Headache and the cervical spine: a critical review

Relationship between echogenicity of deep cervical muscles and pain laterality in subjects suffering from cervicogenic headache

OBJECTIVE

This study investigated the deep upper cervical muscles echogenicity in cervicogenic headache (CGH) patients.

METHODS

The echogenicity of longus capitis (LCAP), rectus capitis posterior major (RCPM), and obliquus capitis superior (OCS) muscles was measured by ultrasonography and analyzed by Image J software in 17 CGH patients matched with 17 healthy subjects.

RESULTS

The echogenicity of all muscles in the CGH group was higher than that in healthy subjects. The echogenicity of the LCAP muscle on the right side was significantly different between the CGH and healthy subjects (p< 0.05), but there was no difference in the echogenicity of RCPM and OCS muscles between the groups (p> 0.05). Additionally, the echogenicity differences did not match with the pain side in CGH patients (p> 0.05).

CONCLUSION

Only the deep anterior muscle (LCAP) echogenicity affected by CGH and fatty infiltration occurred in this muscle. Hence, anterior muscle dysfunction is important in CGH diagnosis and treatment.

The effectiveness of Sustained Natural Apophyseal Glide on Flexion Rotation Test, pain intensity, and functionality in subjects with Cervicogenic Headache: A Systematic Review of Randomized Trials

OBJECTIVE

To determine the effect of sustained natural apophyseal glide (SNAG) on Flexion Rotation Test, pain intensity, and functionality in subjects with Cervicogenic Headache (CH).

METHODS

The research was conducted on five computerized databases PubMed/Medline, Web of Science, PEDro, Lilacs, and Cochrane Library (CENTRAL), using the keywords combination: (sustained natural apophyseal glide OR SNAG OR joint mobilization OR Mulligan) AND (cervicogenic headache) according to PRISMA guidelines. The methodological quality of the included studies was analyzed using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Eight articles fulfilled the eligibility criteria and were included in the review. The selected studies had a methodological quality of 6.6/10 on the PEDro scale and included a total of 357 participants. The SNAG significantly improved pain, Flexion Rotation Test and reduced functional symptoms.

CONCLUSION

The available evidence suggests that SNAG may be a relevant intervention for CH.

Does restoration of sagittal cervical alignment improve cervicogenic headache pain and disability: A 2-year pilot randomized controlled trial

BACKGROUND

To investigate the feasibility and effect of a multimodal program for improving chronic cervicogenic headache (CGH) via the addition of sagittal cervical spine alignment correction.

DESIGN

Pilot, parallel-group, randomized controlled trial.

PARTICIPANTS

60 patients with CGH, straightening of the cervical lordosis, and forward head posture (FHP) were randomly assigned using permuted-block randomization either to a control (n = 30) or an experimental group (n = 30).

INTERVENTIONS

Subjects in both groups received a multimodal program where the denneroll cervical spine extension traction orthotic was added to the experimental group only. Feasibility was assessed through recruitment rate, compliance rate, adherence rate, safety, and global satisfaction in addition to clinical outcome measures: FHP distance, cervical lordosis, headache frequency, headache disability inventory (HDI), headache impact test-6 (HIT-6), and daily defined dose (DDD). Evaluations were performed at: baseline, 10 weeks, 1 year follow up, and 2-year follow up. The assessor was blind to group allocation for all measured outcomes.

RESULTS

The recruitment rate was 60%, 78 % out of them completed the entire study. The recruited participants complied with 98% of the required visits. No adverse events were recorded and greater overall satisfaction with the interventions was reported. Greater improvements were found for the experimental group's cervical lordosis (f = 259.9, P< < .001) and FHP (f = 142.5, P< < .001). At 10 weeks, both groups showed equal improvements in CGH outcomes: headache frequency (P = 0.07), HDI (P = 0.07), HIT-6 (P = .2), and DDD (P = .3). In contrast, at the 1-year and 2-year follow up, between group differences were found for all CGH outcomes, P < .00, indicating greater improvement in the experimental group.

CONCLUSION

The results indicated feasibility for recruitment rate, compliance rate, exercise session adherence, safety, and global satisfaction. At 1-year and 2-year follow-up, the addition of the denneroll orthotic device revealed positive influence on CGH management outcomes.

TRIAL REGISTRATION

The trial was retrospectively registered with the Pan African Clinical Trial Registry (PACTR201605001650300).

An investigation of 3D spinal alignment in cervicogenic headache

BACKGROUND

There is a growing interest in the impact of body posture influences on outcome measures of cervicogenic headache (CGH).

OBJECTIVE

To evaluate differences in the 3D spinal alignment in cases suffering from chronic CGH compared to a group of strictly matched control participants without CGH.

DESIGN

A single-blinded, comparative cohort design.

METHODS

100 participants suffering from frequent headaches for at least 3 months who fulfilled the CHISG criteria for CGH were match by age and sex to 100 asymptomatic control group participants. A 4D Formetric device was used to assess participants' posture variables of: 1) thoracic kyphosis max (ICT-ITL in degrees); 2) trunk lateral imbalance (VP-DM in mm); 3) Trunk anterior inclination (VP-DM in mm); 4) lumbar lordotic angle (ITL-ILS max in degrees); 5) Vertebral rotation (rms) in degrees. A matched-pairs binary logistic regression was used to determine whether measurements of posture demonstrated an association with the likelihood of the presence of CGH.

RESULTS

There were statistically significant differences between the CGH and control group for all posture variables indicating larger posture displacements in the CGH group: ICT-ITL (p < .001), Lateral VP-DM (p < .001), Sagittal VP-DM (p < .001), ITL-ILS (p < .001), RMS (p < .001). Logistic regression revealed that as posture displacement increased, a statistically significant increased likelihood of having CGH occurred: (ICT-ITL (max) (p < .001); Trunk imbalance VP-DM (p < .004); Trunk inclination VP-DM (p < .001); and vertebral rotation (RMS) (p = .007). No such relationship was found for Lumbar Lordosis ITL-ILS max.

CONCLUSIONS

Participants with CGH exhibited increased magnitudes of thoracolumbar posture displacements which corresponded to an increased odds of suffering from CGH compared to matched control participants.

Anterior Cervical Surgery for the Treatment of Cervicogenic Headache Caused by Cervical Spondylosis

Study Design

Retrospective study.

Objective

To report the efficacy of anterior cervical surgery for the relief of cervicogenic headache (CEH) caused by cervical spondylosis.

Methods

From January 2014 to December 2016, a total of 166 cases of cervical radiculopathy and/or myelopathy received anterior cervical decompression and fusion (ACDF) in our institution, among which 50 cases (mean age 44.7 years) were accompanied by CEH and followed up at 3, 6, 12, and 24 months postoperatively, respectively. Neck pain and headache scores according to neck disability index (NDI) were documented for all patients at regular intervals. The results measured at different follow-up time point were compared statistically.

Results

All 50 patients reported neck pain and headache at the same time before surgery. The average NDIs for neck pain before and after surgery were 2.86 (95% CI: 2.7–3.0) preoperatively, 0.98 (95% CI: 0.8–1.1) at 3 months, 0.68 (95% CI: 0.5–0.9) at 6 months, 0.62 (95% CI: 0.5–0.8) at 12 months, and 0.60 (95% CI: 0.4–0.8) at 24 months postoperatively, respectively. The average NDIs for CEH before and after surgery were 2.32 (95% CI: 2.2–2.5) preoperatively, 0.62 (95% CI: 0.5–0.8) at 3 months, 0.60 (95% CI: 0.4–0.8) at 6 months, 0.56 (95% CI: 0.4–0.7) at 12 months, and 0.50 (95% CI: 0.3–0.7) at 24 months postoperatively, respectively. The neck pain and headache improved in all cases and the NDI score of neck pain or headache at each follow-up point after surgery was significantly different from that before surgery (P <0.001). The simple correlation analysis between neck pain and headache was performed, and the Pearson coefficient r was 0.71, indicating a positive correlation between neck pain NDI and headache NDI. No serious surgical complications were found.

Conclusion

Our study suggests that patients with cervical spondylosis complicated with CEH are always accompanied by neck pain. ACDF can not only relieve neck pain but also improve the accompanying CEH.

Comparison of acute effects of superficial and deep dry needling into trigger points of suboccipital and upper trapezius muscles in patients with cervicogenic headache

OBJECTIVE

The purpose of this study was to compare the acute effects of superficial and deep dry needling into trigger points of suboccipital and upper trapezius muscles in patients with cervicogenic headache.

METHODS

Thirty participants (8 men, 22 women) aged 19-60 years (mean age ± SD, 39 ± 10 y) with a clinical diagnosis of cervicogenic headache were randomly divided into superficial and deep groups. Headache index, trigger points tenderness, cervical range of motion (CROM), functional rating index was assessed at baseline, immediate and 1 week after the treatment.

RESULTS

Two approaches of dry needling showed reduction in headache index and trigger points tenderness. Deep dry needling showed greater improvement of cervical range of motion (p < 0.001) and functional rating index (p < 0.01).

CONCLUSION

The application of dry needling into trigger points of suboccipital and upper trapezius muscles induces significant improvement of headache index, trigger points tenderness, functional rating index and range of motion in patients with cervicogenic headache. Deep dry needling had greater effects on CROM and function.

Pregabalin for the management of cervicogenic headache: a double blind study

OBJECTIVES

The primary objective was to evaluate the effects of pregabalin relative to placebo in patients with chronic unilateral cervicogenic headache. Primary and secondary end points: To assess the change from baseline in the frequency of cervicogenic headache days per 28-day period between placebo and treatment group. To assess the change from baseline in the intensity of headache, and health outcome measures.

STUDY DESIGN

This was a double-blind, randomized, placebo-controlled, parallel-group study, evaluating the efficacy and safety of pregabalin in patients with cervicogenic headache.

PROCEDURES

The study consisted of two phases. A baseline of -28 days and a double-blind placebo-controlled phase: with an escalation and maintenance phase, during which patients remained at their highest dose until the end of the study, at Day 86.

RESULTS

Forty one patients were randomized, predominantly females, with a mean age of 52 years old. At screening, both groups had, on average, 26 headache-days per month. By the final phase of the study, the number of headache days dropped to 16 per month for the pregabalin group while remaining stable for the placebo group (p=0.037). No serious adverse events were reported during the study.

CONCLUSION

In this study, primary objectives were achieved with a statistically significant change of ten days in frequency of headache days; with minor side effects that were well tolerated.

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.

Efficacy of Physiotherapy Including a Craniocervical Training Programme for Tension-Type Headache; A Randomized Clinical Trial

We conducted a multicentre, randomized controlled trial with blinded outcome assessment. The treatment period was 6 weeks with follow-up assessment immediately thereafter and after 6 months. The objective was to determine the effectiveness of a craniocervical training programme combined with physiotherapy for tension-type headache. Eighty-one participants meeting the diagnostic criteria for tension-type headache were randomly assigned to an exercise group (physiotherapy and an additional craniocervical training programme) and a control group (physiotherapy alone). The primary outcome measure was headache frequency. Secondary outcomes included headache intensity and duration, Quality of Life (SF-36) and the Multidimensional Headache Locus of Control scale (MHLC). At 6 months' follow-up, the craniocervical training group showed significantly reduced headache frequency, intensity and duration ( P < 0.001 for all). Effect sizes were large and clinically relevant. Loss to follow-up amounted to 3.7±. Physiotherapy including craniocervical training reduces symptoms of tension-type headache significantly over a prolonged time frame.

Cervical Musculoskeletal Impairment in Frequent Intermittent Headache. Part 1: Subjects With Single Headaches

Musculoskeletal disorders are considered the underlying cause of cervicogenic headache, but neck pain is commonly associated with migraine and tension-type headaches. This study tested musculoskeletal function in these headache types. From a group of 196 community-based volunteers with headache, 73 had a single headache classifiable as migraine ( n = 22), tension-type ( n = 33) or cervicogenic headache ( n = 18); 57 subjects acted as controls. Range of movement, manual examination of cervical segments, cervical flexor and extensor strength, the cranio-cervical flexion test (CCFT), cross-sectional area of selected extensor muscles at C2 (ultrasound imaging) and cervical kinaesthetic sense were measured by a blinded examiner. In all but one measure (kinaesthetic sense), the cervicogenic headache group were significantly different from the migraine, tension-type headache and control groups (all P < 0.001). A dicriminant function analysis revealed that collectively, restricted movement, in association with palpable upper cervical joint dysfunction and impairment in the CCFT, had 100% sensitivity and 94% specificity to identify cervicogenic headache. There was no evidence that the cervical musculoskeletal impairments assessed in this study were present in the migraine and tension-type headache groups. Further research is required to validate the predictive capacity of this pattern of impairment to differentially diagnose cervicogenic headache.

Spinal rehabilitative exercise or manual treatment for the prevention of cervicogenic headache in adults

This is the protocol for a review and there is no abstract. The objectives are as follows: To quantify and compare the short- and long-term effects of manual treatment and spinal rehabilitative exercise for cervicogenic headache, classified according to the International Headache Society's (IHS) diagnostic criteria, with an active or placebo/sham comparison or wait-list control.

International consensus on the most useful physical examination tests used by physiotherapists for patients with headache: A Delphi study

BACKGROUND

A wide range of physical tests have been published for use in the assessment of musculoskeletal dysfunction in patients with headache. Which tests are used depends on a physiotherapist's clinical and scientific background as there is little guidance on the most clinically useful tests.

OBJECTIVES

To identify which physical examination tests international experts in physiotherapy consider the most clinically useful for the assessment of patients with headache.

DESIGN/METHODS

Delphi survey with pre-specified procedures based on a systematic search of the literature for physical examination tests proposed for the assessment of musculoskeletal dysfunction in patients with headache.

RESULTS

Seventeen experts completed all three rounds of the survey. Fifteen tests were included in round one with eleven additional tests suggested by the experts. Finally eleven physical examination tests were considered clinically useful: manual joint palpation, the cranio-cervical flexion test, the cervical flexion-rotation test, active range of cervical movement, head forward position, trigger point palpation, muscle tests of the shoulder girdle, passive physiological intervertebral movements, reproduction and resolution of headache symptoms, screening of the thoracic spine, and combined movement tests.

CONCLUSIONS

Eleven tests are suggested as a minimum standard for the physical examination of musculoskeletal dysfunctions in patients with headache.

The importance of craniovertebral and cervicomedullary angles in cervicogenic headache

PURPOSE

Many studies have indicated that cervicogenic headache may originate from the cervical structures innervated by the upper cervical spinal nerves. To date, no study has investigated whether narrowing of the craniovertebral angle (CVA) or cervicomedullary angle (CMA) affects the three upper cervical spinal nerves. The aim of this study was to investigate the effect of CVA and/or CMA narrowing on the occurrence of cervicogenic headache.

MATERIALS AND METHODS

Two hundred and five patients diagnosed with cervicogenic headache were included in the study. The pain scores of patients were determined using a visual analog scale. The nonheadache control group consisted of 40 volunteers. CVA and CMA values were measured on sagittal T2-weighted magnetic resonance imaging (MRI), on two occasions by two radiologists. Angle values and categorized pain scores were compared statistically between the groups.

RESULTS

Intraobserver and interobserver agreement was over 97% for all measurements. Pain scores increased with decreasing CVA and CMA values. Mean angle values were significantly different among the pain categories (P < 0.001). The pain score was negatively correlated with CMA (Spearman correlation coefficient, rs, -0.676; P < 0.001) and CVA values (rs, -0.725; P < 0.001).

CONCLUSION

CVA or CMA narrowing affects the occurrence of cervicogenic headache. There is an inverse relationship between the angle values and pain scores.

Differences between episodic and chronic tension-type headaches in nociceptive-specific trigeminal pathways

BACKGROUND

The trigeminal nociceptive system plays a pivotal role in the pathophysiology of tension-type headaches (TTH).

OBJECTIVE

This study investigated and compared nociceptive-specific trigeminal pathways in patients with episodic and chronic TTH (ETTH and CTTH, respectively) using the nociceptive blink reflex (nBR) and nociceptive trigeminocervical reflex (nTCR).

METHODS

We recorded nBR and nTCR in patients with ETTH and CTTH, and healthy controls using concentric electrodes and subsequently compared the threshold (i.e. sensory, pain) and parameters of reflex (i.e. the R2 component of the nBR and the late responses of the nTCR).

RESULTS

Women with ETTH ( N  = 40) and CTTH ( N  = 32) and age-matched controls ( N  = 40) were recruited. CTTH patients displayed significantly lower amplitude and area under the curve (AUC) values of the R2 component for the nBR compared with those displayed by ETTH patients and controls ( P  < 0.05). Moreover, the amplitude and AUC of the R2 component was negatively correlated with the frequency of headaches, whereas the latency of the R2 component for the nBR was positively correlated with the frequency and duration of headaches in the TTH groups ( P  < 0.05). However, no significant differences in the late response parameters (i.e. latency, duration, amplitude, or AUC) were noted between the groups in terms of the nTCR.

CONCLUSIONS

R2 suppression associated with CTTH suggests decreased brainstem excitability. This may be the result of excessive descending inhibitory influences.

Occipital neuralgia after occipital cervical fusion to treat an unstable jefferson fracture

In this report we describe a patient with an unstable Jefferson fracture who was treated by occipitocervical fusion and later reported sustained postoperative occipital neuralgia. A 70-year-old male was admitted to our center with a Jefferson fracture induced by a car accident. Preoperative lateral X-ray revealed an atlanto-dens interval of 4.8mm and a C1 canal anterior-posterior diameter of 19.94mm. We performed fusion surgery from the occiput to C5 without decompression of C1. The patient reported sustained continuous pain throughout the following year despite strong analgesics. The pain dermatome was located mainly in the great occipital nerve territory and posterior neck. Magnetic resonance images revealed no evidence of cord compression, however a C1 lamina compressed dural sac and C2 root compression could not be excluded. We performed bilateral C2 root decompression via a C1 laminectomy. After decompression, bilateral C2 root redundancy was identified by palpation. After decompression surgery, pain was reduced. This case indicates that occipital neuralgia, suggesting the need for diagnostic block, should be considered in the differential diagnosis of patients with sustained occipital headache after occipitocervical fusion surgery.

The effect of radiofrequency neurotomy of lower cervical medial branches on cervicogenic headache

OBJECTIVE

Cervicogenic headache (CGH) is known to be mainly related with upper cervical problems. In this study, the effect of radiofrequency neurotomy (RFN) for lower cervical (C4-7) medial branches on CGH was evaluated.

METHODS

Eleven patients with neck pain and headache, who were treated with lower cervical RFN due to supposed lower cervical zygapophysial joint pain without symptomatic intervertebral disc problem or stenosis, were enrolled in this study. CGH was diagnosed according to the diagnostic criteria of the cervicogenic headache international study group. Visual analogue scale (VAS) score and degree of VAS improvement (VASi) (%) were checked for evaluation of the effect of lower cervical RFN on CGH.

RESULTS

The VAS score at 6 months after RFN was 2.7±1.3, which were significantly decreased comparing to the VAS score before RFN, 8.1±1.1 (p<0.001). The VASi at 6 months after RFN was 63.8±17.1%. There was no serious complication.

CONCLUSION

Our data suggest that lower cervical disorders can play a role in the genesis of headache in addition to the upper cervical disorders or independently.

Magnetic resonance imaging of craniovertebral structures: clinical significance in cervicogenic headaches

This paper aims to investigate the relevance of morphological changes in the main stabilizing structures of the craniocervical junction in persons with cervicogenic headache (CEH). A case control study of 46 consecutive persons with CEH, 22 consecutive with headache attributed to whiplash associated headache (WLaH) and 19 consecutive persons with migraine. The criteria of the Cervicogenic Headache International Study Group (CHISG) were used for diagnosing CEH; otherwise the criteria of the International Classification of Headache Disorders (ICHD II) were applied. All participants had a clinical interview, and physical and neurological examination. Proton weighted magnetic resonance imaging (MRI) of the craniovertebral junction, and the alar and transverse ligaments were evaluated and blinded to clinical information. The MRI of the craniovertebral and the cervical junctions, the alar and transverse ligaments disclosed no significant differences between those with CEH, WLaH and or migraine. The site of CEH pain was not correlated with the site of signal intensity changes of the alar and transverse ligaments. In fact, very few had moderate or severe signal intensity changes in their ligaments. MRI shows no specific changes of cervical discs or craniovertebral ligaments in CEH.

Differences in cervical musculoskeletal impairment between episodic and chronic tension-type headache

Background: Tension-type headache (TTH) is a headache in which musculoskeletal impairments of the craniocervical region may play an important role in its pathogenesis. We investigated the presence of myofascial, postural and mechanical abnormalities in patients with frequent episodic and chronic tension-type headache (ETTH and CTTH, respectively). Methods: The study population consisted of 36 patients with ETTH, 23 with CTTH and 42 control subjects. Myofascial trigger points (MTrPs) were identified in the upper trapezius, sternocleidomastoid, temporalis and suboccipital muscles. Sagittal C7-tragus angle was measured to evaluate flexor head posture (FHP), and neck mobility was assessed using an inclinometer. Results: Only active MTrPs were significantly different between the ETTH and CTTH groups ( p < .001). Patients with CTTH showed a larger sagittal C7-tragus angle ( p = .011), that is, greater FHP and restricted neck mobility for both rotations compared to controls ( p < .001). Although active MTrPs were correlated with the frequency and duration of headache, no correlations were observed for FHP or neck mobility. Conclusion: Active MTrPs in the craniocervical region contribute to triggering or maintenance of TTH and posture or neck mobility may be a result of chronic headache.

Influential variables associated with outcomes in patients with cervicogenic headache

Cervicogenic headache (CGH) is a common sequela of upper cervical dysfunction with a significant impact on patients. Diagnosis and treatment have been well validated; however, few studies have described characteristics of patients that are associated with outcomes of physical therapy treatment of this disorder. A retrospective chart review of patient data was performed on a cohort of 44 patients with CGH. Patients had undergone a standardized physical therapy treatment approach that included spinal mobilization/manipulation and therapeutic exercise, and outcomes of treatment were determined by quantification of changes in headache pain intensity, headache frequency, and self-reported function. Multiple regression analysis was utilized to determine the relationship between a variety of patient-specific variables and these outcome measures. Increased patient age, provocation or relief of headache with movement, and being gainfully employed were all patient factors that were found to be significantly (P<0.05) related to improved outcomes.

Repeated measures of recent headache, neck and upper back pain in Australian adolescents

The epidemiological and clinical literature identifies strong associations between adult headache, cervical and thoracic spine dysfunction and spinal posture. This paper reports on the prevalence and incidence of headache, neck and upper back pain which occurred in the previous week, in urban Australians aged 13-17 years. Commencing in 1999, we followed a cohort of South Australian students through 5 years of secondary schooling. Of our commencing cohort of students, 132 (30%) provided data on bodily pain every year. For both girls and boys, there was a significantly decreasing prevalence of headache over the study period, while neck pain and upper back pain increased. There was a significantly increasing trend over time for boys with upper back pain. Twenty percent of girls and boys consistently reported headache, neck pain or upper back pain over 5 years. The progression of early adolescent headaches to mid-adolescent neck and upper back pain potentially reflects the adolescents' biomechanical responses to intrinsic and extrinsic imposts. This requires further investigation to understand the causes of adolescent headache, neck and upper thoracic pain.

Treatment of headaches with botulinum toxin

Primary headache disorders, such as migraine, chronic daily headache (CDH), and chronic tension-type headache (CTTH), are some of the most frequent disorders encountered by physicians in the outpatient setting. Chronic headache disorders cause significant morbidity and functional impairment. Despite important advances in both pharmacological and behavioral management of headache disorders, a number of patients remain treatment resistant. Botulinum toxin (BT) is emerging as a new therapeutic alternative in the preventative treatment of headaches. BT has several advantages over current prophylactic strategies, such as reduced side-effect profile and improved patient compliance. Furthermore, there have been several studies supporting the safety and tolerability of BT in the treatment of headache disorders. Although additional large-scale studies are needed to clarify clinical predictors of response as well as optimal dosing, injection sites and mechanism of action, BT has demonstrated efficacy in the treatment of migraines and CDH. The evidence for the treatment for CTTH is less compelling.

Predictors of responsiveness to physiotherapy management of cervicogenic headache

A recent randomized controlled trial tested the effectiveness of therapeutic exercise and manipulative therapy on 200 subjects with cervicogenic headache. Although treatments were efficacious, 25% of patients did not achieve a clinically acceptable outcome--50% reduction in headache frequency. This study aimed to identify predictors from variables in subjects' demographics and headache history which might identify those who did or did not achieve a 50-79% or 80-100% reduction in headache immediately after the active treatments and 12 months postintervention. The results revealed no consistent pattern of predictors, although the absence of light-headedness indicated higher odds of achieving either a 50-79% [odds ratio (OR) = 5.45) or 80-100% (OR = 5.7) reduction in headache frequency in the long term. Headaches of at least moderate intensity, the patient's age and chronicity of headache did not mitigate against a successful outcome from physiotherapy intervention.

Cervicogenic headache: practical approaches to therapy

Cervicogenic headache is a relatively common and still controversial form of headache arising from structures in the neck. The estimated prevalence of the disorder varies considerably, ranging from 0.7% to 13.8%. Cervicogenic headache is a 'side-locked' or unilateral fixed headache characterised by a non-throbbing pain that starts in the neck and spreads to the ipsilateral oculo-fronto-temporal area. In patients with this disorder, attacks or chronic fluctuating periods of neck/head pain may be provoked/worsened by sustained neck movements or stimulation of ipsilateral tender points. The pathophysiology of cervicogenic headache probably depends on the effects of various local pain-producing or eliciting factors, such as intervertebral dysfunction, cytokines and nitric oxide. Frequent coexistence of a history of head traumas suggests these also play an important role. A reliable diagnosis of cervicogenic headache can be made based on the criteria established in 1998 by the Cervicogenic Headache International Study Group. Positive response after an appropriate nerve block is an essential diagnostic feature of the disorder. Differential diagnoses of cervicogenic headache include hemicrania continua, chronic paroxysmal hemicrania, occipital neuralgia, migraine and tension headache. Various therapies have been used in the management of cervicogenic headache. These range from lowly invasive, drug-based therapies to highly invasive, surgical-based therapies. This review evaluates use of drug therapy with paracetamol and NSAIDs, infliximab and botulinum toxin type A; manual modalities and transcutaneous electrical nerve stimulation therapy; local injection of anaesthetic or corticosteroids; and invasive surgical therapies for the treatment of cervicogenic headache. A curative therapy for cervicogenic headache will not be developed until increased knowledge of the aetiology and pathophysiology of the condition becomes available. In the meantime, limited evidence suggests that therapy with repeated injections of botulinum toxin type A may be the most safe and efficacious approach. The surgical approach, which includes decompression and radiofrequency lesions of the involved nerve structures, may also provide physicians with further options for refractory cervicogenic headache patients. Unfortunately, the paucity of experimental models for cervicogenic headache and the relative lack of biomolecular markers for the condition mean much is still unclear about cervicogenic headache and the disorder remains inadequately treated.

A Cochrane review of manipulation and mobilization for mechanical neck disorders

STUDY DESIGN AND OBJECTIVES

Our systematic review of randomized trials assessed whether manipulation and mobilization relieve pain or improve function/disability, patient satisfaction, and global perceived effect in adults with mechanical neck disorders.

SUMMARY OF BACKGROUND DATA

Neck disorders are common, disabling, and costly.

METHODS

Computerized bibliographic databases were searched up to March 2002. Two independent reviewers conducted study selection, data abstraction, and methodologic quality assessment. Relative risk and standardized mean differences were calculated. In the absence of heterogeneity, pooled effect measures were calculated using a random effects model.

RESULTS

Of the 33 selected trials, 42% were high quality trials. Single or multiple (3-11) sessions of manipulation or mobilization showed no benefit in pain relief when assessed against placebo, control groups, or other treatments for acute/subacute/chronic mechanical neck disorders with or without headache. There was strong evidence of benefit favoring multimodal care (mobilization and/or manipulation plus exercise) over a waiting list control for pain reduction [pooled standardized mean differences -0.85 (95% CI: -1.20 to -0.50)], improvement in function [pooled SMD -0.57 (95% CI: -0.94 to -0.21)] and global perceived effect [standardized mean differences -2.73 (95% CI: -3.30 to -2.16)] for subacute/chronic mechanical neck disorders with or without headache.

CONCLUSIONS

Mobilization and/or manipulation when used with exercise are beneficial for persistent mechanical neck disorders with or without headache. Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior. There was insufficient evidence available to draw conclusions for neck disorder with radicular findings. Factorial design would help determine the active agent(s) within a treatment mix.

Quality of life of patients with cervicogenic headache: a comparison with control subjects and patients with migraine or tension-type headache

OBJECTIVE

To establish the health-related quality of life of patients with cervicogenic headache and to compare it with a random Dutch sample of control subjects and with patients with migraine without aura or with episodic tension-type headache.

METHODS

Thirty-seven patients with cervicogenic headache, 42 patients with episodic tension-type headache, and 39 patients with migraine without aura completed a Medical Outcomes Study 36-Item Short Form questionnaire.

RESULTS

Domain scores for "physical functioning" of patients with cervicogenic headache were worse than those of patients with migraine or tension-type headache. Physical functioning scores were lower for patients with tension-type headache than for those with migraine. Migraineurs reported a diminished score for "social functioning" compared to patients with tension-type headache. All Medical Outcomes Study 36-Item Short Form domain scores were significantly lower for patients with cervicogenic headache relative to the control group.

CONCLUSIONS

Patients with cervicogenic headache have a quality of life burden that is substantial. Although impairment in the quality of life of patients with cervicogenic headache is comparable to patients with migraine without aura and those with episodic tension-type headache, there are some specific differences.

Magnetic resonance imaging of patients with cervicogenic headache

Cervicogenic headache (CH) is a syndrome which is postulated to originate from nociceptive structures in the neck or head. The anatomical neck or head structures that are responsible for the pain in CH have not been clearly identified, but the pain in these patients probably originates from the structures of the cervical spine. In this study, cervical MRI were studied in 22 patients with cervicogenic headache and 20 control patients who did not have any disease which may effect the bone and muscle structures of cervical region. MRI imaging of cervical vertebra showed a disc bulging in 10 (45.4%) out of 22 patients with CH and in 9 (45.0%) of 20 controls (P > 0.05). The distribution of pathological lesions in patients and controls were not significantly different (P > 0.05). As a result, MRI may not be an adequate method to detect pathological findings underlying the aetiology of CH such as nerve roots, intervertebral joints and periosteum.

Manipulation and mobilisation for mechanical neck disorders

BACKGROUND

Neck disorders are common, disabling, and costly. The effectiveness of manipulation and mobilisation remains unclear.

OBJECTIVES

To assess whether manipulation and mobilisation, either alone or in combination with other treatments, relieve pain or improve function/disability, patient satisfaction, and global perceived effect in adults with mechanical neck disorders (MND).

SEARCH STRATEGY

Computerised bibliographic databases including CENTRAL, MEDLINE, EMBASE, MANTIS, CINAHL, and ICL, were searched without language restrictions from their respective starting dates to March 2002.

SELECTION CRITERIA

The studies had to be randomised (RCT) or quasi-randomised and investigate the use of manipulation or mobilisation as a treatment for mechanical neck disorders.

DATA COLLECTION AND ANALYSIS

Two independent reviewers conducted citation identification, study selection, data abstraction, and methodological quality assessment. Using a random effects model, relative risk and standardised mean differences were calculated. The reasonableness of combining studies was assessed on clinical and statistical grounds. In the absence of heterogeneity, pooled effect measures were calculated.

MAIN RESULTS

Of the 33 selected trials, 42% were high quality trials. Single sessions of manipulation or multiple sessions (3 to 11 weeks) of manipulation or mobilisation, or manipulation and mobilisation showed a nonsignificant benefit in pain relief when assessed against placebo, control groups or other treatments for acute/subacute/chronic MNDs with or without headache. There was strong evidence of benefit favouring multimodal care over a waiting list control for pain reduction [pooled SMD -0.85 (95% CI: -1.20 to -0.50)], improvement in function [pooled SMD -0.57 (95% CI: -0.94 to -0.21)] and global perceived effect [SMD -2.73 (95% CI: -3.30 to -2.16)] for subacute/chronic MND with or without headache. The common elements in this care strategy were mobilisation and/or manipulation plus exercise. There was moderate evidence of no difference in effect when multimodal care was compared to various other treatments.

REVIEWER'S CONCLUSIONS

Multimodal care has short-term and long-term maintained benefits for subacute/chronic MND with or without headache. The common elements in this care strategy were mobilisation and/or manipulation plus exercise. The evidence did not favour manipulation and/or mobilisation done alone or in combination with various other physical medicine agents; when compared to one another, neither was superior. There was insufficient evidence available to draw conclusions for neck disorder with radicular findings. The added benefit of exercise needs to be further explored. Factorial design would help determine the active treatment agent(s) within a treatment mix. Phase II trials would help identify the most effective treatment characteristics and dosages. Greater attention to methodological quality is needed.

Homeopathic treatment of headaches: a systematic review of the literature

OBJECTIVE

To systematically review published prospective trials relating to the homeopathic treatment of tension type, cervicogenic, and migraine headache.

DATA SOURCES

Pre-MEDLINE, MEDLINE, MANTIS, Cochrane Database of Systematic Reviews, and AMED were searched from the initial indexing year of each database through May 2002. Studies were further identified through a manual search of obtained article references.

STUDY SELECTION

English and non-English randomized clinical trials and prospective observational trials were included if there were at least ten subjects in the homeopathic portion of the trial and, for randomized clinical trials, if there was a placebo group. Treatment in these studies included single dose and individualized homeopathic prescription. Case studies, homeopathic provings, unpublished material, non-peer reviewed papers, and studies that combined multiple homeopathic remedies, introduced other complementary and alternative medicine therapies and/or introduced additional medical therapy for patients in the homeopathic treatment groups were excluded.

DATA EXTRACTION

Qualitative data were extracted from each paper and entered into an evidence table.

DATA SYNTHESIS

A critical evaluation list of 20 methodological items and their operational definitions was used, resulting in a validity score determined for each paper.

RESULTS

Six papers met criteria for inclusion. Three out of the six papers studied migraine headache, two studied cervicogenic and tension type headache, and one included all types of headaches. Four studies were randomized clinical trials, and two were prospective observational studies. Validity scores ranged from 25.0% to 63.4%. Homeopathy was superior to placebo in one randomized clinical trial and equal to placebo in three randomized trials. In no study was homeopathy less effective than placebo in treating headache, or harmful. Two prospective observational studies demonstrated improvement in patients receiving homeopathic care.

CONCLUSION

There is insufficient evidence to support or refute the use of homeopathy for managing tension type, cervicogenic, or migraine headache. The studies reviewed possessed several flaws in design. Given these findings, further research is warranted to better investigate the effectiveness of homeopathic treatment of headaches.

Occipital Nerve Blocks in Postconcussive Headaches

Headaches are common following traumatic brain injuries of all severities. Pain generators may be in the head itself or the neck. Headache assessment is discussed. Diagnosis and treatment of cervical headaches syndromes and, in particular, occipital neuralgia are reviewed. Finally, a retrospective study of 10 postconcussive patients with headaches who were treated with greater occipital nerve blocks is presented. Following the injection(s), 80% had a "good" response and 20% had a "partial" response. Occipital nerve block is a useful diagnostic and treatment modality in the setting of postconcussive headaches.

Do the proposed cervicogenic headache diagnostic criteria demonstrate specificity in terms of separating cervicogenic headache from migraine?

Diagnostic criteria for cervicogenic headache (CH) have been proposed. These criteria are controversial in that they appear to overlap or include characteristics that usually are attributed to migraine headache (MH). Whether these criteria are specific enough to separate CH patients from MH patients remains to be controversial. The literature on this issue is reviewed. In addition, the authors report the results of a study attempting to build a model of variables typically associated with CH or MH, which would identify patients with CH. A significant model could not be built that did not include MH symptoms. As such, it has been concluded that it is unlikely that the criteria for CH will have the specificity required to separate CH patients from MH patients.

Cervicogenic headache after whiplash injury

Cervicogenic headache (CEH) with pain radiating from the neck to the forehead is a common finding after whiplash injury. In most whiplash studies, the whiplash headaches are not defined. Post-whiplash CEH typically is a moderate headache with a benign, but often prolonged course. It probably is unilateral and bilateral. Reduced neck mobility does not seem to be as common after whiplash as in chronic CEH in general. Post-whiplash CEH is accompanied by great disability and high use of medication. Although the natural course seems favorable for unilateral CEH during the first postinjury years, some patients will need specific treatment for their headaches. There is a lack of controlled studies to guide practitioners to choose investigations and treatment for chronic CEH.

Upper cervical anterior diskectomy and fusion improves discogenic cervical headaches

STUDY DESIGN

Retrospective patient identification and prospective data collection were performed.

OBJECTIVE

To evaluate the outcome of anterior cervical diskectomy and fusion for discogenic cervical headaches.

SUMMARY OF BACKGROUND DATA

Cervicogenic headaches affect up to 2.5% of the population. One cause is discogenic pain. Because anterior cervical diskectomy and fusion may improve neck pain, the effect of this procedure on discogenic cervical headaches was evaluated.

METHODS

Nine patients with severe refractory cervicogenic headaches who underwent anterior cervical diskectomy and fusion of the upper cervical discs were retrospectively identified on the basis of clinical, radiographic, and diskography findings. Pain was measured by a numerical rating scale, and function by the Oswestry Disability Index.

RESULTS

The study involved six women and three men with a mean age of 52 (range, 35-72 years) and a mean follow-up period of 37 months (range, 24-49 months). Anterior cervical diskectomy and fusion was performed at both C2-C3 and C3-C4 in seven patients, at C2-C3 in one patient, and at C2-C3, C3-C4, and C4-C5 in one patient. Associated symptoms included nausea, arm pain, dizziness, and visual disturbances. All the patients improved. All stated that they would have the same surgery again for the same outcome. The mean numerical rating score improved from 8 (range, 5-10) to 2.7 (range, 0-7) ( < 0.001), and five patients (56%) had total headache relief. The mean Oswestry Disability Index improved from 62 (range, 42-87) to 35 (range, 2-82) ( < 0.009). The associated symptoms resolved in all the patients. There was early moderate to severe dysphagia in three patients, and mild dysphagia in four patients. At the final follow-up assessment, five patients evidenced mild dysphagia.

CONCLUSIONS

Anterior cervical diskectomy and fusion appears to be quite effective for discogenic cervical headache, but should be reserved for patients who are extremely impaired and refractory to all other treatments.

Post-traumatic myofascial pain of the head and neck

Post-traumatic myofascial pain describes the majority of chronic head and neck pain seen in clinical practice. If conditions such as vascular headaches, neuropathic pain, degenerative cervical joint disease, and dental pain are excluded, myofascial tissues are directly or indirectly involved in all other forms of head and neck pain. The most common of these include temporomandibular disorders, neck pain such as whiplash-associated disorder, cervicogenic headaches, and tension-type headaches. The pathophysiology of these conditions is not widely understood; however, peripheral and central mechanisms appear to play a role.

A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache

STUDY DESIGN

A multicenter, randomized controlled trial with unblinded treatment and blinded outcome assessment was conducted. The treatment period was 6 weeks with follow-up assessment after treatment, then at 3, 6, and 12 months.

OBJECTIVES

To determine the effectiveness of manipulative therapy and a low-load exercise program for cervicogenic headache when used alone and in combination, as compared with a control group.

SUMMARY OF BACKGROUND DATA

Headaches arising from cervical musculoskeletal disorders are common. Conservative therapies are recommended as the first treatment of choice. Evidence for the effectiveness of manipulative therapy is inconclusive and available only for the short term. There is no evidence for exercise, and no study has investigated the effect of combined therapies for cervicogenic headache.

METHODS

In this study, 200 participants who met the diagnostic criteria for cervicogenic headache were randomized into four groups: manipulative therapy group, exercise therapy group, combined therapy group, and a control group. The primary outcome was a change in headache frequency. Other outcomes included changes in headache intensity and duration, the Northwick Park Neck Pain Index, medication intake, and patient satisfaction. Physical outcomes included pain on neck movement, upper cervical joint tenderness, a craniocervical flexion muscle test, and a photographic measure of posture.

RESULTS

There were no differences in headache-related and demographic characteristics between the groups at baseline. The loss to follow-up evaluation was 3.5%. At the 12-month follow-up assessment, both manipulative therapy and specific exercise had significantly reduced headache frequency and intensity, and the neck pain and effects were maintained (P < 0.05 for all). The combined therapies was not significantly superior to either therapy alone, but 10% more patients gained relief with the combination. Effect sizes were at least moderate and clinically relevant.

CONCLUSION

Manipulative therapy and exercise can reduce the symptoms of cervicogenic headache, and the effects are maintained.

Inflammatory mechanisms in cervicogenic headache: an integrative view

Cervicogenic headache is a relatively common and still controversial form of headache that originates from the neck structures. The pathophysiology probably results from various local pain-producing factors, such as intervertebral dysfunction, but the frequent coexistence of a history of head traumas still plays an important role. This report represents a series of pathophysiologic studies performed for patients with cervicogenic headache and the results achieved by a new pharmacologic treatment for the disease.

The relationship of neck injury and post-traumatic headache

Although there may be several causes of post-traumatic headache, neck injury is perhaps the most common. This paper primarily reviews the relationship of neck injury, whiplash, and post-traumatic headache. Mechanisms may include structural damage from acceleration or extension of the neck, development of myofascial pain and trigger points, interaction of the trigeminal nociceptive system with the upper cervical (occipital) nerves, and psychologic and emotional factors. Although some healing will occur, the outcome may depend on a number of human factors (awareness of an impending collision) and the fact that repaired tissue is different from normal, uninjured tissue.

Cervicogenic headache (CEH) after whiplash injury

The main objective of the present investigation was to search for cervicogenic headache (CEH) after whiplash injury. Whiplash patients (n= 587), were followed for a year after their emergency service consultation. A total of 222 patients with headache after 1 month went through interview and examinations at 6 weeks, 6 months and 1 year. All included persons received a questionnaire after 1 year. De novo CEH seemed to be present in 8% at 6 weeks and in 3% at 1 year. Previous car accidents, pre-existing headache and neck pain were more frequent in chronic CEH individuals than in those in the cohort without CEH. Range of motion in the neck was reduced in 65% of chronic CEH individuals hours after the accident, compared with 41% in the cohort. Cybex inclinometer, at 6 weeks and 1 year, demonstrated reduced extension in the neck. CEH seems to be present after whiplash injury, particularly in the early phase. It seems similar to, but probably not identical to, non-whiplash CEH.

Cervicogenic headache: diagnostic evaluation and treatment strategies

Cervicogenic headache is a chronic, hemicranial pain syndrome in which the source of pain is located in the cervical spine or soft tissues of the neck but the sensation of pain is referred to the head. The trigeminocervical nucleus is a region of the upper cervical spinal cord where sensory nerve fibers in the descending tract of the trigeminal nerve converge with sensory fibers from the upper cervical roots. This convergence of upper cervical and trigeminal nociceptive pathways allows the referral of pain signals from the neck to the trigeminal sensory receptive fields of the face and head. The clinical presentation of cervicogenic headache suggests that there is an activation of the trigeminovascular neuroinflammatory cascade, which is thought to be one of the important pathophysiologic mechanisms of migraine. Another convergence of sensorimotor fibers has been described involving intercommunication between the spinal accessory nerve (CN XI), the upper cervical nerve roots, and ultimately the descending tract of the trigeminal nerve. This neural network may be the basis for the well- recognized patterns of referred pain from the trapezius and sternocleidomastoid muscles to the face and head. Diagnostic criteria have been established for cervicogenic headache but its presenting characteristics may be difficult to distinguish from migraine, tension-type headache, or hemicrania continua. A multidisciplinary treatment program integrating pharmacologic, nonpharmacologic, anesthetic, and rehabilitative interventions is recommended. This article reviews the clinical presentation of cervicogenic headache, its diagnostic evaluation, and treatment strategies.

Cervicogenic headache: clinical presentation, diagnostic criteria, and differential diagnosis

Since the first attempt at setting down diagnostic criteria was made in 1990, there has been considerable progress in the field of cervicogenic headache (CEH). CEH makes up a "final common pathway" for several neck disorders that may originate at different levels of the cervical spine. CEH has been defined as being mainly a unilateral headache without sideshift; it may accordingly also be bilateral. Anesthetic blockades are mandatory for scientific work. If the pain is bilateral, it is particularly important that blockades are carried out. Pain stemming from the neck usually spreads to the oculofrontotemporal area. The most characteristic features are symptoms and signs of neck involvement (such as mechanical precipitation of attack, and so forth). Migraine without aura and tension-type headache are the most difficult differential diagnosis problems.

Posttraumatic headache

Chronic posttraumatic headache is a common condition, often part of the postconcussion/posttraumatic syndrome. The pathophysiology is not well understood but includes biological, psychological, and social factors. Tension-type headache is the most common manifestation, but exacerbations of migraine-like headaches often occur. After a structural lesion has been ruled out, the treatment of posttraumatic headache is similar to that of the primary headaches.