences among the three groups in the craniovertebral angle, coronal head tilt angle and scapular upward rotation angle (P<0.05). There was no relationship between postural angles.

Conclusions

The results of this study revealed that forward head posture was evident in people with cervicogenic and migraine headache. Decreased scapular upward rotation seen in the migraine headache group highlights the importance of shoulder girdle-related dysfunctions in people with chronic headaches.

The Neck Disability Index Reflects Allodynia and Headache Disability but Not Cervical Musculoskeletal Dysfunction in Migraine

OBJECTIVE

The Neck Disability Index (NDI) is a self-rated disability tool originally developed for whiplash-associated disorders and validated in cervical musculoskeletal conditions. It is now commonly used to assess neck disability in migraine, but it is unknown whether NDI scores relate to migraine and hypersensitivity, cervical musculoskeletal dysfunction, or both. This single-blinded observational study aimed to determine whether the presence of cervical musculoskeletal dysfunction, migraine features, and hypersensitivity predict NDI scores and whether alternate versions of the NDI (NDI-physical, NDI-8, NDI-5) relate more to cervical musculoskeletal dysfunction.

METHODS

Migraine and neck pain features, the Headache Impact Test (HIT-6), NDI, Allodynia Symptom Checklist (ASC12), and pressure pain thresholds were assessed in 104 participants with migraine and neck pain, 45 previously identified with cervical musculoskeletal dysfunction and 59 without. The NDI score was regressed on the presence or absence of cervical dysfunction, migraine features, HIT-6, total pressure pain threshold, and ASC12 while accounting for neck pain features. The presence of cervical dysfunction was regressed on the scores of NDI versions.

RESULTS

The ASC12 (standardized ß = 0.20) and HIT-6 (standardized ß = 0.18) were significantly predictive of total NDI score, as were neck pain intensity (standardized ß = 0.32) and frequency (standardized ß = 0.44). No scores from alternate NDI versions related to cervical dysfunction.

CONCLUSION

The NDI score is a complex measure of neck disability influenced by migraine disability and hypersensitivity beyond the presence of cervical musculoskeletal dysfunction. This has implications for the clinical interpretation of NDI scores in patients with migraine.

IMPACT

Many patients with migraine and neck pain report neck disability; therefore, it is important to understand if migraine impacts neck disability. The results of this study indicate that clinicians need to consider migraine-related disability and hypersensitivity when managing neck disability in this population.

Effectiveness of spinal mobilization and postural correction exercises in the management of cervicogenic headache: A randomized controlled trial

OBJECTIVE

The study aims to assess the effect of spinal mobilization and postural correction exercises in patients suffering from cervicogenic headache.

METHODS

A randomized controlled trial was conducted with 72 patients. Patients were randomly allocated into three groups: spinal mobilization (n = 24), postural correction exercises (n = 24), and control group (n = 24). The primary outcome measure was headache impact test-6, and secondary outcomes were headache intensity, neck pain intensity, and neck pain-related disability measured at baseline, postintervention, and follow-up period.

RESULT

Comparison of baseline data (at 0 weeks) among groups showed a statistically nonsignificant difference. There was statistically significant improvement at postintervention (immediately after fourth week) in postural correction exercises group [headache disability: 14.95 ± 7.91 (p < .001); headache intensity: 2.58 ± 1.24 (p < .001); neck disability: 27.66 ± 18.71 (p < .001); neck pain: 1.91 ± 1.44 (p < .001)] and spinal mobilization group [headache disability: 13.83 ± 6.21 (p < .001); headache intensity: 2.29 ± 1.23 (p < .001); neck disability: 23.39 ± 19.51 (p < .001); neck pain: 1.72 ± 0.84 (p < .001)] as compared to the control group. The result of within-group analysis suggests that there was a statistically significant improvement in postintervention (immediately after fourth week) and follow-up (immediately after eighth week) scores as compared to baseline (at 0 weeks) scores for all outcomes in postural correction exercises [headache disability (p < .001), headache intensity (p < .001), neck disability (p < .001), neck pain (p < 0 .001)] as well as in spinal mobilization group [headache disability (p < .001), headache intensity (p < .001), neck disability (p < .001), neck pain (p < .001 for pre versus post; p = .001 for pre versus follow-up)]. There was a statistically nonsignificant difference between postintervention and follow-up scores of all the outcomes in the postural correction exercise and spinal mobilization group, which indicates that improvement in these groups was maintained during the follow-up period.

CONCLUSION

Spinal mobilization and postural correction exercises are effective in the management of cervicogenic headache.

Effect of Cervical Decompression on Atypical Symptoms Cervical Spondylosis-A Narrative Review and Meta-Analysis

BACKGROUND

Atypical symptoms of cervical spondylosis refer to symptoms other than the typical symptoms of cervical spondylosis and include headache, nausea, gastrointestinal discomfort, blurred vision, tinnitus, hypomnesia, and palpitations. The role of cervical decompression in mitigating atypical symptoms of cervical spondylosis is still unclear.

METHODS

A comprehensive search of different databases was performed to retrieve articles that studied the effect of cervical decompression on associated atypical symptoms. The data were analyzed to obtain pooled improvement in the various atypical symptoms after cervical decompression.

RESULTS

Twenty-seven studies were included in the meta-analysis. Our analysis showed that cervical decompression was associated with significant improvement in Neck Disability Index-Headache Component (standardized mean difference [SMD], -0.84; 95% confidence interval [CI], -0.94 to -0.74; P < 0.0001), visual analog scale (SMD, -1.47; 95% CI, -1.73 to -1.21; P = 0.0004) and cervicogenic headache (odds ratio [OR], 0.19; 95% CI, 0.06-0.63; P = 0.01). Significant improvement was also observed in vertigo (OR, 0.27; 95% CI, 0.10-0.77; P = 0.02), tinnitus (OR, 0.54; 95% CI, 0.35-0.83; P = 0.02), and nausea (OR, 0.25; 95% CI, 0.13-0.47; P = 0.006) after cervical decompression. Nonsignificant improvement was noticed in the rates of blurred vision, hypomnesia, giddiness, gastrointestinal discomfort, palpitations, and hypertension.

CONCLUSIONS

Our analysis showed that cervicogenic headache, tinnitus, and nausea were significantly relieved after cervical decompression. There was no significant effect of cervical decompression on blurred vision, hypomnesia, giddiness gastrointestinal discomfort, palpitations, and hypertension.

A comparative shape analysis of the cervical spine between individuals with cervicogenic headaches and asymptomatic controls

As some researchers theorized that cervicogenic headache (CEH) might be related to bony and discal features of the cervical spine, this retrospective study examined the shapes of the cervical vertebrae and intervertebral discs (IVDs) of individuals with CEH and compared them to asymptomatic controls. Scans of 40 subjects in their late 20’s–mid 30’s affected with CEH and 40 asymptomatic controls were obtained (overall = 19,040 measurements, age-sex matched, 20 males and 20 females in each group). The following cervical spine variables were measured: Supine lordosis, vertebral body-heights, A-P lengths, mediolateral widths and sagittal-wedging; IVDs heights and sagittal-wedging; pedicle heights, widths and transverse angles; laminar widths and transverse angles; articular facet angles, spinal canal, and transverse foramen lengths, widths, and areas. Both groups had similar shape variation along the cervical in all the measured parameters. There were no significant left–right differences in all measured parameters and no significant differences between the CEH and control groups concerning sex and age. Cervical IVDs were lordotic in shape, whereas their adjacent vertebral bodies were kyphotic in shape except for C2. In conclusion, the shape of the cervical spine and IVDs in subjects in their late 20’s–mid 30’s affected with CEH is identical to asymptomatic controls.

Differentiating migraine, cervicogenic headache and asymptomatic individuals based on physical examination findings: a systematic review and meta-analysis

BACKGROUND

Migraine and cervicogenic headache (CGH) are common headache disorders, although the large overlap of symptoms between them makes differential diagnosis challenging. To strengthen differential diagnosis, physical testing has been used to examine for the presence of musculoskeletal impairments in both conditions. This review aimed to systematically evaluate differences in physical examination findings between people with migraine, CGH and asymptomatic individuals.

METHODS

The databases MEDLINE, PubMed, CINAHL, Web of Science, Scopus, EMBASE were searched from inception until January 2020. Risk of bias was assessed with the Downs and Black Scale for non-randomized controlled trials, and with the Quality Assessment of Diagnostic Accuracy Studies tool for diagnostic accuracy studies. When possible, meta-analyses with random effect models was performed.

RESULTS

From 19,682 articles, 62 studies were included in this review and 41 were included in the meta-analyses. The results revealed: a) decreased range of motion [°] (ROM) on the flexion-rotation test (FRT) (17.67, 95%CI:13.69,21.65) and reduced neck flexion strength [N] (23.81, 95%CI:8.78,38.85) in CGH compared to migraine; b) compared to controls, migraineurs exhibit reduced flexion ROM [°] (- 2.85, 95%CI:-5.12,-0.58), lateral flexion ROM [°] (- 2.17, 95% CI:-3.75,-0.59) and FRT [°] (- 8.96, 95%CI:-13.22,-4.69), reduced cervical lordosis angle [°] (- 0.89, 95%CI:-1.72,-0.07), reduced pressure pain thresholds over the cranio-cervical region [kg/cm²], reduced neck extension strength [N] (- 11.13, 95%CI:-16.66,-5.6) and increased activity [%] of the trapezius (6.18, 95%CI:2.65,9.71) and anterior scalene muscles (2.87, 95%CI:0.81,4.94) during performance of the cranio-cervical flexion test; c) compared to controls, CGH patients exhibit decreased neck flexion (- 33.70, 95%CI:-47.23,-20.16) and extension (- 55.78, 95%CI:-77.56,-34.00) strength [N].

CONCLUSION

The FRT and neck flexion strength could support the differential diagnosis of CGH from migraine. Several physical tests were found to differentiate both headache types from asymptomatic individuals. Nevertheless, additional high-quality studies are required to corroborate these findings.

STUDY REGISTRATION

Following indications of Prisma-P guidelines, this protocol was registered in PROSPERO on 21/05/2019 with the number CRD42019135269 . All amendments performed during the review were registered in PROSPERO, indicating the date and what and why was changed.

Manual joint mobilisation techniques, supervised physical activity, psychological treatment, acupuncture and patient education for patients with tension-type headache. A systematic review and meta-analysis

Background

Tension-type headache (TTH) has been ranked the second most prevalent health condition worldwide. Non-pharmacological treatments for TTH are widely used as a supplement or an alternative to medical treatment. However, the evidence for their effects are limited. Therefore, the aim of this study was to review the evidence for manual joint mobilisation techniques, supervised physical activity, psychological treatment, acupuncture and patient education as treatments for TTH on the effect of headache frequency and quality of life.

Methods

A systematic literature search was conducted from February to July 2020 for clinical guidelines, systematic reviews, and individual randomised controlled trials (RCT). The primary outcomes measured were days with headache and quality of life at the end of treatment along with a number of secondary outcomes. Meta-analyses were performed on eligible RCTs and pooled estimates of effects were calculated using the random-effect model. The overall certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach (GRADE). In addition, patient preferences were included in the evaluation.

Results

In all, 13 RCTs were included. Acupuncture might have positive effects on both primary outcomes. Supervised physical activity might have a positive effect on pain intensity at the end of treatment and headache frequency at follow-up. Manual joint mobilisation techniques might have a positive effect on headache frequency and quality of life at follow-up. Psychological treatment might have a positive effect on stress symptoms at the end of treatment. No relevant RCTs were identified for patient education. The overall certainty of evidence was downgraded to low and very low. No serious adverse events were reported. A consensus recommendation was made for patient education and weak recommendations for the other interventions.

Conclusion

Based on identified benefits, certainty of evidence, and patient preferences, manual joint mobilisation techniques, supervised physical activity, psychological treatment, acupuncture, and patient education can be considered as non-pharmacological treatment approaches for TTH. Some positive effects were shown on headache frequency, quality of life, pain intensity and stress symptoms. Few studies and low sample sizes posed a challenge in drawing solid conclusions. Therefore, high-quality RCTs are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-021-01298-4.

Effectiveness of different physiotherapy interventions in the management of cervicogenic headache: a pilot randomized controlled trial

BACKGROUND

Cervicogenic headache is a secondary headache which leads to decreased functional activity, quality of life and functional disability.

OBJECTIVE

To determine the feasibility and acceptability of different physiotherapy interventions in the management of cervicogenic headache and to determine sample size for a full trial.

TRIAL DESIGN

A pilot randomized controlled trial.

SETTINGS

Various physiotherapy outpatient department.

METHODS

Participants suffering from cervicogenic headache with age 20- 60 years were randomly allocated into four groups. Sessions were given over 4 weeks 4 times a week (16 sessions). The primary outcomes were feasibility of participant recruitment, assessment procedure, retention, adherence, and acceptability. The secondary outcomes were headache impact test-6 for a headache disability, headache diary for headache intensity, frequency, duration, and neck disability index for neck pain, disability measured at baseline, 4th week, and follow up after 1 month.

RESULT

178 subjects were screened based on selection criteria. Out of them, 93 (52%) were eligible and 80 (86%) participated in the study. 96.25% of participants completed the final 8-week assessment. Overall 93.75% of participants completed the entire assessment item across all time points. 95% completed all treatment sessions. 97.5-100% of participants were satisfied with the treatment protocol. No adverse effects were reported by participants. Based on the data obtained from the pilot trial, sample size was determined as 35 participants in each group.

CONCLUSION

The results indicate that the trial methodology and intervention are feasible for implementing a full-powered randomized controlled trial to determine the effectiveness of physiotherapy intervention in the management of cervicogenic headache.

Thoracic spine thrust manipulation for individuals with cervicogenic headache: a crossover randomized clinical trial

Objective: To determine if thoracic spine manipulation (TSM) improves pain and disability in individuals with cervicogenic headache (CeH).Methods: A randomized controlled crossover trial was conducted on 48 participants (mean age: 34.4 years) with CeH symptoms. Participants were randomized to 6 sessions of TSM or no treatment (Hold) and after 4-weeks, groups crossed over. Outcomes were collected at 4, 8 and 12 weeks and included: headache disability inventory (HDI), neck disability index (NDI), and the global rating of change (GRC). Outcomes were analyzed using a linear mixed-effects model with Bonferroni correction. Odds of achieving the minimal clinically important difference (MCID) on the GRC of +4 or greater were also calculated. Scores at 4 weeks represent the only timepoint where 1 group is fully treated and other group has not received any treatment.Results: Comparing hold to active treatment, HDI were not significantly different between groups (mean difference = 7.39, 95 CI: -4.39 to 19.18; P = 0.214) at any timepoint; the NDI was significant (mean difference = 6.90, 95 CI: 0.05 to 13.75; P = 0.048) at 4 weeks. Odds of achieving the +4 MCID on the GRC (OR = 38.0, 95 CI: 6.6 to 220.0; p < 0.001) favored TSM at 4 weeks.Conclusion: TSM had no effect on headache-related disability but resulted in significant improvements in neck-related disability and participant reported perceived improvement. Future studies are needed to examine the long-term impact of TSM in this population.

Neck pain associated with migraine does not necessarily reflect cervical musculoskeletal dysfunction

OBJECTIVE

To identify how frequently the neck pain associated with migraine presents with a pattern of cervical musculoskeletal dysfunction akin to cervical musculoskeletal disorders, and to determine if pain hypersensitivity impacts on cervical musculoskeletal function in persons with migraine.

BACKGROUND

Many persons with migraine experience neck pain and often seek local treatment. Yet neck pain may be part of migraine symptomology and not from a local cervical source. If neck pain is of cervical origin, a pattern of musculoskeletal impairments with characteristics similar to idiopathic neck pain should be present. Some individuals with migraine may have neck pain of cervical origin, whereas others may not. However, previous studies have neglected the disparity in potential origins of neck pain and treated persons with migraine as a homogenous group, which does not assist in identifying the origin of neck pain in individuals with migraine.

METHODS

This cross-sectional, single-blinded study was conducted in a research laboratory at the University of Queensland, Australia. Persons with migraine (total n = 124: episodic migraine n = 106, chronic migraine = 18), healthy controls (n = 32), and persons with idiopathic neck pain (n = 21) were assessed using a set of measures typically used in the assessment of a cervical musculoskeletal disorder, including cervical movement range and accuracy, segmental joint dysfunction, neuromuscular and sensorimotor measures. Pain hypersensitivity was assessed using pressure pain thresholds and the Allodynia Symptom Checklist. People with migraine with diagnoses of comorbid neck disorders were excluded. Cluster analysis was performed to identify how participants grouped on the basis of their performance across cervical musculoskeletal assessments. Post hoc analyses examined the effects of pain hypersensitivity on musculoskeletal function, and if any symptoms experienced during testing were related to musculoskeletal function.

RESULTS

Two distinct clusters of cervical musculoskeletal function were found: (i) neck function similar to healthy controls (n = 108) and (ii) neck dysfunction similar to persons with neck pain disorders (n = 69). Seventy-six of the individuals with migraine (62 with neck pain and 14 without neck pain) were clustered as having normal cervical musculoskeletal function, whereas the remaining 48 with neck pain had cervical dysfunction comparable with a neck disorder. Musculoskeletal dysfunction was not related to pain hypersensitivity or symptoms experienced during testing.

CONCLUSIONS

Neck pain when present with migraine does not necessarily indicate the existence of cervical musculoskeletal dysfunction. Skilled assessment without reliance only on the person reporting symptoms is needed to identify actual cervical dysfunction. Treatments suitable for neck musculoskeletal disorders would seem inappropriate for the individuals without cervical dysfunction. Future studies evaluating any potential effects of such treatments should only select participants with neck pain of cervical origin.

Cervicogenic Headache: Current Perspectives

Background

Cervicogenic headache is a distinct type of headache described in 1980s by Sjaastad, a Norwegian neurologist. It is a not so uncommon headache, which is usually under-diagnosed resulting in suboptimal quality-of-life.

Objective

The aim of this study was to review the current recommendations on diagnosis and management of cervicogenic headache.

Methods and Material

A PubMed search was done for the recent articles on 'cervicogenic headache' published in English literature with the aim of recognizing the current perspectives on cervicogenic headache.

Results

The diagnosis of cervicogenic headache is based on clinical criteria mentioned by the International Headache Society (IHS) and Cervicogenic Headache International Study Group (CHISG). Cervical nerve block may confirm the nociceptive source in majority of cases and is included in CHISG criteria. Non-invasive diagnostic methods like echogenicity of muscles, diffusion tensor imaging (DTI) and single-photon emission tomography (SPECT) are proposed by some authors for avoiding complications associated with blocks. Mainstay of management is physical therapy. Surgical interventions for cervical degenerative disease may relief an associated headache but such interventions are not performed solely for cervicogenic headache.

Conclusion

Headaches with a cervical spine nociceptive source are increasingly being recognized. Current diagnostic criteria and management options are reviewed here.

Assessment of the efficacy of tuina on treating cervicogenic headache: A protocol for systematic review and meta-analysis

BACKGROUND

Cervicogenic headache is a secondary headache characterized by unilateral headache, symptoms, and signs of neck involvement. It is often worsened by neck movement, sustained awkward head position, or external pressure over the upper cervical or occipital region on the symptomatic side. In this systematic review, we aimed to evaluate the efficacy and safety of massage therapy for the treatment of cervicogenic headache.

METHODS

We searched the China National Knowledge Infrastructure, Chinese Scientific Journal Database, Wanfang Database, China Doctoral Dissertations Full-Text Database, China Master's Theses Full-Text Database, Cochrane Central Register of Controlled Trials, PubMed, and Embase. We will select all eligible studies published on or before April 1, 2021. We will use Review Manager 5.4, provided by the Cochrane Collaborative Network for statistical analysis. We then assessed the quality and risk of the included studies and observed the outcome measures.

RESULTS

This meta-analysis further confirmed the benefits of tuina in the treatment of cervicogenic headache.

CONCLUSION

The purpose of this meta-analysis was to explore the effect of tuina on patients with cervicogenic headache and to provide more options for clinicians and patients to treat cervicogenic headache.

ETHICS AND DISSEMINATION

This systematic review will evaluate the efficacy and safety of tuina in the treatment of cervicogenic headache. Since all the data included were published, the systematic review did not require ethical approval.

REGISTRATION NUMBER

INPLASY202150053.

Dry Needling for the Treatment of Tension-Type, Cervicogenic, or Migraine Headaches: A Systematic Review and Meta-Analysis

OBJECTIVE

Dry needling is a treatment technique used by clinicians to relieve symptoms in patients with tension-type headache (TTH), cervicogenic headache (CGH), or migraine. This systematic review's main objective was to assess the effectiveness of dry needling on headache pain intensity and related disability in patients with TTH, CGH, or migraine.

METHODS

Medline/PubMed, Scopus, Embase, PEDro, Web of Science, Ovid, Allied and Complementary Medicine Database/EBSCO, Cochrane Central Register of Controlled Clinical Trials, Google Scholar, and trial registries were searched until April 1, 2020, along with reference lists of eligible studies and related reviews. Randomized clinical trials or observational studies that compared the effectiveness of dry needling with any other interventions were eligible for inclusion. Three reviewers independently selected studies, extracted data, and assessed risk of bias. Random-effects meta-analyses were performed to produce pooled-effect estimates (Morris dppc2) and their respective CIs.

RESULTS

Of 2715 identified studies, 11 randomized clinical trials were eligible for qualitative synthesis and 9 for meta-analysis. Only 4 trials were of high quality. Very low-quality evidence suggested that dry needling is not statistically better than other interventions for improving headache pain intensity in the short term in patients with TTH (SMD -1.27, 95% CI = -3.56 to 1.03, n = 230), CGH (SMD -0.41, 95% CI = -4.69 to 3.87, n = 104), or mixed headache (TTH and migraine; SMD 0.03; 95% CI = -0.42 to 0.48, n = 90). Dry needling provided significantly greater improvement in related disability in the short term in patients with TTH (SMD -2.28, 95% CI = -2.66 to -1.91, n = 160) and CGH (SMD -0.72, 95% CI = -1.09 to -0.34, n = 144). The synthesis of results showed that dry needling could significantly improve headache frequency, health-related quality of life, trigger point tenderness, and cervical range of motion in TTH and CGH.

CONCLUSIONS

Dry needling produces similar effects to other interventions for short-term headache pain relief, whereas dry needling seems to be better than other therapies for improvement in related disability in the short term.

IMPACT

Although further high-methodological quality studies are warranted to provide a more robust conclusion, our systematic review suggested that for every 1 or 2 patients with TTH treated by dry needling, 1 patient will likely show decreased headache intensity (number needed to treat [NNT] = 2; large effect) and improved related disability (NNT = 1; very large effect). In CGH, for every 3 or 4 patients treated by dry needling, 1 patient will likely exhibit decreased headache intensity (NNT = 4; small effect) and improved related disability (NNT = 3; medium effect).

The association between specific temporomandibular disorders and cervicogenic headache

BACKGROUND AND AIMS

Upper neck signs, symptoms and hypomobility have been shown to present with a higher prevalence in patients with temporomandibular disorders (TMDs). However, there is currently no evidence of an association between specific TMDs and cervicogenic headache (CGH). Therefore, the aim of this study was to evaluate the odds ratio and the relative risk of CGH in patients with specific TMDs.

METHOD

116 participants, including 74 patients with TMD (pain-related/intraarticular/mixed TMD) and 42 healthy controls took part in this study. The TMD diagnosis was made by senior faculty members of the Dental School according to the Diagnostic Criteria for TMD, while the cervical diagnosis was made by a qualified senior physical therapist. The analysis comprised the evaluation of the odds ratio of CGH among patients with TMD and the relative risk (RR) for CGH during 14-24 months of follow-up.

RESULTS

Significantly higher odds ratios of cervicogenic headache were found among pain-related and mixed TMD (12.17 and 10.76, respectively) versus healthy controls. During the 14-24 months of follow-up, there was no significant difference of relative risk for CGH among patients with TMD versus healthy controls.

SUMMARY AND CONCLUSIONS

The results support a clear clinical association between painful TMD (pain-related and mixed TMD) and cervicogenic headache.

Consensus among musculoskeletal experts for the management of patients with headache by physiotherapists? A delphi study

BACKGROUND

Though a large amount of research on the management of headache has been conducted, the clinical effectiveness of these treatments remains unclear.

OBJECTIVES

To reach consensus among international musculoskeletal experts on what the most appropriate management is in patients that suffer from headache.

DESIGN

Expert group and Delphi-study.

METHODS

A total of 11 experts participated in the expert panel groups, where the role of physiotherapy in the management of headache was discussed. Afterwards, 14 of the initial 25 participants in the field of headache completed the whole Delphi study, which was conducted over 4 rounds. The first round aimed to identify clinical indicators and treatments that are useful in patients with headache. These questions were then categorized and ranked during the second, third, and fourth rounds. Consensual agreement was set at ≥ 80%.

RESULTS

After the final round, 9 interventions were rated as useful by the participants. In the final extra round, 14 clinical indicators were retrieved as important to decide whether or not to start one of the consensual treatments. The top 3 management strategies were (1) upper cervical spine mobilisations in cervivogenic headache, (2) active mobilisation exercises of the cervical spine in cervivogenic headache, and (3) lifestyle advice in tension-type headache and migraine.

CONCLUSION

International experts agreed that most scientifically established effective treatments are useful in cervicogenic headache. Consensual agreement on treatments for migraine and tension-type headache were only reached for specific treatments. Their recommendations provide a framework for further research and the clinical management of headache.

Does restoration of sagittal cervical alignment improve cervicogenic headache pain and disability: A 2-year pilot randomized controlled trial

BACKGROUND

To investigate the feasibility and effect of a multimodal program for improving chronic cervicogenic headache (CGH) via the addition of sagittal cervical spine alignment correction.

DESIGN

Pilot, parallel-group, randomized controlled trial.

PARTICIPANTS

60 patients with CGH, straightening of the cervical lordosis, and forward head posture (FHP) were randomly assigned using permuted-block randomization either to a control (n = 30) or an experimental group (n = 30).

INTERVENTIONS

Subjects in both groups received a multimodal program where the denneroll cervical spine extension traction orthotic was added to the experimental group only. Feasibility was assessed through recruitment rate, compliance rate, adherence rate, safety, and global satisfaction in addition to clinical outcome measures: FHP distance, cervical lordosis, headache frequency, headache disability inventory (HDI), headache impact test-6 (HIT-6), and daily defined dose (DDD). Evaluations were performed at: baseline, 10 weeks, 1 year follow up, and 2-year follow up. The assessor was blind to group allocation for all measured outcomes.

RESULTS

The recruitment rate was 60%, 78 % out of them completed the entire study. The recruited participants complied with 98% of the required visits. No adverse events were recorded and greater overall satisfaction with the interventions was reported. Greater improvements were found for the experimental group's cervical lordosis (f = 259.9, P< < .001) and FHP (f = 142.5, P< < .001). At 10 weeks, both groups showed equal improvements in CGH outcomes: headache frequency (P = 0.07), HDI (P = 0.07), HIT-6 (P = .2), and DDD (P = .3). In contrast, at the 1-year and 2-year follow up, between group differences were found for all CGH outcomes, P < .00, indicating greater improvement in the experimental group.

CONCLUSION

The results indicated feasibility for recruitment rate, compliance rate, exercise session adherence, safety, and global satisfaction. At 1-year and 2-year follow-up, the addition of the denneroll orthotic device revealed positive influence on CGH management outcomes.

TRIAL REGISTRATION

The trial was retrospectively registered with the Pan African Clinical Trial Registry (PACTR201605001650300).

The Effectiveness of Sternocleidomastoid Muscle Dry Needling in Patients with Cervicogenic Headache

BACKGROUND

Cervicogenic headache (CGH) is a secondary headache with a cervical source that radiates pain to the head or face. Accordingly, one reason of CGH is myofascial trigger points. The purpose of this study was to investigate the effect of one session dry needling (DN) of myofascial trigger points of the sternocleidomastoid (SCM) muscle in patients with CGH.

MATERIALS AND METHODS

In this before-and-after clinical trial, 16 females aged 18-60 years with a clinical diagnosis of CGH were enrolled. All of the patients received one session DN into the myofascial trigger points of the SCM muscle. Headache index (HI), headache duration, headache frequency, and headache disability index (HDI) were assessed at 2 weeks before and 2 weeks after the intervention. This study was registered in Clinical Trials as IRCT20181109041599N1.

RESULTS

One session DN into myofascial trigger points of the SCM muscle showed a significant improvement in HI (P < 0.001). Duration and frequency of headache as well as HDI significantly reduced after intervention (P < 0.001).

CONCLUSION

One session DN into myofascial trigger points of the SCM muscle was effective on improvement of HI, headache duration, headache frequency, and HDI in patients with CGH.