Cervicogenic headache: a personal view

A Study of Exertional Headache's Prevalence and Characteristics Among Conscripts

BACKGROUND

Headache is one of the most common complaints in today's society. Patterns and prevalence of headache, especially headaches associated with physical activity (Exertional Headache) in the population of conscripts in our country is unknown.

OBJECTIVES

In this cross sectional study we tried to answer these questions to some extent.

PATIENTS AND METHODS

Using a Persian questionnaire based on international headache society criteria of headache types (ICHD-II) and a sample size of 300, filled by two trained medical doctors, we gathered our data and analyzed it with an acceptable P value of < 0.05 and a confidence interval of 95%.

RESULTS

Headache prevalence among our conscript participants was 78.7%. The prevalence of exertional headache was 12.7%. EH sufferers' mean age was 22.16 (SD: 2.60) years. EH was found more often bilaterally and almost equally pulsating or compressive. The main location of pain was frontotemporal region. The most common aggravating and alleviating factors of EH were hot environment and discontinuation of exercise respectively.

CONCLUSIONS

Our team provided a reasonable database of exertional headache and its characteristics in conscripts' population which could be used in further investigations to improve their general health and function.

Post-traumatic headache: is it for real? Crossfire debates on headache: pro

Mild traumatic brain injury is very common in Western societies, affecting approximately 1.8 million individuals in the USA. Even though between 30% and 90% of patients develop post-traumatic headache, post-traumatic headache remains a very controversial disorder. Particularly when it comes to chronic post-traumatic headache following mild closed head injury and headache attributed to whiplash injury. Some experts are disputing its existence as a genuine disorder. Indistinct disease classification, unresolved pathophysiological mechanism, and the role of accident-related legal issues further fuel this controversy. The complex combination of pain and neuropsychological symptoms needs further research in understanding the underlying pathophysiological mechanisms associated with the acute headache following trauma but more so the mechanisms associated with the development of chronic pain in some patients. Investigators should refrain from oversimplifying these complex mechanisms as hysteric exaggeration of everyday complains and from implying greed as motivation for this potentially very disabling disease.

Post-traumatic headache

Post-traumatic headache (PTH) is a very controversial disorder, particularly when it comes to chronic PTH following mild closed head injury and headache attributed to whiplash injury. Nevertheless, mild traumatic brain injury is very common in Western societies, affecting approximately 1.8 million individuals in the USA. Between 30 and 90% of patients develop PTH. Generally, this headache resolves within the first 3 weeks after the accident without any specific therapy or long-term complications but in a minority of patients chronic PTH develops and can be associated with serious neurological and neuropsychological deficits. Sufficient psychological or neurobiological markers for PTH do not exist, thus treatment can be very challenging and should always be multidisciplinary, even in the early stages of disease, to make every reasonable effort in preventing the development of chronic pain.

An anatomic and morphometric study of C2 nerve root ganglion and its corresponding foramen

STUDY DESIGN

Exposing and measuring the dorsal root ganglion of the second cervical spinal nerve (C2 ganglion) and the second intervertebral space, which is present between posterior arch of atlas (APA) and lamina of axis (LA).

OBJECTIVES

This study aims to investigate the shape, size, and relation of the C2 ganglion with the adjacent structures that limits the corresponding intervertebral space and the alterations of relation between C2 ganglion and APA and between C2 ganglion and LA with the movements of the head bilaterally.

SUMMARY OF BACKGROUND DATA

In previous studies, the position and the heights of the C2 ganglion have been described. But the shape of the C2 ganglion and its relation to APA and LA by the movement of the head had not been considered previously.

METHODS

Upper cervical spines of 20 cadavers were dissected posteriorly. The muscles attaching to the atlas and axis were resected to ease the head movements. The heights of the C2 ganglion and space were measured in anatomic position and in hyperextension with opposite rotation position of the head. Originally in this study, plastic dough casts were used to obtain reliable outcomes.

RESULTS

The shape of the ganglions was defined in three types: 70% were oval, 20% were spindle-like, and 10% were spherical. The height of the C2 ganglion was 4.97 +/- 0.92 mm on the right side and 4.6 +/- 0.84 mm on the left side. The height of the intervertebral space in anatomic position and in hyperextension with rotation to the opposite position of the head were, respectively, 9.74 +/- 1.77 mm and 7.48 +/- 1.44 mm on the right side and 9.64 +/- 1.47 mm and 7.12 +/- 0.96 mm on the left side. There was no bone contact or impact to the ganglion in each position of the head.

CONCLUSION

The C2 ganglions are confident in their place between APA and LA. No bone contact to the C2 ganglion was detected in either normal limited or in forced head motions.

Diagnosis and follow-up of minor cervical trauma

In order to evaluate sensitivity, specificity and accuracy of radiographic findings, 1347 patients with minor cervical injury underwent clinical, orthopaedic, neurosurgical examination, and were classified as monosymptomatic (only cervical pain) or polysymptomatic (cervical pain plus additional symptoms). X-rays were taken in anteroposterior, lateral and open-mouth views; additional views if necessary. X-ray outcome was normal in 69.8% of monosymptomatic patients and there were no fractures. In 45.1% of polysymptomatic patients, outcome was normal, but there were seven fractures. Computed tomography/magnetic resonance (CT/MR) was performed in patients with documented injury and/or strong persistent symptoms. X-ray follow-up at 4-6 weeks included flexion-extension examination. Elevated statistical radiographic values were reached. All patients with minor cervical trauma should undergo clinical, neurosurgical and three-view radiographic follow-up. A simplified algorithm could lead to substantial savings and decrease patients' exposure to radiation.

Headaches and exercise

Exercise-related headache is one of the most common medical problems affecting the modern-day athlete. Despite the high prevalence of headache in community populations, the epidemiology of sports-related headache is unclear. In certain collision sports, up to 50% of athletes report regular headaches as a consequence of their athletic participation. The classification of the different types of sport-related headache by the International Headache Society (IHS) and in previously published articles does not adequately encompass the clinical problem faced by team physicians. Confusion exists where terms such as 'effort headache' and 'exertional headache' may be used to describe similar entities. In this review, the specific headache entities discussed include benign exertional headache, effort headache, acute post-traumatic headache and cervicogenic headache. For the sports physician, an understanding of the variety of specific headache syndromes that occur with particular sports is necessary for everyday clinical practice. This article reviews the common exercise-related headache syndromes and attempts to provide a framework for their overall management. Team physicians also need to be cognisant that many of the standard preparations used to treat headaches may be banned drugs under International Olympic Committee (IOC) rules.

Interobserver reliability in physical examination of the cervical spine in patients with headache

OBJECTIVE

To assess interobserver reliability of two expert headache neurologists when examining the cervical spine of patients with headache.

BACKGROUND

The diagnosis of cervicogenic headache involves the physical examination of the cervical spine.

METHODS

Twenty-four patients diagnosed as having migraine, tension-type headache, or cervicogenic headache were included in the study. After interview, each patient's cervical spine was examined in a structured way. Reliability was assessed by Cohen's kappa.

RESULTS

Reduced range of motion in the cervical spine showed kappa scores indicating moderate agreement. Provocation of headache revealed moderate-to-substantial agreement. Assessment of zygapophyseal joint pressure pain showed slight-to-fair agreement. The kappa values of the circumscribed characteristic tender points showed agreement ranging from "not better than chance" to "substantial agreement."

CONCLUSIONS

Our study showed that the interobserver reliability of expert headache neurologists was satisfactory in the majority of the physical examination tests of the cervical spine in patients with different headache syndromes. However, standardization of the clinical tests in order to improve their reliability is recommended.

Cervicogenic headache: a comparison with migraine and tension-type headache

Cervicogenic headache (CEH) is a neck-generated headache syndrome. Attacks may be similar to migraine (M) or tension-type headache (TTH). In order to test the accuracy of the IHS diagnostic criteria for M and episodic TTH and of the criteria for CEH of Sjaastad et al., 33 CEH, 65 M, and 29 TTH were evaluated according to the CEH criteria, and CEH patients were tested for M and TTH according to the IHS criteria. Only 30% of the CEH patients met the criteria for M, 3% met the criteria for TTH, and 66% were neither M nor TTH. The mean number of criteria met, sex, age, and age of onset were also analysed, and the results indicate an inequality among these three headache types. The most important differentiating aspects were the site and radiation of the pain, the temporal pattern, and the induction of attacks from neck posture, movements, and/or digital pressure. CEH clearly differs from M and TTH. Existing criteria adequately distinguish the three headaches.

Further clinical clarification of the muscle dysfunction in cervical headache

The Headache Classification Committee of the International Headache Society listed impairments in cervical muscle function as criteria for headaches of cervical spine origin. Fifteen subjects with cervical headache and 15 controls were tested for the frequency of abnormal responses to passive stretching and abnormal muscle contraction. A new test of cranio-cervical flexion was used to assess the contraction of the deep neck flexors. Results indicated a trend towards a higher frequency of abnormal response to passive stretching of the muscles examined in the cervical headache group but only the upper trapezius proved significantly different to the control group. Deep neck flexor muscle contraction was significantly inferior in the cervical headache group. From the perspective of physical characterization of cervical headache, it appears that response from passive stretch of muscle may not be a strong criterion for cervical headache but deep neck flexor performance may have potential to identify musculoskeletal involvement in headache. The finding may also provide positive directions for conservative treatment of cervical headache.

Greater occipital nerve blockade in cervicogenic headache

Cervicocogenic headache (CeH) is a relatively common disorder. Although on ideal treatment is available so far, blockades in different structures and nerves may be temporarily effective. We studied the effects of 1-2 mL 0.5% bupivacaine injection at the ipsilateral greater occipital nerve (GON) in 41 CeH patients. The pain is significantly reduced both immediately and as long as 7 days after the blockade. The improvement is less marked during the first two days, a phenomenon we called "tilde pattern". GON blockades may reduce the pool of exaggerated sensory input and antagonize a putative "wind-up-like effect" which may explain the headache improvement.

Headache and the cervical spine: a critical review

Headache related to the cervical spine is often misdiagnosed and treated inadequately because of confusing and varying terminology. Primary headaches such as tension-type headache and migraine are incorrectly categorized as "cervicogenic" merely because of their occipital localization. Cervicogenic headache as described by Sjaastad presents as a unilateral headache of fluctuating intensity increased by movement of the head and typically radiates from occipital to frontal regions. Definition, pathophysiology; differential diagnoses and therapy of cervicogenic headache are demonstrated. Ipsilateral blockades of the C2 root and/or greater occipital nerve allow a differentiation between cervicogenic headache and primary headache syndromes such as migraine or tension-type headache. Neither pharmacological nor surgical or chiropractic procedures lead to a significant improvement or remission of cervicogenic headache. Pains of various anatomical regions possibly join into a common anatomical pathway, then present as cervicogenic headache, which should therefore be understood as a homogeneous but also unspecific pattern of reaction.

Cervicogenic headache. Josey's cases revisited

Before Sjaastad coined the term cervicogenic headache (CR) 15 years ago, neck-related headaches have been considered by different authors for many years. Even after the publication of diagnostic criteria, dispute on the clinical picture, differential diagnosis, pathophysiology and treatment of CR still persists. A paper published in 1949 by Josey reports on 6 "illustrative" cases of cervical-related headaches. Indeed, looked from a more recent perspective, those cases could eventually correspond to CH. Important topics such as the relatively high frequency, fixed unilaterality of the pain, relation to previous trauma, irradiation from the back to the forehead, normal or slightly abnormal roentgenograms, and the mechanical precipitation of attacks are some of the topics considered by Josey. The female gender was not prevalent in Josey's series. Traction and analgesics were basically the recommended treatment. CR is probably a common disorder, an idea already considered by a clinician in 1949. This syndrome was not adequately described before Sjaastad's group papers in the 80's.

Recognizing exercise-related headache

Active patients may suffer not only from the common headache syndromes that plague the general population, but also from headache brought on by exercise. Valsalva-type maneuvers can bring on exertional headache; maximal or submaximal aerobic activity can precipitate effort headache. Trauma to the head and neck can lead to posttraumatic headache. Other headache syndromes in athletes include cervicogenic headache, goggle headache, diver's headache, and altitude headache.