A multicenter, prospective, single-arm study of 60-day peripheral nerve stimulation of the occipital nerves for the treatment of headache

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of a 60-day peripheral nerve stimulation (PNS) treatment targeting the occipital nerves for reducing pain and improving function in individuals diagnosed with cervicogenic headache or occipital neuralgia.

BACKGROUND

Headache conditions are prevalent and commonly disabling, and conventional therapeutic strategies are often insufficient. Development of a percutaneous 60-day PNS treatment has created new opportunities to evaluate PNS of the occipital nerves.

METHODS

This study was an institutional review board-approved, multicenter, prospective, single-arm study that enrolled participants from October 2022 to March 2024. Participants with cervicogenic headache or occipital neuralgia received a 60-day PNS treatment targeting the occipital nerves. The primary endpoint was the proportion reporting clinically significant (≥30%) reductions in average pain and/or pain interference at end of treatment (EOT). Additional analysis included the proportion of participants with ≥50% reduction in average pain intensity and/or pain interference and additional outcomes including Patient Global Impression of Change, six-item Headache Impact Test, and Neck Disability Index.

RESULTS

At EOT, 90% of participants (18/20) met the primary endpoint. Further, 85% (17/20) and 83% (15/18) reported ≥50% reductions in pain and/or pain interference at EOT and 3 months, respectively. Clinically meaningful improvements were observed in functional and headache-related disability and quality-of-life measures. All study-related adverse events were non-serious.

CONCLUSION

Most participants reported significant reductions in pain and/or pain interference following 60-day PNS targeting the occipital nerves. Outcomes through 3 months demonstrate how 60-day PNS offers an effective approach for the treatment of headache.

Clinical features, risk factors, and a nomogram for predicting refractory cervicogenic headache: a retrospective multivariate analysis

Introduction

Given the intricate nature and varied symptoms of cervicogenic headache, its treatment can be challenging, potentially leading to refractory cervicogenic headache. We aimed to identify risk factors that could help predict the development of refractory cervicogenic headache in patients with cervicogenic headache.

Methods

This is a retrospective cohort study of patients diagnosed with cervicogenic headache between January 1, 2022 and March 1, 2024 who underwent greater occipital nerve block. Data were collected by reviewing patients' medical records and pain questionnaires. Covariates were selected using univariate and multivariate logistic regression analyses. A predictive nomogram model was developed to predict the unresponsiveness of the greater occipital nerves to anesthetic blockade.

Results

Of the 82 patients studied, 46 experienced relief from headache following greater occipital nerve blocks, whereas 36 did not. In a multivariate analysis of patients with refractory cervicogenic headache, factors such as C2-C3 sensory loss [odds ratio (OR) = 13.10, 95% confidence interval (CI): 1.45-118.54], bilateral headache (OR = 7.99, 95% CI: 1.36-47.07), having two or more types of pain sources (OR = 5.51, 95% CI: 1.01-30.16), and limited cervical range of motion (>1) (OR = 13.05, 95% CI: 2.28-74.59) were identified as major prognostic indicators of unresponsiveness to greater occipital nerve blocks in cases of large occipital and cervical spine-related factors.

Conclusion

Patients with severely limited cervical spine mobility, bilateral headaches, and C2-C3 sensory loss may not respond well to greater and lesser occipital nerve block therapy. Pain originating from multiple sources is typically associated with less favorable outcomes.

Prevalence and relative frequency of cervicogenic headache in population- and clinic-based studies: A systematic review and meta-analysis

BackgroundCervicogenic headache is a rare headache disorder which is garnering increasing clinical and research interest, but whose prevalence and clinical phenotype is surrounded by uncertainty. We found it timely to systematically appraise the current literature on prevalence, relative frequency, and clinical features of cervicogenic headache in population- and clinic-based settings.MethodsPubMed and Embase were searched for observational, population- and clinic-based studies published between 1 January 1942 and 3 September 2024 that reported on the prevalence and relative frequency of cervicogenic headache, diagnosed according to the International Classification of Headache Disorders. The titles, abstracts, and full text-articles were screened by two independent investigators. To estimate prevalence and pooled relative frequency of cervicogenic headache across clinic- and population-based studies, random-effects meta-analyses were conducted. The study was pre-registered on PROSPERO (identifier: CRD42024498128) and reported in accordance with the Guidelines for Meta-Analyses of Observational Studies in Epidemiology.ResultsThree studies met the inclusion criteria from the International Classification of Headache Disorders for diagnosing cervicogenic headache. One was population-based reporting on the prevalence and two were clinic-based reporting on the relative frequency of cervicogenic headache among adult patients who were evaluated for headache in a tertiary care unit. The one population study reported a prevalence of 3.9% with females representing 77.8% of those affected. In the two clinic-based studies, the relative frequency was found to be 3.1% (95%, CI, 2.6-3.8) amongst the adult outpatient population of 3165 patients evaluated for headache, with women representing 80.8% (95%, CI, 71.9-87.4).ConclusionsBased on this meta-analysis, data on the prevalence and relative frequency of cervicogenic headache are limited. The scarcity of data stresses the need for further research into cervicogenic headache, the diagnostic criteria, and its current position in the International Classification of Headache Disorders.

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.

Effects of sustained natural apophyseal glides versus rocabado 6 × 6 program in subjects with cervicogenic headache

BACKGROUND

Cervicogenic headache is designated as the most common type of secondary headache that results from conditions affecting the neck's bony components, muscles, and intervertebral discs rather than the head itself.

OBJECTIVE

The purpose was to determine the effects of Sustained Natural Apophyseal Glides (SNAGs) versus the Rocabado 6 × 6 program in subjects with cervicogenic headaches.

METHODS

This study was a randomized clinical trial. The sample size was 38, and participants aged 20-60 years (mean age 40.22 ± 9.66) suffering from cervicogenic headaches were randomly allocated using the lottery method into two groups with 19 participants in each group. Assessment of subjects was done before starting treatment and by the end of the 8th week for all the variables. Outcome measures were the Neck Disability Index (NDI), 6-item Headache Impact Test (HIT-6), Flexion-Rotation test (FRT) to assess the rotation range of motion at the level of C1-C2 (goniometer) and the Numeric Pain Rating Scale (NPRS) for the intensity of pain. Data analysis was done by SPSS (IBM) 25. To check the normality of the data the Shapiro-Wilk test was used.

RESULTS

In the Shapiro-Wilk test p-value of all the testing variables i.e. NDI, HIT-6 score, FRT and NPRS was > 0.05, data was normally distributed and parametric tests were used. Group A showed a considerable improvement (p < 0.05) in all variables compared to Group B, while within-group analysis of both groups shows that all outcome measures show significant results (p < 0.05).

CONCLUSION

It was concluded that both SNAGs and Rocabado's 6 × 6 exercises were effective for the treatment of cervicogenic headache but the effects of headache SNAG were superior and produced more improvement in intensity of headache, disability, frequency of headache, duration of headache as compared to Rocabado 6 × 6 exercises.

TRIAL REGISTRATION NUMBER

This study was registered at ClinicalTrials.gov ID: NCT05865808 on date 19/05/2023.

Cranial Autonomic Symptoms and Neck Pain in Differential Diagnosis of Migraine

Cranial autonomic symptoms and neck pain have been reported to be highly prevalent in migraine, although they are rarely considered in clinical evaluation. The aim of this review is to focus on the prevalence, pathophysiology, and clinical characteristics of these two symptoms, and their importance in the differential diagnosis between migraines and other headaches. The most common cranial autonomic symptoms are aural fullness, lacrimation, facial/forehead sweating, and conjunctival injection. Migraineurs experiencing cranial autonomic symptoms are more likely to have more severe, frequent, and longer attacks, as well as higher rates of photophobia, phonophobia, osmophobia, and allodynia. Cranial autonomic symptoms occur due to the activation of the trigeminal autonomic reflex, and the differential diagnosis with cluster headaches can be challenging. Neck pain can be part of the migraine prodromal symptoms or act as a trigger for a migraine attack. The prevalence of neck pain correlates with headache frequency and is associated with treatment resistance and greater disability. The convergence between upper cervical and trigeminal nociception via the trigeminal nucleus caudalis is the likely mechanism for neck pain in migraine. The recognition of cranial autonomic symptoms and neck pain as potential migraine features is important because they often contribute to the misdiagnosis of cervicogenic problems, tension-type headache, cluster headache, and rhinosinusitis in migraine patients, delaying appropriate attack and disease management.

The Significance of Pain Drawing as a Screening Tool for Cervicogenic Headache and Associated Symptoms in Chronic Fatigue

Purpose

Patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) present with a broad spectrum of symptoms, including headache. A simple, yet powerful tool – the pain drawing identifies essential aspects such as pain distribution. The aim with this study was to 1) evaluate the significance of pain drawing as a screening tool for cervicogenic headache using a predefined C2 pain pattern, 2) assess whether there was an association between dizziness/imbalance and a C2 pain pattern, and 3) compare subgroups according to the pain drawing with respect to pain characteristics and quality of life.

Patients and Methods

Pain drawings and clinical data from 275 patients investigated for ME/CFS were stratified into: 1) cervicogenic headache as determined by a C2 pain pattern, 2) headache with no C2 pain pattern, and 3) no headache. For inference logistic regression presented with odds ratios (OR) and 95% confidence intervals (95% CI) and Kruskal–Wallis test were applied.

Results

One hundred sixteen participants (42%) were stratified to the group for which the pain drawing corresponded to the C2 pain pattern, thus indicating putative cervicogenic origin of the headache. Dizziness/imbalance was strongly associated with a C2 pain pattern; OR 6.50 ([95% CI 2.42–17.40] p ˂ 0.00), whereas this association was non-significant for patients with headache and no C2 pain pattern. Those demonstrating a C2 pain pattern reported significantly higher pain intensity (p = 0.00) and greater pain extent (p = 0.00) than the other groups, and lower health-related quality of life (p = 0.00) than the group with no headache.

Conclusion

For patients with chronic fatigue who present with a C2 pain pattern (interpreted as cervicogenic headache) the pain drawing seems applicable as a screening tool for signs associated with neuropathic and more severe pain, dizziness and reduced quality of life as detection of these symptoms is essential for targeted treatment.

Digital pain extent is associated with pain intensity but not with pain-related cognitions and disability in people with chronic musculoskeletal pain: a cross-sectional study

Background

To evaluate whether digital pain extent is associated with an array of psychological factors such as optimism, pessimism, expectations of recovery, pain acceptance, and pain self-efficacy beliefs as well as to analyse the association between digital pain extent and pain intensity and pain-related disability in people with chronic musculoskeletal pain.

Methods

A descriptive cross-sectional study conducted in a primary health care setting was carried out including 186 individuals with chronic musculoskeletal pain. Patient-reported outcomes were used to assess psychological factors, pain intensity, and pain-related disability. Digital pain extent was obtained from pain drawings shaded using a tablet and analysed using novel customized software. Multiple linear regression models were conducted to evaluate the association between digital pain extent and the aforementioned variables.

Results

Digital pain extent was statistically significantly associated with pain intensity. However, digital pain extent was not associated with any psychological measure nor with pain-related disability.

Discussion

The results did not support an association between digital pain extent and psychological measures.

Prevalence of trigeminocervical convergence mechanisms in episodic and chronic migraine

BACKGROUND

Migraine pain location and trigeminocervical convergence have limited diagnostic value and have usually been assessed using non-standard verbal descriptors in a small number of centers.

OBJECTIVE

To use non-verbal descriptors of migraine pain location to determine the prevalence of trigeminocervical convergence mechanisms in patients with episodic and chronic migraine. In addition, we explored the factors associated with the presence of convergence.

METHODS

A multicenter study was carried out. The explicit pain location was explored by asking subjects to indicate, on an electronic form, three points on the anterolateral side and three points on the posterolateral side of the head and neck that represented the common locations of their migraine pain. We evaluated associations of the pain pattern with demographic and psychological features, comorbidities, lifestyle and other headache characteristics.

RESULTS

97 episodic and 113 chronic migraine patients were included. Convergence was present in 116 migraineurs (55%) who indicated dominance of pain in the posterior cervical region. This site was more often involved in the chronic migraine group (21 vs. 33%; p=0.034). The number of migrainous/altered sensitivity symptoms (OR=1.39; 95%CI 1.14-1.71) was associated with convergence independently of the chronification status. In this symptom group, there were statistical associations between convergence and vomiting (p=0.045), tactile allodynia (p<0.001), nuchal rigidity (p<0.001) and movement allodynia (p=0.031).

CONCLUSIONS

Trigeminocervical convergence is common in migraineurs and, in practice, it might be found frequently in chronic migraineurs. Some features commonly found in this group, such as altered sensitivity symptoms, are associated with this phenomenon.

The Spatial Extent of Pain Is Associated with Pain Intensity, Catastrophizing and Some Measures of Central Sensitization in People with Frozen Shoulder

The aim of this cross-sectional study was to explore the spatial extent of pain and its association with clinical symptoms, psychological features, and pain sensitization in people with frozen shoulder (FS). Forty-eight individuals with FS completed pain drawings (PDs) and reported their clinical symptoms including pain intensity (Visual Analogue Scale) and shoulder disability (Shoulder Pain and Disability Index). Moreover, pain sensitization measurements (pressure pain thresholds, temporal summation, conditioned pain modulation, and Central Sensitization Inventory (CSI)) were assessed. Psychological features were assessed by Pain Catastrophizing Scale (PCS) and Pain Vigilance and Awareness Questionnaire. Pain frequency maps were generated, Margolis rating scale was used for pain location, and Spearman correlation coefficients were computed. The mean (SD) pain extent was 12.5% (6.7%) and the most common painful area was the anterolateral shoulder region (100%). Women presented a more widespread pain distribution compared with men. Significant positive associations were obtained between pain extent and current pain intensity (rs = 0.421, p < 0.01), PCS (rs = 0.307, p < 0.05) and CSI (rs = 0.358, p < 0.05). The anterolateral region of the shoulder was the most common painful area in people with FS. Women with FS presented more extended areas of pain; and a more widespread distribution of pain was correlated with higher levels of pain, pain catastrophizing and pain sensitization.

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.

The Relationship Among Pain Location, Complications, and Quality of Life in Individuals With Fibromuscular Dysplasia

BACKGROUND

Fibromuscular dysplasia (FMD), a nonatherosclerotic arterial disease, can cause pain and vascular complications. The aim of this study was to examine the impact of FMD symptoms and complications on quality of life, depression, anxiety, and self-rated health.

DESIGN

This was a cross-sectional, correlational study.

METHODS

Participants were adults with a diagnosis of FMD. Quality of life (36-Item Short Form Health Survey), anxiety and depression (Patient-Reported Outcomes Measurement Information System [PROMIS®]), self-rated health question, and symptom/complication questionnaires were mailed to patients with FMD. Scores were compared with symptoms and complications. Multivariable linear models were fit for symptoms and survey scores. Ordinal regression was used for self-rated health. Backwards selection was run for each model. Alpha of 0.05 and 95% confidence intervals were used.

RESULTS

Of the 162 (275 total; 47.8%) patients who returned surveys (156 female), 130 had carotid or vertebral artery involvement (80.2%). Migraine (p < .001), neck pain (p = .036), and flank pain (p = .025) were associated with decrease in Mental Component scores. Migraine (p = .002) and neck pain (p = .023) were associated with lower Physical Component scores. Patients reporting abdominal pain compared with those without had 4.88 points higher depression. Abdominal pain (p = .031) and pulsatile tinnitus (p = .011) were associated with greater anxiety. Migraine was associated with (p = .002) lower self-rated health. Participants with history of stroke/transient ischemic attack had 2.42 (1.08, 5.46; p = .033) times the odds of poor self-rated health compared with those without stroke/transient ischemic attack.

CONCLUSIONS

Among patients with FMD, presence of pain and history of vascular complications were related to lower quality of life and self-rated health.

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.

Inter, intra-examiner reliability and validity of inertial sensors to measure the active cervical range of motion in patients with primary headache

We analyzed the inter- and intra-examiner reliability of Werium inertial sensors and the cervical range of motion (CROM) instrument for the measurement of active CROM (AcROM) in patients with primary headache. Another objective is to analyze the validity of the inertial sensors (Werium). The literature has reported symptomatology features in patients diagnosed with primary headache similar to that of patients with cervicogenic headache. The International Classification of Headache (ICHD-III) established the presence of reduced AcROM as a diagnostic criterion for cervicogenic headache. Several instruments are used for this measurement, with limitations in their applicability in daily clinical practice. A prospective longitudinal repeated measures study was conducted to assess the intra- and inter-rater reliability and validity of Werium inertial sensors in 20 adults with chronic primary headache. For the inter-rater analysis, the intraclass correlation coefficient (ICC) values were above 0.75 for all movements, indicating a good level of reliability. For the intra-rater results, the ICC values obtained by the Werium inertial sensors for all cervical movements were good for rater A (ICC >0.80) and rater B (ICC >0.84). For the validity, the ICCs obtained by the Werium inertial sensors compared with the CROM instrument for all cervical movements were moderate for both raters (ICC > 0.70, respectively). Values obtained in the standard error of measurement, minimum detectable change at 90% and limits of agreement also indicated good agreement. Werium inertial sensors have shown good to excellent reliability results, both intra- and inter-examiner (ICC > 0.75). Likewise, when the sensors were compared with another validated instrument (CROM device) they obtained high reliability results (ICC > 0.70). These results plus its relatively low price and ease of use allow us to recommend it in daily clinical practice to measure AcROM in patients with chronic primary headache.

Digital pain drawings are a useful and reliable tool for assessing patients with temporomandibular disorders

BACKGROUND

Temporomandibular disorders (TMD) are characterised by complex symptomatology and their assessment can be enhanced using pain drawings (PD).

OBJECTIVES

To evaluate the location and extent of pain in people TMD using digital PD, and to explore their association with clinical features. Reliability of pain extent and pain location using PD was also assessed.

METHODS

Forty volunteers with TMD completed two consecutive digital PDs. Clinical features were captured from self-reported questionnaire. Additionally, secondary hyperalgesia was measured using the pressure pain threshold (PPT). The correlation between pain extent and clinical features was investigated using Spearman rank correlation coefficients. Reliability of pain extent was evaluated using intraclass correlation coefficient (ICC) and Bland-Altman plots. The Jaccard index was computed to assess the reliability of pain location.

RESULTS

Analysis of the PDs indicated that people with TMD commonly experience pain in other body regions including the neck, the shoulder and the low back. Except for PPT and pain catastrophising, all other clinical features were significantly correlated with pain extent. The ICCs of pain extent for all body charts were very high (ICCs 95% CI from 0.73 to 0.96), and Bland-Altman plots showed mean biases close to zero with narrow limits of agreement. The reliability of pain location was also supported by Jaccard index mean scores above 0.68.

CONCLUSIONS

People with TMD showed widespread pain, and pain extent was associated with pain intensity, neck and headache-related disability, depression, anxiety, hyperventilation and central sensitivity. The reliability of measuring pain extent and pain location was confirmed.