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

The occurrence of cervicogenic headache: A mapping review

BACKGROUND

Occurrence of cervicogenic headache (CeH), mostly expressed by estimates of the prevalence, ranges between 0.4% and 42%. However, transparency on such estimates is lacking, which hinders generalizing results.

OBJECTIVE

Mapping the occurrence (expressed by incidence/prevalence) of CeH.

DESIGN

Mapping review.

METHOD

A systematic literature search of PubMed, EMBASE, Web of Science, Scopus databases (last search update January 28th, 2025). The search query comprised terminology relating to "CeH", "prevalence", "incidence".

RESULTS

Thirty-four publications were included (prevalence n = 32, incidence n = 2). The prevalence of CeH varied depending on the geographical location (Norway: 0.17% - USA: 69%), population (age: 0.17%-56.7%, chronic headache: 0.17% - computer users: 64.5%), setting (inpatient: 13.8%-69%, outpatient: 0.38%-10%), diagnostic criteria (International Headache Society: 0.38%-40%, Cervicogenic Headache International Study Group: 0.17%-64.5%), and diagnostic process (questionnaires: 5.3%-64.5%, clinical examination: 0.17%-56.7%, diagnostic block: 0.17%-16.1%).

CONCLUSION

Most publications were retrieved from Europe, Asia, and the United States. One multicentre study provided results for the African continent. No conclusion could be drawn on the incidence of CeH. The populations studied (e.g., general, age-stratified, specific), settings (e.g., hospital, private practice, clinics, emergency services), diagnostic criteria (e.g., International Headache Society or Cervicogenic Headache International Study Group) and processes (e.g., questionnaires, clinical examination) were heterogeneous. Four publications required a diagnostic block in the diagnostic process. A standardized methodology, especially regarding the diagnostic criteria and process, is needed to compare studies, guarantee quality, and provide estimates to inform policy makers.

Expert Consensus on Dry Needling Practices for Headache: An International Delphi Study Protocol

Background: Dry needling is increasingly utilized by clinicians in the treatment of patients with headaches. Although current evidence supports the use of dry needling for reducing headache pain, needling approaches are inconsistent among published studies, and no guidelines on dry needling for headaches have been established. Methods: A study will be conducted using the Delphi method, consisting of three rounds of questionnaires sent to an expert panel of clinicians and researchers. Results: To guide the development of the initial survey, we completed a literature review of articles related to dry needling for headaches. A steering committee will assess the initial survey items synthesized from the literature search and provide recommendations for the first and subsequent rounds of the study. Percentage agreement will be the primary measure throughout all rounds of this study. We define consensus to have been reached when 75% agreement is achieved. Conclusions: We seek to develop clinical recommendations that will guide research and treatment practices regarding dry needling for headaches. Having consensus-driven recommendations on dry needling for headaches will assist researchers in the design of future studies on this condition. In addition, having guidelines that clinicians can reference prior to the delivery of dry needling for headaches would benefit patient care.

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.

Interventional neuromodulation techniques for cervicogenic headache

Cervicogenic headache is a debilitating secondary headache condition that reduces the quality of life for many. Its etiology involves pathologies in one or more of the complex cervical structures, such as cervical muscles, ligaments, facet joints, intervertebral discs, and C1-3 nerve roots. Mainstream conservative treatments, such as medication and physical therapy, are designed to address these underlying pathologies. In addition, recent advancements in neurostimulation techniques can aid in treatment-resistant or intolerant cases. This narrative review aims to critically evaluate the current treatment options for cervicogenic headaches, with a special emphasis on the efficacy of novel neuromodulation techniques and identifying their strength and limitations in treating cervicogenic headaches.

Differences in physical examination findings between those who present with or without headache soon after a whiplash injury: a cross-sectional study

AIM

To determine differences in physical examination findings between people with acute whiplash-associated disorders (WAD) with and without headache.

METHODS

In this cross-sectional study, participants with acute WAD were evaluated to assess differences in the presence of physical impairments. The following were assessed: pain intensity on manual palpation the over spinous process of C1-C3, zygapophyseal joints of C0-C4, and trapezius, sternocleidomastoid, suboccipitalis, masseter and temporalis muscles; cervical range of motion (ROM); flexion-rotation test (FRT); forward head posture; cranio-cervical flexion test (CCFT); neck flexor and extensor endurance; pressure-pain thresholds (PPT) over neural structures and upper limb neural tests (ULNT) in addition to median UNLT + CCF. Correlation analyses were performed to assess the association between examination findings and headache intensity. Logistic regression and discriminant analyses were also performed.

RESULTS

Forty-seven participants (26 men and 21 women; mean age = 38.9 years old) were included in the study. 60% of the participants presented with headache. Several examination findings were significantly different between groups. A group of examination findings composed of neck endurance, manual palpation over cervical and muscular structures, PPT, CCFT, ROM and FRT could discriminate between groups with a sensitivity of 86.7% and specificity of 90%.

CONCLUSIONS

Several neuromusculoskeletal features are different between people with acute WAD with or without headache. A combination of features could distinguish between groups with high levels of sensitivity and specificity.

Local Dynamic Stability of Trunk During Gait Can Detect Dynamic Imbalance in Subjects with Episodic Migraine

BACKGROUND/HYPOTHESIS

Motion sensitivity symptoms, such as dizziness or unsteadiness, are frequently reported as non-headache symptoms of migraine. Postural imbalance has been observed in subjects with vestibular migraine, chronic migraine, and aura. We aimed to assess the ability of largest Lyapunov's exponent for a short time series (sLLE), which reflects the ability to cope with internal perturbations during gait, to detect differences in local dynamic stability between individuals with migraine without aura (MO) with an episodic pattern between attacks and healthy subjects (HS).

METHODS

Trunk accelerations of 47 MO and 38 HS were recorded during gait using an inertial measurement unit. The discriminative ability of sLLE was assessed through receiver-operating characteristics curves and cutoff analysis. Partial correlation analysis was conducted between the clinical and gait variables, excluding the effects of gait speed.

RESULTS

MO showed higher sLLE values, and reduced pelvic rotation, pelvic tilt, and stride length values. sLLEML and pelvic rotation showed good ability to discriminate between MO and HS and were correlated with the perceived pain, migraine disability assessment score, and each other.

CONCLUSIONS

these findings may provide new insights into the postural balance control mechanism in subjects with MO and introduce the sLLEML as a potential measure of dynamic instability in MO.

Combined and isolated effects of workstation ergonomics and physiotherapy in improving cervicogenic headache and work ability in office workers: a single-blinded, randomized controlled study

OBJECTIVE

The objective of the study is to compare and investigate the combined and individual effects of workstation ergonomics, physiotherapy and patient education in improving CgH headaches and work ability in office workers.

METHODS

96 eligible CgH participants were divided into the ergonomics modifications group (EMG; n = 24), physiotherapy group (PTG; n = 24), and ergonomics modifications combined with physiotherapy group (EPG; n = 24) and education control group (CNG; n = 24), the participants received the respective treatment for 4 weeks. Primary (CgH frequency) and secondary (CgH pain intensity, CgH disability, flexion rotation test (right and left), neck disability index and work ability) scores were measured. The effects of treatment at various intervals were analyzed with a 4 × 4 linear mixed model analysis (LMM) between treatment groups and time intervals.

RESULTS

Four weeks following training EPG group showed more significant changes in primary outcome CgH frequency; 4.6 CI 95% 3.63 to 5.56 when compare to control group. The same gradual improvement was noticed at 8 weeks 8.2 CI 95% 7.53 to 8.86 and at 6 months follow up 11.9 CI 95% 11.25 to 12.54 when compare to other groups (p = 0.001) which is statistically 52.97% improvement. Similar improvements can be seen in the secondary outcome measures such as CgH pain intensity, CgH disability, flexion rotation test (right and left), neck disability index and work ability in EPG group than the EMG, PTG, and CNG groups (p = 0.001) at 4 weeks, 8 weeks and at 6 months' follow-up.

CONCLUSION

This study observed that the workstation ergonomics and physiotherapy group experienced significantly more improvements in cervicogenic headache patients.

CLINICAL TRIAL REGISTRATION

Identifier NCT05827185.

Reduction of neck pain severity in patients with medication-overuse headache

BACKGROUND

Neck pain and primary headache disorders are highly prevalent in populations and clinical cohorts. Medication-overuse headache (MOH) is a treatable secondary headache, mainly developing in migraine sufferers, that accounts for the majority of patients presenting to headache clinics. Nevertheless, the association between neck pain and MOH has not been reported. This study evaluated the prevalence and clinical course of neck pain in patients with MOH before and after MOH treatment.

METHODS

We analyzed 635 MOH patients enrolled in a nationwide, prospective, multicenter MOH registry. Demographics and clinical data were collected at baseline and 3 months to evaluate changes in the status and severity of neck pain and headache. Severity of neck pain was graded into 4 groups, and severe neck pain was defined as grade 3 or 4.

RESULTS

Among 635 patients with MOH, 366 (57.6%) reported neck pain at baseline. MOH patients with neck pain had an earlier onset of their primary headache disorder (23.4 ± 12.7 vs. 26.2 ± 13.3 years, p = 0.007). Although monthly headache days were comparable between the patients with neck pain and those without neck pain, the neck pain group had higher levels of anxiety (7.4 ± 5.8 vs. 6.4 ± 5.4, p = 0.017), more severe cutaneous allodynia (2.4 ± 3.3 vs. 1.8 ± 3.0, p = 0.038), and poorer quality of life (171.7 ± 70.4 vs. 184.0 ± 68.9, p = 0.029). At 3 months, 456 (71.8%) were followed-up, and 257 (56.4%) were recovered from MOH. Compared to the baseline, the proportion of severe neck pain (40.4% vs. 19.4%, p < 0.001) was decreased. The proportion of severe neck pain was much lower in patients with recovery from MOH compared to those without (4.7% vs. 15.1%, p < 0.001).

CONCLUSIONS

Neck pain in MOH patients was associated with earlier onset of headache, higher levels of anxiety and allodynia, and poorer quality of life. Improvement in neck pain improvement was linked to recovery from MOH. These findings suggest the potential importance of integrating and management of neck pain into clinical practice for MOH.

Debunking myths in headache diagnosis for the pain practitioner

With headache being one of the most common chief complaints, it is essential for pain practitioners to interpret and differentiate a variety of headache characteristics to accurately diagnose and treat specific headache disorders. Certain misconceptions often lead to misdiagnosis. This article presents and discusses six myths about several common headache disorders (migraine, tension-type headache, cluster headache, cervicogenic headache, sinus headache, and occipital neuralgia) often encountered in clinical practice. The discussion is based primarily on the International Classification of Headache Disorders, 3rd edition and the latest studies. Recognizing and understanding the intricacies behind key headache diagnoses will help providers devise appropriate plans to better care for their patients.

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.

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.

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.

Musculoskeletal dysfunctions and physiotherapy treatment strategies in patients with migraine

BACKGROUND

Neck pain is prevalent in patients with migraine but its role for the physiotherapy management is unclear.

METHOD

In this narrative review, results of studies, contributing to the overall understanding of musculoskeletal dysfunctions in patients with migraine are summarized, as are approaches to subgroup migraine and attempts to improve migraine non-pharmacologically.

RESULTS

Our line of research shows that musculoskeletal dysfunctions are prevalent in patients with migraine. Pain provocation during manual palpation of the upper cervical spine might be relevant when referred pain to the head is elicited. This subgroup of patients might benefit from physiotherapy treatment to the neck. Preliminary data from treatment studies shows that a small reduction of headache and migraine days can be achieved when treating the neck. The reduction in migraine days might be enhanced when treating migraine as a chronic pain disease and adding pain neuroscience education to the neck treatment.

CONCLUSIONS

Physiotherapy assessment and treatment plays a role in the management of migraine. The effectiveness of different physiotherapy approaches and pain neuroscience education needs to be evaluated further in randomized controlled trials.

The cervical spine in tension type headache

INTRODUCTION

The concept that headaches may originate in the cervical spine has been discussed over decades and is still a matter of debate. The cervical spine has been traditionally linked to cervicogenic headache; however, current evidence supports the presence of cervical musculoskeletal dysfunctions also in tension-type headache.

PURPOSE

This position paper discusses the most updated clinical and evidence-based data about the cervical spine in tension-type headache.

IMPLICATIONS

Subjects with tension-type headache exhibit concomitant neck pain, cervical spine sensitivity, forward head posture, limited cervical range of motion, positive flexion-rotation test and also cervical motor control disturbances. In addition, the referred pain elicited by manual examination of the upper cervical joints and muscle trigger points reproduces the pain pattern in tension-type headache. Current data supports that the cervical spine can be also involved in tension-type headache, and not just in cervicogenic headache. Several physical therapies including upper cervical spine mobilization or manipulation, soft tissue interventions (including dry needling) and exercises targeting the cervical spine are proposed for managing tension-type headache; however, the effectiveness of these interventions depends on a proper clinical reasoning since not all will be equally effective for all individuals with tension-type headache. Based on current evidence, we propose to use the terms cervical "component" and cervical "source" when discussing about headache. In such a scenario, in cervicogenic headache the neck can be the cause (source) of the headache whereas in tension-type headache the neck will have a component on the pain pattern, but it will be not the cause since it is a primary headache.

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.

Headache production during physical examination in patients with and without headache attributed to a whiplash injury: A case-control study

BACKGROUND

Provocation of headache on physical examination of the neck may reflect a role of cervical structures in the presence of acute whiplash-associated headache (WAH).

OBJECTIVE

To determine differences in headache provocation during physical tests in people with and without WAH after a whiplash injury.

DESIGN

Case-control study.

METHODS

Forty-seven people with acute whiplash-associated disorders participated, 28 with WAH. Passive accessory intervertebral movement over the tubercle of C1, the spinous processes of C2-C3 and facet joints of C0-C4, the flexion-rotation test (FRT), manual palpation of cranio-cervical muscles and the upper limb neurodynamic test + cranio-cervical flexion were assessed bilaterally twice by a blinded examiner; headache provocation was determined. Cohen's kappa and Chi-squared were determined to evaluate the intra-rater reliability of test results and differences between groups, respectively. A logistic regression model was also performed.

RESULTS

Intra-rater reliability of headache provocation was good or excellent for most tests. Significant differences between groups were found with higher positive tests in WAH for the assessment of C2 (68%), the most painful side of C0-C1 (57%), C1-C2 (75%) and C2-C3 (53%), most (79%) and least (25%) restricted sides of the FRT, and manual palpation of the most painful side for the trapezius (53%), masseter (50%) and temporalis (46%) muscles. Provocation of headache during the assessment of C2 and C1-C2 on the most painful side demonstrated the highest association with WAH.

CONCLUSION

Mechanical provocation of headache is more frequent in people with WAH than in those without headache soon after a whiplash injury.

Intramuscular Electrical Stimulation for the Treatment of Trigger Points in Patients with Chronic Migraine: A Protocol for a Pilot Study Using a Single-Case Experimental Design

Background and Objectives: Trigger points (TrPs) are prevalent in patients with migraine headaches. Needling interventions targeting TrPs in migraine patients may reduce the intensity and frequency of headaches, yet systematic reviews reveal a lack of robust evidence. Intramuscular electrical stimulation (IMES) is a modality that delivers electrical current into muscles and TrPs, with recent studies suggesting it may amplify the therapeutic effects of dry needling peripherally and centrally. This could be advantageous for patients with migraine and symptomatic TrPs. Materials and Methods: This study will implement a multiple baseline single-case experimental design (SCED). In a clinical setting, a SCED study lends itself to conducting research with only a few patients that each serve as their own controls. In this SCED study, four participants with chronic migraine will be enrolled in a non-concurrent manner and randomized to one of four baseline measurement periods (4, 5, 6 or 7 weeks), leading to four potentially different start dates for each participant in the intervention phase. During the intervention phase, patients will receive five sessions of dry needling with IMES, one session per week for five weeks. The primary outcome measure will be headache frequency, i.e., the reduction in the number of headache days over a one-month period using electronic headache diary data from the Migraine Buddy smartphone application. Secondary outcome measures will be changes in mean migraine pain intensity using a numeric pain rating scale (NPRS), migraine disability using the Migraine Disability Assessment Test (MIDAS), the Headache Impact Test (HIT-6), and changes in selected cervical musculoskeletal impairments including pressure pain thresholds (PPTs) over TrPs, the craniocervical flexion test (CCFT), and cervical active range of motion (AROM). Primary and secondary outcome measures will be analyzed separately using both visual and statistical analyses. Results: Actively recruiting participants. This project was approved by the Mass General Brigham Institutional Review Board (protocol #2023P000931) and is registered with ClinicalTrials.gov (NCT05893914). Conclusions: This study will seek to determine the effects of a five-week intervention period of IMES to TrPs in the posterior cervical muscles of subjects with chronic migraine.

Headache frequency and neck pain are associated with trapezius muscle T2 in tension-type headache among young adults

BACKGROUND

Tension-type headache (TTH) is the most prevalent primary headache disorder. Neck pain is commonly associated with primary headaches and the trigemino-cervical complex (TCC) refers to the convergence of trigeminal and cervical afferents onto neurons of the brainstem, thus conceptualizes the emergence of headache in relation to neck pain. However, no objective biomarkers exist for the myofascial involvement in primary headaches. This study aimed to investigate the involvement of the trapezius muscles in primary headache disorders by quantitative magnetic resonance imaging (MRI), and to explore associations between muscle T2 values and headache frequency and neck pain.

METHODS

This cohort study prospectively enrolled fifty participants (41 females, age range 20-31 years): 16 subjects with TTH only (TTH-), 12 with mixed-type TTH plus migraine (TTH+), and 22 healthy controls (HC). The participants completed fat-suppressed T2-prepared three-dimensional turbo spin-echo MRI, a headache diary (over 30 days prior to MRI), manual palpation (two weeks before MRI), and evaluation of neck pain (on the day of MRI). The bilateral trapezius muscles were manually segmented, followed by muscle T2 extraction. Associations between muscle T2 and the presence of neck pain as well as the number of days with headache (considering the 30 days prior to imaging using the headache calendar) were analyzed using regression models (adjusting for age, sex, and body mass index).

RESULTS

The TTH+ group demonstrated the highest muscle T2 values (right side: 31.4 ± 1.2 ms, left side: 31.4 ± 0.8 ms) as compared to the TTH- group or HC group (p < 0.001). Muscle T2 was significantly associated with the number of headache days (β-coefficient: 2.04, p = 0.04) and the presence of neck pain (odds ratio: 2.26, p = 0.04). With muscle T2 as the predictor, the area under the curve for differentiating between HC and the TTH+ group was 0.82.

CONCLUSIONS

Increased T2 of trapezius muscles may represent an objective imaging biomarker for myofascial involvement in primary headache disorders, which could help to improve patient phenotyping and therapy evaluation. Pathophysiologically, the increased muscle T2 values could be interpreted as a surrogate of neurogenic inflammation and peripheral sensitization within myofascial tissues.

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.

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.

Additional effects of pain neuroscience education combined with physiotherapy on the headache frequency of adult patients with migraine: A randomized controlled trial

Aim To assess the efficacy of pain neuroscience education combined with physiotherapy for the management of migraine.Background Physiotherapy can significantly reduce the frequency of migraine, but the evidence is based only on a few studies. Pain neuroscience education might pose a promising treatment, as it addresses migraine as a chronic pain disease.Methods In this non-blinded randomized controlled trial, migraine patients received physiotherapy + pain neuroscience education or physiotherapy alone, preceded by a three-month waiting period. Primary outcomes were frequency of headache (with and without migraine features), frequency of migraine and associated disability.Results Eighty-two participants were randomized and analyzed. Both groups showed a decrease of headache frequency (p = 0.02, d = 0.46) at post-treatment (physiotherapy: 0.77 days, 95%CI: -0.75 to 2.29 and physiotherapy + pain neuroscience education: 1.25 days, 95%CI: -0.05 to 2.55) and at follow-up (physiotherapy: 1.93, 95%CI: 0.07 to 3.78 and physiotherapy + pain neuroscience education: 3.48 days, 95%CI: 1.89 to 5.06), with no difference between groups (p = 0.26, d = 0.26). Migraine frequency was reduced significantly in the physiotherapy + pain neuroscience education group, and not in the physiotherapy group, at post-treatment (1.28 days, 95%CI: 0.34 to 2.22, p = 0.004) and follow-up (3.05 days, 95%CI: 1.98 to 5.06, p < 0.0001), with a difference between groups at follow-up (2.06 days, p = 0.003). Migraine-related disability decreased significantly in both groups (physiotherapy: 19.8, physiotherapy + pain neuroscience education: 24.0 points, p < 0.001, d = 1.15) at follow-up, with no difference between groups (p = 0.583). Secondary outcomes demonstrated a significant effect of time with no interaction between time and group. No harm or adverse events were observed during the study.Conclusion In comparison to physiotherapy alone, pain neuroscience education combined with physiotherapy can further reduce the frequency of migraine, but had no additional effect on general headache frequency or migraine-related disability.Trial Registration The study was pre-registered at the German Clinical Trials Register (DRKS00020804).

Inter-rater reliability, discriminatory and predictive validity of neck movement control tests in office workers with headache and/or neck pain

BACKGROUND

Movement control tests (MCTs) are clinical tests to evaluate impairment of movement and associated neuromuscular control and are commonly used to evaluate people with neck pain or headache conditions. The aim of this study was to establish inter-rater reliability as well as discriminatory and predictive validity for seven MCTs of the upper (UCS) and lower cervical spine (LCS) in office workers with headache or neck pain.

METHODS

Seven MCTs of the UCS (3) and LCS (4) were performed at baseline on 140 office workers which were included in a cluster randomized controlled trial. The occurrences of headache and neck pain were established at baseline (discriminatory validity) and at a 15-month follow-up (predictive validity). Inter-rater-reliability was established in a separate cross-sectional study.

RESULTS

MCTs showed slight to almost perfect inter-rater reliability but limited discriminatory (baseline) and limited to small predictive validity (15-month follow up) for different subgroups of office workers with headache and/or neck pain. MCTs of the UCS showed limited discriminatory validity, especially for rotation in participants with headache and neck pain compared to those with headache only (Negative Likelihood-ratio: 0.82, 95% CI: 0.69-0.98). Participants with neck pain only and ≥1/4 positive MCTs for the sagittal plane had an increased risk for future neck pain (Relative risk: 3.33, 95% CI: 1.05-10.56).

DISCUSSION

MCTs of the UCS and LCS are reliable but have only limited to small validity to predict future headache events in office workers. Insufficient sagittal plane movement control may predict neck pain relapses in the future.

Cervicogenic headache, an easy diagnosis? A systematic review and meta-analysis of diagnostic studies

BACKGROUND

The diagnosis of cervicogenic headache (CGH) remains a challenge for clinicians as the diagnostic value of detailed history and clinical findings remains unclear.

OBJECTIVES

To update and evaluate available evidence of the prevalence and the diagnostic accuracy of the detailed history and clinical findings for CGH in adults with headache.

DESIGN

Systematic review with meta-analysis.

METHODS

CINAHL, Cochrane Central, Embase, PEDro and PubMed were searched for studies before March 2022 that reported detailed history and/or clinical findings related to the diagnosis of cervicogenic headache. Study selection, risk of bias assessment (QUADAS-2 and PROBAST), and data extraction were performed. Meta-analyses for the cervical flexion-rotation test (CFRT) was performed. Certainty of the evidence was assessed with the GRADE approach.

RESULTS

Eleven studies were included. Moderate certainty evidence indicated that the CFRT differentiated CGH from lower cervical facet-induced headache, migraine, concomitant headaches or asymptomatic subjects (Se 83.0% [95%CI:70.0%-92.0%]; Sp 83.0% [95%CI:71.0%-91.0%]; positive LR 5.0 [95%CI:2.6-9.5]; negative LR 0.2 [95%CI:0.1-0.4]; n = 4 studies; n = 182 participants). Several diagnostic classifications and test clusters based on headache history and clinical findings can be useful, despite uncertain accuracy, in formulating the diagnosis of CGH.

CONCLUSION

Evidence support to undertake an evaluation of headache history and signs and symptoms and a physical examination of the patient neck to diagnose CGH. During the physical examination, a positive or negative CFRT probably has a small to moderate effect on the probability of a patient having a CGH. The diagnostic value of the other findings remains unclear.

TRIAL REGISTRATION

#CRD42020201772.

CEFALEIA CERVICOGÊNICA

Objetivo: Contextualizar a cefaleia cervicogênica descrevendo sua etiologia, fisiopatologia, quadro clínico, critérios diagnósticos e tratamentos, para nortear a sociedade médica diante da patologia que está em crescente aumento de sua incidência. Métodos: O presente estudo realizou buscas nas bases de dados PubMed, Nature, Scielo e Wiley, utilizando os descritores cefaleia cervicogênica, e foram analisados trabalhos publicados entre os anos de 1980 e 2022, em todos os idiomas, além das respectivas traduções em inglês. Como fator de inclusão foi considerado: “trabalhos publicados dentro do escopo do estudo dentro do intervalo de tempo citado e relacionados a cefaleia cervicogênica e como fator de exclusão foi considerado: “trabalhos não relacionados ao tema de estudo e com relatos já ultrapassados de acordo com a literatura atual”. Resultados: Foram encontrados 1.319 artigos, após leitura e análise dos artigos foram selecionados 27 artigos, e de acordo com a relevância no assunto fazem parte do escopo do trabalho. Em relação a cefaleia cervicogênica é possível classifica-la como uma cefaleia secundária, atribuída a transtornos cervicais, com sintomatologia heterogênea, geralmente apresentando-se como uma cefaleia unilateral, não latenjante e não excruciante, podendo ser desencadeada por pontos gatilhos em região cervical podendo ainda se apresentar com pródomos autonômicos. Sua etiologia e fisiopatologia tem ligação direta com transtornos cervicais e irritação das fibras aferentes de C1-C2-C3, além da convergência para o núcleo trigêmeo-cervical aumentando a variabilidade de sintomas. Seu diagnóstico é baseado em critérios diagnósticos e existem uma grande variedade de tratamentos com eficácia limitada. Conclusão: A cefaleia cervicogênica pode se apresentar de formas heterogêneas dificultado seu diagnóstico e sendo subdiagnosticada e tratada erroneamente em até 50% dos casos, seu aumento em decorrência da pandemia alerta para a melhoria no diagnóstico e tratamento da cefaleia cervicogênica e os distúrbios osteomusculares associados.  

Cervical musculoskeletal impairments in the 4 phases of the migraine cycle in episodic migraine patients

OBJECTIVE

To assess cervical musculoskeletal impairments during the 4 phases of a migraine cycle in episodic migraine patients, controlling for the presence of concomitant neck pain.

METHODS

Differences in cervical musculoskeletal impairments were assessed during the 4 migraine phases in episodic migraine patients and compared with healthy controls controlling for concomitant neck pain. Cervical musculoskeletal impairments were assessed as follow: cervical active range of motion; flexion rotation test; craniocervical flexion test and calculation of activation pressure score; the total number of myofascial trigger points in head/neck muscles; the number of positivevertebral segments (headache's reproduction) during passive accessory intervertebral movement; pressure pain thresholds over C1, C2, C4, C6 vertebral segments bilaterally, trigeminal area, hand, and leg. Signs of pain sensitization were assessed by evaluating mechanical pain threshold over trigeminal area and hand, pressure pain thresholds, and the wind-up ratio. The Bonferroni-corrected p-value (05/4 = 0.013) was adopted to assess the difference between groups, while a p-value of 0.05 was considered significant for the correlation analysis.

RESULTS

A total of 159 patients and 52 controls were included. Flexion rotation test and craniocervical flexion test were reduced in all 4 phases of the migraine cycle versus healthy controls (p < 0.001). The number of myofascial trigger points and positive vertebral segments was increased in all 4 phases of the migraine cycle versus healthy controls (p < 0.001). Flexion, extension, and total cervical active range of motion and cervical pressure pain thresholds were reduced in episodic migraine in the ictal phase versus controls (p < 0.007) with no other significant differences. Outside the ictal phase, the total cervical active range of motion was positively correlated with trigeminal and leg pressure pain threshold (p < 0.026), the number of active myofascial trigger points and positive positive vertebral segments were positively correlated with higher headache frequency (p=0.045), longer headache duration (p < 0.008), and with headache-related disability (p = 0.031). Cervical pressure pain thresholds were positively correlated with trigeminal, hand, and leg pressure pain threshold (p < 0.001), and trigeminal and leg mechanical pain thresholds (p < 0.005), and negatively correlated with the wind-up ratio (p < 0.004).

CONCLUSION

In all phases of the migraine cycle, independent of the presence of concomitant neck pain, episodic migraine patients showed reduced flexion rotation test and craniocervical flexion test and an increased number of myofascial trigger points and passive accessory vertebral segments. These impairments are correlated with enhanced headache duration, headache-related disability, and signs of widespread pain sensitization. Reduction in active cervical movement and increased mechanical hyperalgesia of the cervical was consistent in ictal episodic migraine patients and the subgroups of episodic migraine patients with more pronounced widespread sensitization.

Occipital nerve block and Maitland physiotherapy: review of treatment techniques based on positive results

Cervicogenic headache is a clinical condition that has a direct impact on quality of life and labor productivity and its underdiagnosis and lack of consensus on the appropriate treatment aggravates even more the condition. This work aims to systematize the protocol that has the highest success rate so far, based on the study carried out in Pindamonhangaba, São Paulo, Brazil. The results demonstrated with the occipital block and Maitland physiotherapy were exceptional and its methodology will be carried out as performed during the study. Conclusion: Regardless of the substance used for the blockade, its combination with Maitland's physiotherapy was shown to be favorable and its description can help other professionals and also enable reproduction in other studies.