Cervicogenic headache: evaluation of the original diagnostic criteria

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cervical musculoskeletal impairments and pressure pain sensitivity in office workers with headache

BACKGROUND

Office workers are specifically vulnerable to headache conditions. Neck pain is reported by almost 80% of patients with headaches. Associations between currently recommended tests to examine cervical musculoskeletal impairments, pressure pain sensitivity and self-reported variables in headache, are unknown. The aim of this study is to evaluate whether cervical musculoskeletal impairments and pressure pain sensitivity are associated with self-reported headache variables in office workers.

METHODS

This study reports a cross-sectional analysis using baseline data of a randomized controlled trial. Office workers with headache were included in this analysis. Multivariate associations, controlled for age, sex and neck pain, between cervical musculoskeletal variables (strength, endurance, range of motion, movement control) and pressure pain threshold (PPT) over the neck and self-reported headache variables, such as frequency, intensity, and the Headache-Impact-Test-6, were examined.

RESULTS

Eighty-eight office workers with a 4-week headache frequency of 4.8 (±5.1) days, a moderate average headache intensity (4.5 ± 2.1 on the NRS), and "some impact" (mean score: 53.7 ± 7.9) on the headache-impact-test-6, were included. Range of motion and PPT tested over the upper cervical spine were found to be most consistently associated with any headache variable. An adjusted R2 of 0.26 was found to explain headache intensity and the score on the Headache-Impact-Test-6 by several cervical musculoskeletal and PPT variables.

DISCUSSION

Cervical musculoskeletal impairments can explain, irrespective of coexisting neck pain, only little variability of the presence of headache in office workers. Neck pain is likely a symptom of the headache condition, and not a separate entity.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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.

Translating the new International IFOMPT Cervical Framework into a framework flowchart for clinical practice and education

BACKGROUND

In 2020, a revised version of the International IFOMPT Cervical Framework was published. This framework provides both physical therapists and educators the necessary information to guide the assessment of the cervical spine region for potential vascular pathologies of the neck in advance of planned Orthopaedic Manual Therapy (OMT) interventions.

OBJECTIVE

The objective was to develop a framework flowchart which is useful in clinical practice and education to assist physical therapists to improve the safety of OMT, and apply this in a case report.

METHODS

The framework was developed in co-creation with manual therapy experts, researchers, educators in manual therapy, patients, medical specialists and the Manual Therapy Association in The Netherlands and Belgium. Manual therapists and patients tested the framework for intelligibility and usefulness.

RESULTS

A framework flowchart is developed and presented, that is easy to use in both clinical practice and education. It is a visual representation of the sequence of steps and decisions needed during the process. A case description of a patient with neck pain and headache is added to illustrate the clinical usefulness of the framework flowchart.

CONCLUSION

The framework flowchart helps physical therapists in their clinical reasoning to provide safe OMT interventions.

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.  

Neural Basis of Etiopathogenesis and Treatment of Cervicogenic Orofacial Pain

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

Outcomes of Degenerative Cervical Myelopathy From The Perspective of Persons Living With the Condition: Findings of a Semistructured Interview Process With Partnered Internet Survey

STUDY DESIGN

Mixed-methods cross-sectional study.

OBJECTIVES

Degenerative cervical myelopathy (DCM) is a common and disabling condition. While classically, assessment and diagnosis has focused on neuromuscular symptoms, many other disabilities have been linked. The aim of this study was to explore the consequences of DCM for those with lived experience, producing a long list to inform the development of a core outcome set for DCM research.

METHODS

A 2-stage process was used: a focus group session of people with DCM (PwCM) and their supporters (n = 8) discussed the impact of DCM. This was used to develop a preliminary list of consequences, which were then placed into a survey of an online community of DCM sufferers (n = 224). Survey participants were asked to tick the consequences that they had experienced and given the opportunity to submit additional. Additional consequences were reviewed by a group of healthcare professionals and PwCM and included if not already represented. Demographic information including disease severity, age, and sex were captured for sampling comparison.

RESULTS

A total of 52 outcomes were identified from the focus group and nominally divided into 2 categories; symptoms (36 outcomes) and handicaps (18 outcomes), and further evaluated using a survey. All outcomes were recognized by at least 5% of respondents. A further 16 outcomes were added following the survey.

CONCLUSIONS

A list of DCM consequences has been defined from the perspective of PwCM. This will now be evaluated as part of AO Spine RECODE-DCM, an international multistakeholder collaboration to establish a core outcome set for research.

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.

The Effect of Adding Dry Needling to Physical Therapy in the Treatment of Cervicogenic Headache: A Randomized Controlled Trial

OBJECTIVE

To compare the long-term effect of adding real or sham dry needling with conventional physiotherapy in cervicogenic headache.

DESIGN

A randomized controlled trial.

SETTING

Physiotherapy Clinic, Rouhani Hospital of Babol University of Medical Sciences, Iran.

SUBJECTS

Sixty-nine patients with cervicogenic headache.

METHODS

Patients were randomly assigned into a control group (n = 23) receiving conventional physical therapy; a dry needling group (n = 23) receiving conventional physical therapy and dry needling on the cervical muscles; placebo needling group (n = 23) receiving conventional physical therapy and superficial dry needling at a point away from the trigger point. The primary outcome was the headache intensity and frequency. Neck disability, deep cervical flexor performance and range of motion were secondary outcomes. Outcomes were assessed immediately after treatment and one, three and six months later.

RESULTS

Sixty-five patients were finally included in the analysis. Headache intensity and neck disability decreased significantly more in the dry needling compared to sham and control groups after treatment and during all follow-ups. The frequency of headaches also reduced more in the dry needling than in control and sham groups, but it did not reach statistical significance. Higher cervical range of motion and enhancement of deep cervical flexors performance was also observed in the dry needling compared to sham and control groups.

CONCLUSION

Dry needling has a positive effect on pain and disability reduction, cervical range of motion and deep cervical flexor muscles performance in patients with cervicogenic headache and active trigger points, although the clinical relevance of the results was small.

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 Second Short Form of the McGill Pain Questionnaire as the useful additional tool for differential diagnostics of migraine and cervicogenic headache]

OBJECTIVE

To study the effectiveness of the Second Short Form of the McGill Pain Questionnaire (SF-MPQ-2) as an instrument for assessment and comparison of quantitative characteristics of pain in patients with chronic musculoskeletal impairment of the cervical spine and nonspecific neck pain accompanied by chronic migraine or cervicogenic headache (CeH).

MATERIAL AND METHODS

Forty-nine patients, aged from 19 to 60 years (mean age 42.8±10.4), were divided into 2 comparable by age and gender groups with migraine (n=18) and CeH (n=31). Neck pain and headache intensity was measured by the 11-points Numerical Rating Scale (NRS). Quality of pain and related symptoms were measured by SF-MPQ-2. Multidisciplinary and multimodal approaches were applied for treatment, including several modalities of manual therapy.

RESULTS

Headache intensity was higher in the migraine group in comparison with the CeH group (7.8±1.7 vs 6.0±1.5, respectively; p<0.05). No significant differences in neck pain intensity were found (6.2±1.8 vs 5.3±1.7; p=0.08). Patients with migraine usually chose more descriptors than patients with CeH (14 vs 4, respectively) and higher range of their intensity (p<0.001). By the end of treatment session, the number of descriptors and their intensity decreased significantly on all SF=MPQ-2 scales (p<0.001) in both groups. Most patients of migraine and CeH group were satisfied with treatment (83% and 97%, respectively) and marked «much improved» and «very much improved» on the 7-point Patient Global Impression of Change scale.

CONCLUSION

SF-MPQ-2 is a useful tool for differential diagnosis of migraine and CeH, as it contains the sufficient number of descriptors and the scale for measuring their intensity.

Spinal manipulation and perineural electrical dry needling in patients with cervicogenic headache: a multicenter randomized clinical trial

BACKGROUND CONTEXT

Spinal manipulation, spinal mobilization, and exercise are commonly used in individuals with cervicogenic headache (CH). Dry needling is being increasingly used in the management of CH. However, questions remain about the effectiveness of these therapies and how they compare to each other.

PURPOSE

The present study aims to compare the combined effects of spinal manipulation and dry needling with spinal mobilization and exercise on pain and disability in individuals with CH.

STUDY DESIGN/SETTING

Randomized, multicenter, parallel-group trial.

PATIENT SAMPLE

One hundred forty-two patients (n=142) with CH from 13 outpatient clinics in 10 different states were recruited over a 36-month period.

OUTCOME MEASURES

The primary outcome was headache intensity as measured by the Numeric Pain Rating Scale. Secondary outcomes included headache frequency and duration, disability (Neck Disability Index), medication intake, and the Global Rating of Change (GROC). Follow-up assessments were taken at 1 week, 4 weeks, and 3 months.

METHODS

Patients were randomized to receive upper cervical and upper thoracic spinal manipulation plus electrical dry needling (n=74) or upper cervical and upper thoracic spinal mobilization and exercise (n=68). In addition, the mobilization group also received a program of craniocervical and peri-scapular resistance exercises; whereas, the spinal manipulation group also received up to eight sessions of perineural electrical dry needling. The treatment period for both groups was 4 weeks. The trial was prospectively registered at ClinicalTrials.gov (NCT02373605). Drs Dunning, Butts and Young are faculty within the AAMT Fellowship and teach postgraduate courses in spinal manipulation, spinal mobilization, dry needling, exercise and differential diagnosis. The other authors declare no conflicts of interest. None of the authors received any funding for this study.

RESULTS

The 2 × 4 analysis of covariance revealed that individuals with CH who received thrust spinal manipulation and electrical dry needling experienced significantly greater reductions in headache intensity (F=23.464; p<.001), headache frequency (F=13.407; p<.001), and disability (F=10.702; p<.001) than those who received nonthrust mobilization and exercise at a 3-month follow-up. Individuals in the spinal manipulation and electrical dry needling group also experienced shorter duration of headaches (p<.001) at 3 months. Based on the cutoff score of ≥+5 on the GROC, significantly (X²=54.840; p<.001) more patients (n=57, 77%) within the spinal manipulation and electrical dry needling group achieved a successful outcome compared to the mobilization and exercise group (n=10, 15%) at 3-month follow-up. Between-groups effect sizes were large (0.94<standardized mean score difference<1.25) in all outcomes in favor of the spinal manipulation and electrical dry needling group at 3 months. In addition, significantly (X²=29.889; p<.001) more patients in the spinal manipulation and electrical dry needling group (n=49, 66%) completely stopped taking medication for their pain compared to the spinal mobilization and exercise group (n=14, 21%) at 3 months.

CONCLUSION

Upper cervical and upper thoracic high-velocity low-amplitude thrust spinal manipulation and electrical dry needling were shown to be more effective than nonthrust mobilization and exercise in patients with CH, and the effects were maintained at 3 months.

Sources of Cervicogenic Headache Among the Upper Cervical Synovial Joints

OBJECTIVES

The study sought to assess the utility of controlled diagnostic blocks in patients with probable cervicogenic headache by determining the prevalence of sources of pain among the upper and lower synovial joints of the cervical spine.

METHODS

Controlled diagnostic blocks were performed in 166 consecutive patients who clinically exhibited features consistent with a diagnosis of probable cervicogenic headache. Data were collected on how often a particular source of pain could be pinpointed and how often particular diagnostic blocks provided a positive yield.

RESULTS

In patients in whom headache was the dominant complaint, diagnostic blocks succeeded in establishing the source of pain in 75% of patients. The C2-3 joint was the source of pain in 62%, followed by the C1-2 (7%) and C3-4 (6%). In patients in whom headache was less severe than neck pain, blocks were successful in 67%. C2-3 was the source of pain in 42%, followed by lower cervical joints in 18% and the C3-4 joint in 7%.

CONCLUSIONS

Controlled diagnostic blocks can establish the source of pain in the majority of patients presenting with probable cervicogenic headache, with C2-3 being the most common source. On the basis of pretest probability, diagnostic algorithms should commence investigations at C2-3. Second and third steps in the algorithm should differ according to whether headache is the dominant or nondominant complaint.

Cryoneurolysis for cervicogenic headache - a double blinded randomized controlled study

Background and aims Cervicogenic headache (CEH) is a debilitating condition and analgesics have limited effect. Percutaneous cryoneurolysis is thus still in use although the clinical evidence is lacking. We present a randomized, controlled study to assess the clinical efficacy of cryoneurolysis compared with a corticosteroid combined with a local anaesthetic. Methods In a university-based outpatient pain clinic we performed a randomized, double blinded, comparative study with an 18-week follow-up. After positive diagnostic test blocks 52 eligible patients were randomly allocated in a ratio of 3:2, 31 participants to occipital cryoneurolysis and 21 participants to injections of 1 mL methylprednisolone 40 mg/mL (Depo-Medrol®) combined with 1 mL bupivacaine 5 mg/mL. Results We observed a significant pain reduction of more than 50% in both treatment groups, slightly improved neck function and reduced number of opioid consumers. After 6-7-weeks, however, pain intensity increased gradually, but did not reach baseline within 18 weeks. Although cryoneurolysis provided a more prolonged effect, the group differences did not reach statistical significance. Health related quality of life and psychological distress improved minimally. A large number reported minor and transient side effects, but we found no significant group differences. After 18 weeks, 29% rated the headache as much improved, and 12 (24%) somewhat improved, but a large proportion (78%) reported need for further intervention/treatment. Conclusions Cryoneurolysis provided substantial, but temporary pain relief, and the effect was not significantly different from injections of a corticosteroid combined with a local anaesthetic. Participants were selected by a single test block, and the neurolytic procedure was guided by anatomical landmarks and nerve stimulation. A stricter patient selection and an ultrasound-guided technique might have improved the results. Cryoneurolysis provides temporary pain relief not significantly superior to corticosteroid injection, and the results question the value of occipital cryoneurolysis for a chronic pain condition like CEH. Implications Occipital cryoneurolysis may be considered when non-invasive treatments appear insufficient, but only for patients who have responded substantially to test blocks. A risk of local scar and neuroma formation by repeated cryoneurolysis, leading to neuropathic pain has been discussed by other researchers.

Headache and neck

Cervicogenic headache (CEH) is currently identified with different diagnostic criteria. The latest one is the International classification of headache disorders (ICHD), 3rd edition (2018). At the present time, there are not enough published articles with reliable sensitivity and specificity that may support a classification for clinical and research purposes. Current literature suggests improvement to the classification(s). The ICHD criteria should be modified to reach an optimal sensitive and specific level to identify CEH as a secondary headache. The B, C1, and C2 criteria should be implemented with proposed suggestions. The C3 criterion should be upgraded. Criteria such as mechanical precipitation of pain by digital pressure on neck trigger points and specific movements, strictly unilateral pain without side-shift, diffuse unilateral shoulder and arm pain, pain starting posteriorly and spreading anteriorly should be integral part of the classification.

Can physical testing be used to distinguish between migraine and cervicogenic headache sufferers? A protocol for a systematic review

INTRODUCTION

Differential diagnosis of migraine and cervicogenic headache (CGH) can be challenging given the large overlap of symptoms, commonly leading to misdiagnosis and ineffective treatment. In order to strengthen the differential diagnosis of headache, previous studies have evaluated the utility of physical tests to examine for musculoskeletal impairment, mainly in the cervical spine, which could be provoking or triggering headache. However, no systematic review has attempted to evaluate whether physical tests can differentiate CGH from migraine or both conditions from asymptomatic subjects.

METHODS/ANALYSIS

A systematic review protocol has been designed and is reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P). A sensitive topic-based search strategy is planned which will include databases, hand searching of key journals and consultation of relevant leading authors in this field. Terms and keywords will be selected after discussion and agreement. Two independent reviewers will perform the search and select studies according to inclusion and exclusion criteria, including any cohort or observational studies evaluating the topic of this review; a third reviewer will confirm accuracy. A narrative synthesis will be developed for all included studies and, if possible, a meta-analysis will be conducted. The overall quality of the evidence will be assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) checklist for diagnostic accuracy studies and the Downs and Black scale for those studies where the QUADAS-2 checklist cannot be applied.

ETHICS AND DISSEMINATION

Ethical approval is not required since no patient information will be collected. The results will provide a deeper understanding about the possibility of using physical tests to differentiate cervicogenic headache from migraine and from asymptomatic subjects, which has direct relevance for clinicians managing people with headache. The results will be published in a peer-reviewed journal and presented at scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42019135269.

Cervical musculoskeletal impairments in migraine and tension type headache: A systematic review and meta-analysis

AIMS

Neck pain is common in migraine and tension type headache (TTH). This review aimed to examine the evidence for cervical musculoskeletal impairments in these headaches.

METHODS

Databases PubMed (Medline), EMBASE, CINAHL, SCOPUS, and Web of Science were searched from inception to December 2018. Observational studies using a comparator group were included. Risk of bias was assessed using the Appraisal tool for Cross-Sectional Studies. Results were pooled using random effects meta-analysis. Level of evidence for each outcome was assigned based on risk of bias, consistency of results and magnitude of difference between participants with headache and controls. (PROSPERO registration: CRD42018083683).

RESULTS

Of 48 studies included, the majority were rated moderate risk of bias due to possible confounding influences. In total, 17 cervical outcomes were assessed, with confidence in findings ranging from very low to moderate levels. Compared to controls, participants with TTH had greater forward head posture (FHP) (MD = -6.18°, 95% CI [-8.18°, -4.18°]) and less cervical range of motion (ROM) (greatest difference transverse plane MD = -15.0°, 95% CI [-27.7°, -2.3°]. Participants with migraine demonstrated minimally reduced cervical ROM (greatest difference sagittal plane MD = -5.4°, 95% CI [-9.9°, -0.9°]. No differences presented in head posture, strength, craniocervical flexion test performance or joint position error between migraineurs and controls.

CONCLUSIONS

TTH presented with more findings of cervical musculoskeletal impairments than migraine however levels of confidence in findings were low. Future studies should differentiate episodic from chronic headache, identify coexisting musculoskeletal cervical disorders, and describe neck pain behaviour in headache.

Comparison of range of motion during the cervical flexion rotation versus the side-bending rotation test in individuals with and without hyperlaxity

Objective: The flexion rotation test (FRT) is used to determine C1-2 involvement in individuals with neck pain and headaches. Some individuals present with generalized joint hyperlaxity (GJH) which could influence the results of this test, which relies on a soft tissue locking mechanism. The purpose of this study was to examine the side-bend rotation test (SBRT), which utilizes osseous locking, compared to the FRT. Methods: Thirty-eight healthy individuals (25 female, 26.03 years) were assessed for GJH via the Beighton Hypermobility Index (BHI). A blinded examiner performed the FRT and SBRT bilaterally, measuring ROM using a digital goniometer device. Results: Statistically significant differences in ROM were present for the FRT based on negative (0-3) and positive (4-9) BHI score: (Right 46.4±3.6, 49.6±4.8, p=.031), (Left 45.5±3.5, 49.0±5.2, p=.023); no differences were observed for the SBRT (Right 37.6±4.3, 38.9±3.4), (Left 37.7±4.2, 37.6±3.4).  When further stratifying the groups, a one-way ANOVA and post-hoc testing revealed significant differences of FRT range of motion between the BHI 7-9 group(52.4 ± 4.4 -53.9 ± 3.4) compared to BHI 0-3 (45.4 ± 3.6-46.2 ± 3.5) and 4-6 groups (46.0 ± 3.7-46.4 ± 2.2), p < .001; there were no significant differences between the 0-3 and 4-6 groups. There were no between group differences for the SBRT, BHI 0-3 (37.5 ± 4.4-37.7 ± 4.3), BHI 7-9 (39.9 ± 3.7-39.2 ± 3.5). Discussion: Individuals with GJH demonstrated significant differences in ROM for the FRT, but not the SBRT. The SBRT may be a useful alternative to the FRT for individuals with hyperlaxity. However, further research needs to be conducted to assess the diagnostic ability of this test in individuals with cervical pathology.

Psychometric properties of the Numeric Pain Rating Scale and Neck Disability Index in patients with cervicogenic headache

Background

Self-reported disability and pain intensity are commonly used outcomes in patients with cervicogenic headaches. However, there is a paucity of psychometric evidence to support the use of these self-report outcomes for individuals treated with cervicogenic headaches. Therefore, it is unknown if these measures are reliable, responsive, or result in meaningful clinically important changes in this patient population.

Methods

A secondary analysis of a randomized clinical trial (n = 110) examining the effects of spinal manipulative therapy with and without exercise in patients with cervicogenic headaches. Reliability, construct validity, responsiveness and thresholds for minimal detectable change and clinically important difference values were calculated for the Neck Disability Index and Numeric Pain Rating Scale.

Results

The Neck Disability Index exhibited excellent reliability (ICC = 0.92; [95 % CI: 0.46–0.97]), while the Numeric Pain Rating Scale exhibited moderate reliability (ICC = 0.72; [95 % CI: 0.08–0.90]) in the short term. Both instruments also exhibited adequate responsiveness (area under the curve; range = 0.78–0.93) and construct validity ( p < 0.001) in this headache population.

Conclusions

Both instruments seem well suited as short-term self-report measures for patients with cervicogenic headaches. Clinicians and researchers should expect at least a 2.5-point reduction on the numeric pain rating scale and a 5.5-point reduction on the neck disability index after 4 weeks of intervention to be considered clinically meaningful.

Self-report and subjective history in the diagnosis of painful neck conditions: A systematic review of diagnostic accuracy studies

Rising healthcare costs and inherent risks with over-utilizing diagnostic imaging require a quality subjective examination to improve effectiveness and time management of physical examinations. This systematic review investigates the diagnostic accuracy of subjective history and self-report items to determine if there is significant alteration in the probability of identifying specific painful neck conditions. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed.

INCLUSION CRITERIA

1) Written in the English language 2) Cervical pain with/without referred upper extremity or head pain 3) Subjective history or self-report items 4) Study designs that reported diagnostic statistics or allowed calculation of sensitivities, specificities, diagnostic odds ratios, and likelihood ratios 5) used a reference standard that has a sensitivity or specificity ≥75% or a diagnostic tool that is strongly supported in the literature where this data is not available. Quality Assessment of Studies of Diagnostic Accuracy II was performed to evaluate risk of bias. Five studies with 830 total patients met the inclusion criteria. Conditions commonly reported in the literature included: cervical radiculopathy, cervical myelopathy, degenerative joint disease, and cervicogenic headache. Individual history questions show minimal diagnostic value in identifying cervical conditions without the physical examination. The value of the subjective history report is important and requires further investigation for specific neck conditions. Clustering symptoms may provide more insight than individual history items in future studies. The diagnostic value of history for neck conditions may be underrepresented due to the lack of studies that isolate subjective examination from the physical examination.

LEVEL OF EVIDENCE

3a.

Calcitonin Gene-Related Peptide in Cervicogenic Headache

Trigeminovascular activation is involved in the pathophysiology of migraine and cluster headache. The marker evaluated best for trigeminovascular activation is calcitonin gene-related peptide (CGRP) in the cranial circulation. It is unknown whether trigeminovascular activation plays any role in cervicogenic headache (CEH). The objective of this study was to investigate CGRP plasma levels in CEH patients in relation to headache state. To compare plasma CGRP levels between the peripheral and the cranial circulation. Blood from both external jugular veins and from the antecubital vein was drawn from 11 patients with CEH. Plasma CGRP levels were measured by radioimmunoassay. No difference was found between CGRP levels assessed on days with and without headache. There was no difference beween CGRP levels from the symptomatic and the asymptomatic external jugular vein and the antecubital vein. There is no evidence for an activation of the trigeminovascular system in CEH. In certain cases, clinical differentiation between CEH and migraine without aura is difficult. Plasma CGRP levels might serve as a biological marker to distinguish the two headache entities.

Can atlas spina bifida-occulta be a cause of cervicogenic headaches?

Cervicogenic headaches are a nosologic entity recently recognized. In our common practice, we have noticed a relative frequency of the atlas spina-bifida occulta during the brain CT scan realized for headaches without cranio-encephalic causes or any other anomaly of the upper cervical region. The aim of this study was to determine a possible connection between cervicogenic headaches (CEH) and atlas spina-bifida occulta. A 2 years prospective and descriptive study in 20 black patients having an atlas spina-bifida occulta diagnosed with a brain CT scan. The mean age of the patients was 43.17 ± 18.35 years (extremes: 24 and 72 years). A light female predominance was noticed (sex-ratio = 1.5). The frequency of symptomatic spina-bifida was 1.72 % (17 cases). The mean age at onset was 31.84 years. The pain was sub-occipital in 14 cases, occipital in 8 cases, bilateral in 12 cases and unilateral in 5 cases. The mean duration of the attacks was 72 ± 24 h and the pain intensity was moderate (16 cases); mean and range were 3.6 and 3–6. The frequency of attacks varied between 1 per 7 months (n = 2) and 2 per week (n = 1) in those with non-daily headache. One attack per 5–7 weeks was the most commonly occurring attack frequency. The pain was reproduced by the pressure of the occipital region or upper cervical in 15 cases. The mean number of criteria was five and there was a strong positive correlation between criteria and CEH (χ² = 45.57; V = 0.62). The associated signs were photophobia and nausea in one case each. Indomethacin, Ergotamine and/or Sumatriptan were without any antalgic effect in 16 cases. Pain ceased after an anesthetic blockade of C2 (16 cases). The results show that atlas spina-bifida occulta is not involved in CEH pure form genesis. On a small sample, the atlas spina-bifida seems to be a cause of CEH associated with headache and disorders of the neck.

Efficacy of interventions used by physiotherapists for patients with headache and migraine-systematic review and meta-analysis

AIM

We aimed to conduct a systematic review evaluating the effectiveness of interventions used by physiotherapists on the intensity, frequency and duration of migraine, tension-type (TTH) and cervicogenic headache (CGH).

METHODS

We performed a systematic search of electronic databases and a hand search for controlled trials. A risk of bias analysis was conducted using the Cochrane risk of bias tool (RoB). Meta-analyses present the combined mean effects; sensitivity analyses evaluate the influence of methodological quality.

RESULTS

Of 77 eligible trials, 26 were included in the RoB assessment. Twenty trials were included in meta-analyses. Nineteen out of 26 trials had a high RoB in >1 domain. Meta-analyses of all trials indicated a reduction of TTH ( ITALIC! p < 0.0001; mean reduction -1.11 on a 0-10 visual analog scale (VAS); 95% CI -1.64 to -0.57) and CGH ( ITALIC! p = 0.0002; mean reduction -2.52 on a 0-10 VAS; 95% CI -3.86 to -1.19) pain intensity, CGH frequency ( ITALIC! p < 0.00001; mean reduction -1.34 days per month; 95% CI -1.40 to -1.28), and migraine ( ITALIC! p = 0.0001; mean reduction -22.39 hours without relief; 95% CI -33.90 to -10.88) and CGH ( ITALIC! p < 0.00001; mean reduction -1.68 hours per day; 95% CI -2.09 to -1.26) duration. Excluding high RoB trials increased the effect sizes and reached additional statistical significance for migraine pain intensity ( ITALIC! p < 0.00001; mean reduction -1.94 on a 0-10 VAS; 95% CI -2.61 to -1.27) and frequency ( ITALIC! p < 0.00001; mean reduction -9.07 days per month; 95% CI -9.52 to -8.62).

DISCUSSION

Results suggest a statistically significant reduction in the intensity, frequency and duration of migraine, TTH and CGH. Pain reduction and reduction in CGH frequency do not reach clinically relevant effect sizes. Small sample sizes, inadequate use of headache classification, and other methodological shortcomings reduce the confidence in these results. Methodologically sound, randomized controlled trials with adequate sample sizes are required to provide information on whether and which physiotherapy approach is effective. According to Grading of Recommendations Assessment, Development and Evaluation (GRADE), the current level of evidence is low.

The flexion-rotation test performed actively and passively: a comparison of range of motion in patients with cervicogenic headache

Limitation in cervical spine range of motion (ROM) is one criterion for diagnosis of cervicogenic headaches (CHs). The flexion-rotation test, when performed passively (FRT-P), has been shown to be a useful test in diagnosis of CH. Few investigations have examined the flexion-rotation test when performed actively (FRT-A) by the individual, and no studies have examined the FRT-A in a symptomatic population. The purpose of this study was to compare ROM during the FRT-A and FRT-P in patients with CH and asymptomatic individuals and to compare ROM between sides for these two versions of the test. Twelve patients with CH and 10 asymptomatic participants were included in the study. An eight-camera Motion Analysis system was used to measure head motion relative to the trunk during the FRT-P and the FRT-A. Cervical rotation ROM was measured in a position of full cervical flexion for both tests. No significant difference was observed between right and left sides for cervical rotation ROM during the FRT-P nor the FRT-A when performed by asymptomatic participants. In patients with CH, a significant difference was observed between sides for the FRT-P (P = 0.014); however, the FRT-A failed to reveal bilateral descrepancy in rotation ROM.

An investigation of cervical spinal posture in cervicogenic headache

BACKGROUND

Cervicogenic headache (CGH) is defined as headache symptoms originating from the cervical spine. Cervical dysfunction from abnormal posture has been proposed to aggravate or cause CGH, but there are conflicting reports as to whether there is an association between posture and CGH.

OBJECTIVE

The purpose of this study was to evaluate differences in cervical spinal posture, measured on radiographs, between patients with probable CGH and asymptomatic control participants.

DESIGN

A single-blinded comparative measurement design was used.

METHODS

Differences in postural variables from radiographs between participants with CGH (n=30) and age- and sex-matched asymptomatic control participants (n=30) were determined using paired t tests or the nonparametric equivalent. Postural variables were general cervical lordosis (GCL, Cobb angle C2-C7), upper cervical lordosis (UCL, sagittal alignment C2 compared with C3-C4), and C2 spinous process horizontal deviation. Logistic regression determined postural variables, increasing the likelihood of CGH.

RESULTS

There were no significant differences in posture between the CGH and control groups. The mean GCL was 10.97 degrees (SD=7.50) for the CGH group and 7.17 degrees (SD=5.69) for the control group. The mean UCL was 11.86 degrees (SD=6.46) for the CGH group and 9.44 degrees (SD=4.28) for the control group. The mean C2 spinous process horizontal deviation was 3.00 mm (SD=1.66) for the CGH group and 2.86 mm (SD=2.04) for the control group. However, there was a significant association between greater GCL and an increased likelihood of having CGH (odds ratio=1.08; 95% confidence interval=1.001, 1.191).

LIMITATIONS

The findings are limited to an association between GCL and posture, as cause and effect cannot be determined.

CONCLUSIONS

The association between greater GCL and increased likelihood of having CGH suggests that GCL might be considered in the treatment of patients with CGH. However, as the data do not support posture as a cause of CGH, it is unknown whether addressing posture would reduce CGH.

C2 nerve root on magnetic resonance imaging of occipital neuralgia

STUDY DESIGN

Review and grade the morphology of the C1-C2 neural foramina, from the MR images of patients who underwent C1-C2 spinal surgery, and determine the relationship with ON.

OBJECTIVE

To evaluate the feasibility of MRI for C1-C2 neural foramen evaluation with a new grading system and to correlate the C1-C2 neural foramen grade with ON.

SUMMARY OF BACKGROUND DATA

There have been no MRI studies of patients with and without ON in relation to C2 nerve root ganglion findings.

METHODS

Among the registry of 124 patients who underwent C1-C2 spinal surgery between July 2004 and May 2012 in Seoul National University Bundang Hospital, we enrolled 101 patients who had information about ON and a relevant preoperative cervical spine MR image. A total of 202 neural foramina were evaluated with our new C1-C2 neural foramen grading system (grade, 0-3) using consensus reading by 2 experienced radiologists who were blinded to the clinical information. The relationship between the C1-C2 grading system and ON was assessed using a χ test and Fisher exact test. Inter- and intraobserver reliability agreement was assessed using the κ statistic.

RESULTS

All C1-C2 neural foramina were delineated on T2 parasagittal images. Among 202 C1-C2 neural foramina, grade zero was found in 49 foramina (24.3%), grade 1 in 95 (47.0%), grade 2 in 30 (14.9%), and grade 3 in 28 (13.9%). Grade 1 stenosis was most frequently noted. The grade 2 group had the most frequent prevalence of ON (43.3%), followed by grade 3 (35.7%), grade zero (30.6%), and grade 1 (29.5%). However, the relationship between the grade and ON was not statistically significant. Inter- and intraobserver agreements were substantially high.

CONCLUSION

C1-C2 neural foramina can be depicted on MR image. However, the relationship between the new grading system for C1-C2 neural foramina and ON was not statistically significant.

LEVEL OF EVIDENCE

4.

A pain in the eye

A 38-year-old woman presented with chronic left retro-orbital pain and photophobia. Palpation of the left occipital prominence revealed tenderness in the area of the greater occipital nerve and reproduced the eye pain. The diagnosis of cervicogenic headache was confirmed by symptom resolution following left greater occipital nerve blockade. The functional association between the greater occipital nerve and the trigeminal nerve provides a potential mechanism for this case of cervicogenic eye pain.

A pilot study to investigate the short-term effects of specific soft tissue massage on upper cervical movement impairment in patients with cervicogenic headache

OBJECTIVES

Upper cervical movement impairment and muscle dysfunction have been identified as core components of cervicogenic headache (CGH) pathogenesis. The purpose of this single-group pre-post test pilot study was to investigate the short-term effects of a specific soft tissue massage (SSTM) intervention to the cervical spine on range of upper cervical motion.

METHODS

Eight subjects (mean age 28.1 years) with published criteria of CGH (mean history of headache for 7.1 years) were investigated. Range of rotation of the upper cervical spine to the left and right was determined by the flexion-rotation test. Movement was assessed in three phases: pre-intervention, intervention, and post-intervention. The SSTM intervention consisted of an 8-minute soft tissue massage to the cervical muscles bilaterally.

RESULTS

Pre-intervention measures of flexion-rotation test range of motion prior to the intervention over two assessment points were consistent. In contrast, a repeated measures analysis of variance revealed a significant improvement in range of rotation to the left and right after the first (P<0.01), second (P<0.01), but not third intervention (P = 0.19), from an average range of 27.5° at baseline to 45.9° at the third treatment session. After the 2-week post-intervention phase, range of motion remained stable without decline, and was considered full range.

DISCUSSION

This pilot study provides preliminary evidence of the potential for SSTM to improve, at least in the short-term, upper cervical range of motion in people with CGH.

Is there a difference in head posture and cervical spine movement in children with and without pediatric headache?

Pediatric headache is an increasingly reported phenomenon. Cervicogenic headache (CGH) is a subgroup of headache, but there is limited information about cervical spine physical examination signs in children with CGH. Therefore, a cross-sectional study was designed to investigate cervical spine physical examination signs including active range of motion (ROM), posture determined by the craniovertebral angle (CVA), and upper cervical ROM determined by the flexion-rotation test (FRT) in children aged between 6 and 12 years. An additional purpose was to determine the degree of pain provoked by the FRT. Thirty children (mean age 120.70 months [SD 15.14]) with features of CGH and 34 (mean age 125.38 months [13.14]) age-matched asymptomatic controls participated in the study. When compared to asymptomatic controls, symptomatic children had a significantly smaller CVA (p < 0.001), significantly less active ROM in all cardinal planes (p < 0.001), and significantly less ROM during the FRT (p < 0.001), especially towards the dominant headache side (p < 0.001). In addition, symptomatic subjects reported more pain during the FRT (p < 0.001) and there was a significant negative correlation (r = -0.758, p < 0.001) between the range recorded during the FRT towards the dominant headache side and FRT pain intensity score. This study found evidence of impaired function of the upper cervical spine in children with CGH and provides evidence of the clinical utility of the FRT when examining children with CGH.

Diagnostic distribution of 100 unilateral, side-locked headaches consulting a specialized clinic

OBJECTIVES

We analyzed the diagnoses of patients consulting due to strictly unilateral headaches.

METHODS

We prospectively collected data from 100 consecutive patients. Diagnosis followed the ICHD-II criteria.

RESULTS

They accounted for 18.9% of the 528 patients seen in the study period. They were more frequent in males (58%). Age ranged from 19 to 81 years. Diagnostic distribution was: cluster headache (38 cases), a variety of secondary headaches (14 cases), migraine (11 cases), cervicogenic headaches (9 cases), hemicrania continua (8 cases), nummular headache (6 cases), psychiatric headache (5 cases), paroxysmal hemicranias (4 cases), short-lasting unilateral neuralgiform headache attacks syndrome (3 cases), stabbing headache (1 case), and hypnic headache (1 case). Mean ages at onset fell between 47 and 58 years for several diagnoses (cervicogenic, nummular, psychiatric, hemicrania continua and paroxysmal hemicrania headaches), and were 22 years for migraine, 32 for cluster and in general older than 55 years for secondary headaches.

CONCLUSIONS

Strictly unilateral headaches account for almost 20% of headaches in subjects attending a headache clinic. Trigeminal-autonomic cephalgias in general (52%) and cluster headache in particular (38%) are the most frequent diagnoses, but secondary headaches account for 1 of 5 cases. Age at onset can be of help in their presumptive diagnosis.

Diagnostic work-up of an elderly patient with unilateral head and neck pain. A case report

Headache patients frequently contact physiotherapists and manual therapists. In case of elderly patients with unilateral headache, neck and facial pain clinical practice guidelines recommend further referral for medical investigation to exclude red flags. The present patient was seen in a multidisciplinary headache clinic. He was referred by the neurologist (headache specialist) for physiotherapeutic assessment after screening for red flags, including giant cell arteritis (GCA). After first assessment, GCA was considered unlikely, since the sedimentation rate, as a marker for inflammation, was only slightly elevated. The purpose of the referral was to exclude cervicogenic headache (CEH) and to explore physical treatment as a therapeutic option. Physiotherapeutic assessment consisted of a history taking on CEH signs (Sjaastad criteria, 1998), followed by cervical spine assessment including tests for neck mobility, joint pain, and endurance of the short neck flexors. The patient's history revealed no specific signs of CEH and cervical spine assessment was negative. In consultation with the neurologist, the diagnosis of CEH was abandoned. Since palpation of the temporal artery proved to be painful, laboratory examination and biopsy of the temporal artery were thereafter performed, this time revealing GCA. Appropriate treatment (high dose steroids) was initiated promptly, with a good clinical evolution. The presented case shows the potential of a multidisciplinary collaboration in the clinical diagnostic work-up of patients with head and neck pain.

Role of greater occipital nerve blocks and trigger point injections for patients with dizziness and headache

BACKGROUND

The trigeminocervical system is integral in cervicogenic headache. Cervicogenic headache frequently coexists with complaints of dizziness, tinnitus, nausea, imbalance, hearing complaints, and ear/eye pain. Controversy exists as to whether this constellation of symptoms may be cervically mediated.

OBJECTIVES

To determine whether a wider spectrum of cervically mediated symptoms exist, and to investigate a potential role of greater occipital nerve blocks (GON) and trigger point injections (TPI) in these patients.

METHODS

Retrospective review of GON/TPI performed in a tertiary otoneurology/headache clinic from May 2006 to March 2007 for suspected cervically mediated symptoms. Data included chief complaint, secondary symptoms, response to injection, pre-GON/TPI posterior vertex sensation changes to pinprick, cervical spine examination, and response to vibration of cervical and suboccipital musculature.

RESULTS

Total number of 147 patients were included. Chief complaints in decreasing frequency: dizziness (93%), tinnitus (4%), headache (3%), and ear discomfort (0.7%). Overall symptoms in decreasing frequency: dizziness (97%), headache (88%), neck pain (63%), tinnitus (23%), and ear discomfort (22%). Improvements after GON/TPI: neck range of motion (71%), headache (57%), neck pain (52%), ear discomfort (47%), dizziness (46%), and tinnitus (30%). Dizziness responders had neck position asymmetries (84%), reproducible dizziness by cervical and suboccipital musculature vibration (75%), and preinjection posterior vertex sensory changes (60%).

CONCLUSIONS

A wider spectrum of cervically mediated symptoms may exist by influence of trigeminocervical and vestibular circuitry through cervical afferent neuromodulation. Certain examination findings may help to predict benefit from GON/TPI.

The influence of lower cervical joint pain on range of motion and interpretation of the flexion-rotation test

OBJECTIVE

The purpose of this study was to investigate the impact of lower cervical facet joint pain (CFP) on the flexion-rotation test (FRT).

METHODS

A single blind, comparative group design was used to investigate whether lower CFP influences FRT mobility and examiner interpretation. Twenty-four subjects were evaluated, 12 with cervicogenic headache (age 26-63 years) and 12 with lower CFP (age 44-62 years), confirmed by therapeutic cervical facet joint intervention. A single blinded examiner conducted the FRT, reporting the test state (positive or negative) before measuring range of motion using a goniometer. Subjects with lower CFP were evaluated by the FRT prior to therapeutic intervention and were excluded from analysis if they did not gain complete symptomatic relief following the procedure. Only subjects with immediate complete relief were included.

RESULTS

The average range of unilateral rotation to the limited side during the FRT was 26 and 37.5° for the cervicogenic headache and lower CFP groups respectively. The difference between groups was significant (P<0.01). Sensitivity and specificity for cervicogenic headache diagnosis was 75 and 92% respectively. A receiver operating curve revealed that an experienced examiner using the FRT was able to make the correct diagnosis 90% of the time (P<0.01), with a positive cut-off value of 32°.

DISCUSSION

These findings provide further evidence for the clinical utility of the FRT in cervical examination and cervicogenic headache diagnosis.

Cervicogenic headache: a review comparison with migraine, tension-type headache, and whiplash

Cervicogenic headache (CEH) is a well-recognized syndrome. Proposed diagnostic criteria differentiate CEH from migraine and tension-type headache (TTH) in most of the cases. The best differentiating factors include side-locked unilateral pain irradiating from the back and evidence of neck involvement--attacks may be precipitated by digital pressure over trigger spots in the cervical/nuchal areas or sustained awkward neck positions. Migrainous traits may be present in some cases. Cervical lesions are not necessarily seen, and most common cervical lesions do not produce CEH. Whiplash may occasionally induce headaches. This is suspected when the pain onset and the whiplash trauma are close in time. Whiplash-related headaches tend to be short-lasting, admitting mostly a TTH or a CEH-like phenotype. Neuroimaging abnormalities are not necessarily expected in CEH. Whiplash patients must undergo cervical imaging mostly in connection with the trauma, as no abnormalities are pathognomonic in chronic cases.

Comparative analysis and diagnostic accuracy of the cervical flexion-rotation test

The aim of this study was to compare the findings of the cervical flexion–rotation test (FRT) between subjects with probable cervicogenic headache (CGH), migraine without aura (Migraine), and multiple headache forms (MHF). An additional aim was to identify the diagnostic accuracy of the FRT in CGH evaluation. Sixty subjects were evaluated: 20 with CGH, 20 with Migraine, and 20 with MHF. Subject and headache symptoms were evaluated by questionnaire. A single-blind examiner conducted the FRT, reporting the test state (positive or negative) before measuring range of motion using a goniometer. The average range of unilateral rotation to the most restricted side was 25°, 42° and 35° for groups CGH, Migraine and MHF, respectively. The difference between groups was significant (P < 0.001). Range of rotation was significantly reduced in the CGH group when compared to groups Migraine (P < 0.001) and MHF (P = 0.001), with an additional smaller significant difference between groups Migraine and MHF (P = 0.039). A receiver operating curve revealed that an experienced examiner using the FRT was able to make the correct diagnosis 85% of the time (P < 0.001), with a positive cut-off value of 30°. Multivariate regression analysis revealed that 44% of the variance in FRT range of motion was explained by the presence of two variables: neck movement or positions provoke headache, and neck symptoms precede headache, but not by other factors associated with migraine. These findings provide further evidence supporting the clinical utility of the FRT in CGH evaluation.