Head Pain Referral During Examination of the Neck in Migraine and Tension-Type Headache

1. Headache: The Journal of Head and Face Pain

   Volume 52, Issue 8, pages 1226–1235, September 2012

1. Dean H. Watson MAppSc^*, 
2. Peter D. Drummond PhD

Objective.— To investigate if and to what extent typical head pain can be reproduced in tension-type headache (TTH), migraine without aura sufferers, and controls when sustained pressure was applied to the lateral posterior arch of C1 and the articular pillar of C2, stressing the atlantooccipital and C2-3 segments respectively.

Background.— Occipital and neck symptoms often accompany primary headache, suggesting involvement of cervical afferents in central pain processing mechanisms in these disorders. Referral of head pain from upper cervical structures is made possible by convergence of cervical and trigeminal nociceptive afferent information in the trigemino-cervical nucleus. Upper cervical segmental and C2-3 zygapophysial joint dysfunction is recognized as a potential source of noxious afferent information and is present in primary headache sufferers. Furthermore, referral of head pain has been demonstrated from symptomatic upper cervical segments and the C2-3 zygapophysial joints, suggesting that head pain referral may be a characteristic of cervical afferent involvement in headache.

Methods.— Thirty-four headache sufferers and 14 controls were examined interictally. Headache patients were diagnosed according the criteria of the International Headache Society and comprised 20 migraine without aura (females n = 18; males n = 2; average age 35.3 years) and 14 TTH sufferers (females n = 11; males n = 3; average age 30.7 years). Two techniques were used specifically to stress the atlantooccipital segments (Technique 1 – C1) and C2-3 zygapophysial joints (Technique 2 – C2). Two techniques were also applied to the arm – the common extensor origin and the mid belly of the biceps brachii. Participants reported reproduction of head pain with “yes” or “no” and rated the intensity of head pain and local pressure of application on a scale of 0 -10, where 0 = no pain and 10 = intolerable pain.

Results.— None of the subjects reported head pain during application of techniques on the arm. Head pain referral during the cervical examination was reported by 8 of 14 (57%) control participants, all TTH patients and all but 1 migraineur (P < .002). In each case, participants reported that the referred head pain was similar to the pain they usually experienced during TTH or migraine. The frequency of head pain referral was identical for Techniques 1 and 2. The intensity of referral did not differ between Technique 1 and Technique 2 or between groups. Tenderness ratings to thumb pressure were comparable between the Techniques 1 and 2 when pressure was applied to C1 and C2 respectively and across groups. Similarly, there were no significant differences for tenderness ratings to thumb pressure between Technique 1 and Technique 2 on the arm or between groups. While tenderness ratings to thumb pressure for Technique 2 were similar for both referral (n = 41) and non-referral (n = 7) groups, tenderness ratings for Technique 1 in the referral group were significantly greater when compared with the non-referral group (P = .01).

Conclusions.— Our data support the continuum concept of headache, one in which noxious cervical afferent information may well be significantly underestimated. The high incidence of reproduction of headache supports the evaluation of musculoskeletal features in patients presenting with migrainous and TTH symptoms. This, in turn, may have important implications for understanding the pathophysiology of headache and developing alternative treatment options.

Cervical Facet Arthropathy and Occipital Neuralgia: Headache Culprits

CURRENT PAIN AND HEADACHE REPORTS

Volume 14, Number 6, 418-423, DOI: 10.1007/s11916-010-0151-5

J. D. Hoppenfeld

Abstract

Cervicogenic headache (CH) is pain referred from the neck. Two common causes are cervical facet arthropathy and occipital neuralgia. Clinical diagnosis is difficult because of the overlying features between primary headaches such as migraine, tension-type headache, and CH. Interventional pain physicians have focused on supporting the clinical diagnosis of CH with confirmatory blocks. The treatment of cervical facet arthropathy as the source of CH is best approached with a multidimensional plan focusing on physical therapy and/or manual therapy. The effective management of occipital neuralgia remains challenging, but both injections and neuromodulation are promising options.

Cervicogenic headache, Occipital neuralgia, Cervical facet arthropathy, Occipital nerve stimulation, Occipital nerve block

CURRENT PAIN AND HEADACHE REPORTS

Volume 14, Number 6, 418-423, DOI: 10.1007/s11916-010-0151-5

J. D. Hoppenfeld

Abstract

Cervicogenic headache (CH) is pain referred from the neck. Two common causes are cervical facet arthropathy and occipital neuralgia. Clinical diagnosis is difficult because of the overlying features between primary headaches such as migraine, tension-type headache, and CH. Interventional pain physicians have focused on supporting the clinical diagnosis of CH with confirmatory blocks. The treatment of cervical facet arthropathy as the source of CH is best approached with a multidimensional plan focusing on physical therapy and/or manual therapy. The effective management of occipital neuralgia remains challenging, but both injections and neuromodulation are promising options.

Reliability of manual examination and frequency of symptomatic cervical motion segment dysfunction in cervicogenic headache

Manual Therapy
Toby Hall, Kathy Briffa, Diana Hopper, Kim Robinson
Received 3 December 2009; received in revised form 26 April 2010; accepted 8 June 2010.
published online 07 July 2010.

Abstract

This study investigated the reliability of manual examination procedures and the frequency that each or multiple segments in the upper cervical spine above the C4 vertebra were the dominant source of pain in subjects with cervicogenic headache (CGH). Eighty subjects were evaluated, 60 with CGH (39 females, mean age 33 years) and arbitrarily a further 20 asymptomatic subjects (13 females, mean age 34 years) included to reduce examiner bias, but subsequently omitted from data analysis. Two experienced physiotherapists examined on the same day each subject with standard manual examination procedures, independently rating each segment in the upper cervical spine above the C4 vertebra for involvement. Examiners were blind to each other’s findings and the subject’s clinical status. Standard and adjusted Kappa coefficients were calculated for each segment in symptomatic subjects only. Chi-squared analysis for goodness of fit was used to identify the segment that was most frequently determined the predominant symptomatic segment. Manual examination above the C4 vertebra showed good reliability. The C1/2 segment was most commonly symptomatic, with a positive finding at this segment in 63% of cases. The high frequency of C1/2 involvement in CGH highlights the importance of examination and treatment procedures for this motion segment.

School of Physiotherapy, Curtin Innovation Health Research Institute, Curtin University of Technology, Hayman Road, Bentley, Perth, Western Australia

Physical Examination and Self-Reported Pain Outcomes From a Randomized Trial on Chronic Cervicogenic Headache

Journal of Manipulative and Physiologic Therapeutics

Volume 33, Issue 5, Pages 338-348 (June 2010)
Darcy Vavrek, ND, MSa, Mitchell Haas, DC, MAb, Dave Peterson, DCc
Received 23 July 2009; received in revised form 17 November 2009; accepted 29 November 2009.



Abstract

Objective

Objective clinical measures for use as surrogate markers of cervicogenic headache (CGH) pain have not been established. In this analysis, we investigate relationships between objective physical examination (PE) measures with self-reported CGH outcomes.



Methods

This is an exploratory analysis of data generated by attention control PE from an open-label randomized clinical trial. Of 80 subjects, 40 were randomized to 8 treatments (spinal manipulative therapy or light massage control) and 8 PE over 8 weeks. The remaining subjects received no PE. Physical examination included motion palpation of the cervical and upper thoracic regions, active cervical range of motion (ROM) and associated pain, and algometric pain threshold evaluated over articular pillars. Self-reported outcomes included CGH and neck pain and disability, number of CGH headaches, and related disability days. Associations between PE and self-reported outcomes were evaluated using generalized linear models, adjusting for sociodemographic differences and study group.



Results

At baseline, number of CGH and disability days were strongly associated with cervical active ROM (P < .001 to .037). Neck pain and disability were strongly associated with ROM-elicited pain (P < .001 to .035) but not later in the study. After the final treatment, pain thresholds were strongly associated with week 12 neck pain and disability and CGH disability and disability days (P ≤ .001 to .048).



Conclusions

Cervical ROM was most associated with the baseline headache experience. However, 4 weeks after treatment, algometric pain thresholds were most associated. No one PE measure remained associated with the self-reported headache outcomes over time.

a Assistant Professor of Research, Center for Outcomes Studies, Western States Chiropractic College, Portland, Ore
b Dean of Research, Center for Outcomes Studies, Western States Chiropractic College, Portland, Ore
c Professor of Chiropractic Sciences, Western States Chiropractic College, Portland, Ore

Submitted requests for reprints to: Darcy Vavrek, ND, MS, Center for Outcomes Studies, Western States Chiropractic College, 2900 132nd Avenue, Portland, OR 97230-3009

Upper Cervical Facet Joint and Spinal Rami Blocks for the Treatment of Cervicogenic Headache

Headache: The Journal of Head and Face Pain
Early View (Articles online in advance of print)

Published Online: 28 Jan 2010
Brief Communications
Linqiu Zhou, MD; Zarinah Hud-Shakoor, DO; Christopher Hennessey, PA-C; Avi Ashkenazi, MDFrom the Thomas Jefferson University – Neurology, Philadelphia, PA, USA (A. Ashkenazi); Thomas Jefferson University – Rehabilitation Medicine, Philadelphia, PA, USA (L. Zhou and Z. Hud-Shakoor); Underwood Memorial Hospital – Orthopedic Surgery, Woodbury, NJ, USA (C. Hennessey).
Correspondence to L. Zhou, 1225 North Broad Street, Suite 3, Woodbury, NJ 08096, USA. 

ABSTRACT

(Headache 2010;••:••-••)

Objective.—To evaluate the efficacy of upper cervical facet joint injections and spinal rami blocks in the treatment of cervicogenic headache.

Background.—Cervicogenic headache has been recognized as a common and often disabling disorder. The treatment of this headache type remains challenging.

Methods.—We conducted a retrospective chart review of 31 patients with refractory cervicogenic headache who underwent fluoroscopically guided C1/2, C2/3 facet joint injections and C2, C3 spinal rami blocks using a mixture of 0.25% bupivacaine and 3 mg betamehtasone. The outcome measures were the change in headache severity, assessed using an 11-point numerical pain scale, after treatment, and the duration of head pain relief.

Results.—Twenty-eight (90.3%) patients experienced >50% headache relief after treatment, with an average duration of 21.7 (1-90) days. Mean (±SD) head pain intensity decreased from 7.5 ± 1.3 before treatment to 2.7 ± 1.9 immediately after it (P < .0001). The procedures were well tolerated.

Conclusions.—C1/2, C2/3 facet joint injections and C2, C3 spinal rami blocks were effective and well tolerated for the treatment of cervicogenic headache in this study. The procedures provided significant and prolonged pain relief in the majority of patients. Larger controlled studies are needed to further evaluate the efficacy of this treatment modality in cervicogenic headache.

Cervicogenic Headache

Pain Practice
Volume 10 Issue 2, Pages 124 - 130 Published Online: 23 Feb 2010Evidence-based Interventional Pain Medicine according to Clinical Diagnoses
Hans van Suijlekom, MD, PhD*; Jan Van Zundert, MD, PhD, FIPP †‡ ; Samer Narouze, MD, FIPP § ; Maarten van Kleef, MD, PhD, FIPP ‡ ; Nagy Mekhail, MD, PhD, FIPP §
*Department of Anesthesiology and Pain Management, Catharina Ziekenhuis, Eindhoven, The Netherlands, † Department of Anesthesiology and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg Genk, Belgium, ‡ Department of Anesthesiology and Pain Management, University Medical Centre Maastricht, Maastricht, The Netherlands, § Pain Management Department, Cleveland Clinic, Cleveland, Ohio, U.S.A.
Correspondence to M. van Kleef, MD, PhD, Maastricht University Medical Centre, Department of Anesthesiology and Pain Management, PO Box 5800, 6202 AZ Maastricht, The Netherlands. Email: maarten.van.kleef@mumc.nl 

ABSTRACT

Cervicogenic headache is mainly characterized by unilateral headache symptoms which arise from the neck radiating to the fronto-temporal and possibly to the supra-orbital region. Physical examination to find evidence of a disorder known to be a valid cause of headache encompasses movement tests of the cervical spinal column and segmental palpation of the cervical facet joints and soft tissues of the neck.

Injection of the nervus occipitalis major is recommended after unsatisfactory results with conservative treatments (1 B+). In the case of an unsatisfactory outcome after injection of the nervus occipitalis major, radiofrequency treatment of the ramus medialis (medial branch) of the cervical ramus dorsalis can be considered (2 B±).

If the result is unsatisfactory pulsed radiofrequency treatment of the ganglion spinale (dorsal root ganglion) of C2 and/or C3 can be considered in a study context (O).

Cervicogenic Headache

Pain Practice Volume 10 Issue 2, Pages 124 - 130

Published Online: 23 Feb 2010

EVIDENCE-BASED MEDICINE
Evidence-based Interventional Pain Medicine according to Clinical Diagnoses
6. Cervicogenic Headache
Hans van Suijlekom, MD, PhD*; Jan Van Zundert, MD, PhD, FIPP †‡ ; Samer Narouze, MD, FIPP § ; Maarten van Kleef, MD, PhD, FIPP ‡ ; Nagy Mekhail, MD, PhD, FIPP §
*Department of Anesthesiology and Pain Management, Catharina Ziekenhuis, Eindhoven, The Netherlands, † Department of Anesthesiology and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg Genk, Belgium, ‡ Department of Anesthesiology and Pain Management, University Medical Centre Maastricht, Maastricht, The Netherlands, § Pain Management Department, Cleveland Clinic, Cleveland, Ohio, U.S.A.
Correspondence to M. van Kleef, MD, PhD, Maastricht University Medical Centre, Department of Anesthesiology and Pain Management, PO Box 5800, 6202 AZ Maastricht, The Netherlands. Email: maarten.van.kleef@mumc.nl 
 
ABSTRACT

Cervicogenic headache is mainly characterized by unilateral headache symptoms which arise from the neck radiating to the fronto-temporal and possibly to the supra-orbital region. Physical examination to find evidence of a disorder known to be a valid cause of headache encompasses movement tests of the cervical spinal column and segmental palpation of the cervical facet joints and soft tissues of the neck. Injection of the nervus occipitalis major is recommended after unsatisfactory results with conservative treatments (1 B+). In the case of an unsatisfactory outcome after injection of the nervus occipitalis major, radiofrequency treatment of the ramus medialis (medial branch) of the cervical ramus dorsalis can be considered (2 B±). If the result is unsatisfactory pulsed radiofrequency treatment of the ganglion spinale (dorsal root ganglion) of C2 and/or C3 can be considered in a study context (O).

Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment

The Lancet Neurology, Volume 8, Issue 10, Pages 959 - 968, October 2009

Nikolai Bogduk MD a b , Jayantilal Govind MBChB c d ‡
Summary
Cervicogenic headache is characterised by pain referred to the head from the cervical spine. Although the International Headache Society recognises this type of headache as a distinct disorder, some clinicians remain sceptical. Laboratory and clinical studies have shown that pain from upper cervical joints and muscles can be referred to the head. Clinical diagnostic criteria have not proved valid, but a cervical source of pain can be established by use of fluoroscopically guided, controlled, diagnostic nerve blocks. In this Review, we outline the basic science and clinical evidence for cervicogenic headache and indicate how opposing approaches to its definition and diagnosis affect the evidence for its clinical management. We provide recommendations that enable a pragmatic approach to the diagnosis and management of probable cervicogenic headache, as well as a rigorous approach to the diagnosis and management of definite cervical headache.

Clinical observation on tuina therapy for cervicogenic headache

Journal of Acupuncture and Tuina Science
Volume 7, Number 6 / December, 2009

Ning Li, Jing Liu, and Meng-fo Zhang. Jiangsu Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing, 210028, P. R. China
Received: 8 October 2009 Published online: 5 December 2009


Abstract
Objective To observe the clinical effects of tuina therapy for cervicogenic headache.
Methods Fifty-four cases were randomized allocated into tuina group and medicine group, 27 cases in each group. The patients in the tuina group treated with tuina therapy, and the patients in the medicine group take ibuprofen orally. The headache degree (Visual Analogue Scale, VAS), frequency of headache occurrence and the neck disability index (NDI) were compared 2 weeks pre-treatment and 2 weeks post-treatment.
Results Before treatment, there were no significant differences in the headache VAS, frequency and NDI between the two groups. After treatment, headache VAS, frequency and NDI were significantly decreased, and there were statistical differences between the tuina group and the medicine group (P<0.01).
Conclusion Tuina therapy is more effective for treating cervicogenic headache than routine dose of ibuprofen.

Tui na is a chinese manipulative therapy: Click: http://en.wikipedia.org/wiki/Tui_na) 

Occipital Nerve Blocks: When and What to Inject?

Headache: The Journal of Head and Face Pain

Volume 49 Issue 10, Pages 1521 - 1533 Published Online: 6 Aug 2009 Copyright © 2009 American Headache Society

Joshua Tobin, MD; Stephen Flitman, MD

From 21st Century Neurology – Neurology, Phoenix, AZ, USA.

Correspondence to J. Tobin, 21st Century Neurology – Neurology, 2601 North Third Street Suite 125, Phoenix, AZ 85004, USA.

Conflict of Interest: None

ABSTRACT

Introduction.—Occipital nerve block (ONB) is a promising treatment for headaches. Its indications, selection criteria, and best techniques are not clear, however.

Objective.—To summarize in narrative format what is known about ONBs and what needs to be learned.

Methods.—MD Consult and Google Scholar were searched using the terms occipital, suboccipital, block, and injection to identify relevant articles that were reviewed. This process was repeated for all additional pertinent articles identified from these articles, and so on, until no additional articles were identified.

Results.—A total of 21 articles were identified.

Conclusions.—Occipital nerve block is an effective treatment for cervicogenic headache, cluster headache, and occipital neuralgia. While a double blinded randomized placebo controlled clinical trial is lacking, multiple open label studies reported favorable results for migraine. Two other possible uses of ONB worthy of further study are use as a rescue treatment and as an adjunctive treatment for medication overuse headache. ONB may be effective for tension headache, but only under very specific circumstances. ONB is either ineffective or only effective under as yet unstudied circumstances for hemicrania continua and chronic paroxysmal hemicrania. Some practitioners use occipital nerve (ON) tenderness to palpation (TTP) or reproduction of headache pain with ON pressure (RHPONP) as selection criteria for identifying appropriate patients. While only a clinical trial can produce a definitive answer, current evidence suggests that these selection criteria are not necessary for cervicogenic headache or cluster headache. Occipital neuralgia by definition involves TTP of the ONs. Whether RHPONP or ON TTP predicts success in migraine is unclear, and may relate to whether steroids are used. A single blinded randomized controlled trial evaluating local anesthetic with steroids vs local anesthetic alone for transformed migraine reported slightly worse results with steroids, but there are several alternate explanations for this finding other than steroids being counterproductive. The technique of repetitive ONBs deserves further study.

Deep Cervical Muscle Dysfunction and Head/Neck/Face Pain

Practical Pain Management. Vol.9, No.1 Jan/Feb 2009
by Leonard B. Goldstein, DDS, PhD and Howard W. Makofsky, PT, DHSc, OCS

Nearly fifty percent (50%) of the population is affected by cervical spine pain and/or headaches during their lives.1 Headache is not only one of the most common human ailments,2 but also accounts for the expenditures of billions of health care dollars annually and is a leading cause of lost time from work.3

Cervical dysfunction may be seen in up to seventy percent (70%) of the population suffering from any type of headache.4 This suggests that the cervical spine may be either a causative or contributing factor in the pathogenesis of many headaches.5

The pilot study by Placzek, Pagett, et al. demonstrated and supported the theory that headache may be influenced by cervical muscle strength, and that weakness of the cervical spine musculature may lead to abnormal stress on the upper cervical facets which are related to head and neck pain. It is further speculated that stability, and thus normal function and biomechanics, is dependent on a balance of anterior and posterior cervical muscle balance. Despite advances, the pathogenesis of tension-type headache is not clearly understood. However, cervical musculoskeletal abnormalities have been linked to multiple headache types.6-8

In the study published by Fernandez-De-Las-Penas, Perez-De-Heredia, Molero-Sanchez, and Miangolarra-Page,9 the authors presented results similar to those previously reported:

impairment in deep neck flexor muscles in individuals with cervicogenic headaches, and
deficits in the performance of the cranio-cervical flexion test (ie., reduced endurance or holding capacity of the deep neck flexor muscles).
Please refer to the Jan/Feb 2009 issue for the complete text.

Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment

The Lancet Neurology, Volume 8, Issue 10, Pages 959 - 968, October 2009

Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment
Original Text Nikolai Bogduk MD a b , Jayantilal Govind MBChB c d ‡

Summary

Cervicogenic headache is characterised by pain referred to the head from the cervical spine. Although the International Headache Society recognises this type of headache as a distinct disorder, some clinicians remain sceptical. Laboratory and clinical studies have shown that pain from upper cervical joints and muscles can be referred to the head. Clinical diagnostic criteria have not proved valid, but a cervical source of pain can be established by use of fluoroscopically guided, controlled, diagnostic nerve blocks. In this Review, we outline the basic science and clinical evidence for cervicogenic headache and indicate how opposing approaches to its definition and diagnosis affect the evidence for its clinical management. We provide recommendations that enable a pragmatic approach to the diagnosis and management of probable cervicogenic headache, as well as a rigorous approach to the diagnosis and management of definite cervical headache.

a Newcastle Bone and Joint Institute, Royal Newcastle Centre, Newcastle, New South Wales, Australia
b Faculty of Health Sciences, University of Newcastle, Callaghan, New South Wales, Australia
c Pain Management Unit, Canberra Hospital, Woden, Australian Capital Territory, Australia
d School of Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
Correspondence to: Nikolai Bogduk, Newcastle Bone and Joint Institute, Royal Newcastle Centre, PO Box 664J, Newcastle, New South Wales 2300, Australia
‡ Dr Govind died on June 16, 2009