Cervicogenic headache in the general population: the Akershus study of chronic headache

Effects of meridian sinew tuina after identifying the treatment area under ultrasound localization combined with greater and third occipital nerve injections in cervicogenic headache: a randomized controlled trial protocol

Introduction

Cervicogenic headache (CEH) is a secondary headache characterized by chronic, unilateral headache. Ultrasound-guided injections of the greater occipital nerve (GON) and the third occipital nerve (TON) are effective in the treatment of CEH, as is meridian sinew tuina for the treatment of CEH, but the evidence of clinical efficacy of combining these two therapies is valid. Therefore, we have designed a randomized controlled trial with the aim of investigating the efficacy and safety of ultrasound localization meridian sinew tuina combined with GON and TON injections for the treatment of CEH.

Methods and analysis

In this study, we enroll 60 patients experiencing CEH. The control group receives ultrasound-guided injections of GON and TON. The intervention group is treated with ultrasound localization meridian sinew tuina combined with the injection of GON and TON. Meridian sinew tuina is performed once a day for 30 min for 3 days. The primary observational index includes the Short-Form of McGill Pain Questionnaire (SF-MPQ). The Secondary outcomes include Cervical Range of Motion (ROM) and Medical Infrared Thermography (MIT). MIT is used to measure the change in skin temperature in the area of the patient's meridian sinew tuina treatment of GON and TON before and after the intervention. There are 5 time points assessed as baseline, day 3, day 15, day 30, and day 60.

Discussion

This study proposes to combine ultrasound-guided injections of GON and TON for the treatment of CEH after identifying the treatment area of meridian sinew tuina under ultrasound localization. Meanwhile, MIT is utilized to provide objective evidence of the efficacy of CEH.

Clinical trial registration

ChiCTR2300076128.

Myofascial Release for the Treatment of Tension-Type, Cervicogenic Headache or Migraine: A Systematic Review and Meta-Analysis

Objective

To assess the effectiveness of myofascial release (MFR) techniques on the intensity of headache pain and associated disability in patients with tension-type headache (TTH), cervicogenic headache (CGH), or migraine.

Design

A systematic review and meta-analysis.

Methods

Eight databases were searched on September 15, 2023, including PubMed, Scopus, Web of Science, CINAHL, Cochrane Library, Embase, CNKI, and Wanfang Database. The risk of bias was evaluated utilizing the Cochrane Risk of Bias 2 (RoB 2) tool.

Results

Pooled results showed that MFR intervention significantly reduces pain intensity [SMD = -2.01, 95% CI (-2.98, -1.03), I2 = 90%, P < 0.001] and improves disability [SMD = -1.3, 95% CI (-1.82, -0.79), I2 = 74%, P < 0.001]. Subgroup analysis based on the type of headache revealed significant reductions in pain intensity for CGH [SMD = -2.01, 95% CI (-2.73, -1.29), I2 = 63%, P < 0.001], TTH [SMD = -0.86, 95% CI (-1.52, -0.20), I2 = 50%, P=0.01] and migraine [SMD = -6.52, 95% CI (-8.15, -4.89), P < 0.001] and in disability for CGH [SMD = -1.45, 95% CI (-2.07, -0.83), I2 = 0%, P < 0.001]; TTH [SMD = -0.98, 95% CI (-1.32, -0.65), I2 = 0%, P < 0.001] but not migraine [SMD = -2.44, 95% CI (-6.04, 1.16), I2 = 97%, P=0.18].

Conclusion

The meta-analysis results indicate that MFR intervention can significantly alleviate pain and disability in TTH and CGH. For migraine, however, the results were inconsistent, and there was only moderate quality evidence of disability improvement for TTH and CGH. In contrast, the quality of other evidence was low or very low.

Physical Therapist Interventions to Reduce Headache Intensity, Frequency, and Duration in Patients With Cervicogenic Headache: A Systematic Review and Network Meta-Analysis

OBJECTIVE

The aim of this study was to assess the efficacy of physical therapist interventions on the intensity, frequency, and duration of headaches, as well as on the quality of life of patients with cervicogenic headache.

METHODS

The following databases were searched up to October 2022: Physiotherapy Evidence Database, Web of Science, Pubmed, and Cochrane Library. Randomized controlled trials assessing the effect of physical therapist interventions on adults with cervicogenic headache were included. Quality appraisal was conducted using the Cochrane risk of bias 2.0 tool and the Confidence in Network Meta-analysis web app. Synthesis methods were conducted in accordance with the Cochrane Handbook.

RESULTS

Of the 28 identified reports, 23 were included in the quantitative synthesis. Manipulation plus dry needling was the highest-ranked intervention to reduce the short-term headache intensity (mean difference [MD] = -4.87; 95% CI = -8.51 to -1.24) and frequency (MD = -3.09; 95% CI = -4.93 to -1.25) when compared to a control intervention. Other high-ranked and clinically effective interventions (when compared to a control intervention) were muscle-energy technique plus exercise (MD = 4.37; 95% CI = -8.01 to -0.74), as well as soft tissue techniques plus exercise (MD = -3.01; 95% CI = -5.1 to -0.92) to reduce short-term headache intensity, and dry needling plus exercise (MD = -2.92; 95% CI = -4.73 to -1.11) to reduce short-term headache frequency. These results were based on a low certainty of evidence.

CONCLUSION

The 4 most highly ranked interventions can be considered in clinical practice. However, no conclusive recommendation can be made due to the low certainty of evidence.

IMPACT

Combined interventions such as spinal joint manipulation plus dry needling and muscle-energy technique or soft tissue techniques or dry needling plus exercises seem to be the best interventions to reduce short-term cervicogenic headache intensity and/or frequency.

The Efficacy of Manual Therapy and Pressure Biofeedback-Guided Deep Cervical Flexor Muscle Strength Training on Pain and Functional Limitations in Individuals with Cervicogenic Headaches: A Randomized Comparative Study

Objective

This study aimed to compare the efficacy of manual therapy and pressure biofeedback-guided DCFM strength training on pain intensity and functional limitations in individuals with CGH. Trial Design. A double-blinded, two-arm parallel group randomized comparative design.

Methods

After applying the eligibility criteria, sixty out of eighty-nine CGH patients were recruited from King Saud University Medical Center in Riyadh and randomly allocated to intervention groups using simple random sampling. Group 1 underwent pressure biofeedback-guided DCFM strength training and conventional treatment, while Group 2 received manual therapy and conventional treatment for three consecutive weeks. The main outcome measures were scores on the visual analog scale (VAS) and the headache disability index (HDI). One assessor and two physical therapists were blinded to group allocation.

Results

Sixty out of eighty participants aged 29-40 years were randomized into intervention groups (n = 30/group; age (mean ± standard deviation): group 1 = 35.0 ± 2.82; group 2 = 34.87 ± 2.60), and their data were analyzed. A significant improvement (95% CI, p < 0.05) was observed within each group when comparing the VAS and HDI scores between baseline and postintervention. In contrast, between-group comparisons for the outcome score of VAS and HDI revealed nonsignificant differences in the first, second, and third weeks after intervention, except for the VAS score, which showed a significant difference in weeks 2 and 3 after intervention. Cohen's d-value indicated that the intervention effect size for reducing pain was larger in group 1 than in group 2 at weeks 2 and 3.

Conclusion

Compared with manual therapy, pressure biofeedback-guided DCFM strength training showed a greater reduction in pain intensity (assessed using the VAS) at weeks two and three. However, both treatments were equally effective in lowering headache-related functional limitations in patients with CGH. This trial is registered with ClinicalTrial.gov PRS (Identifier ID: NCT05692232).

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.

Headache and orofacial pain: A traffic-light prognosis-based management approach for the musculoskeletal practice

Introduction

Headache (HA) is one of the most prevalent disabling conditions worldwide and is classified as either primary or secondary. Orofacial pain (OFP) is a frequent pain perceived in the face and/or the oral cavity and is generally distinct from a headache, according to anatomical definitions. Based on the up-to-date classification of the International Headache Society, out of more than 300 specific types of HA only two are directly attributed to the musculoskeletal system: The cervicogenic HA and HA attributed to temporomandibular disorders. Because patients with HA and/or OFP frequently seek help in the musculoskeletal practice, a clear and tailored prognosis-based classification system is required to achieve better clinical outcomes.

Purpose

The aim of perspective article is to suggest a practical traffic-light prognosis-based classification system to improve the management of patients with HA and/or OFP in the musculoskeletal practice. This classification system is based on the best available scientific knowledge based on the unique set-up and clinical reasoning process of musculoskeletal practitioners.

Implications

Implementation of this traffic-light classification system will improve clinical outcomes by helping practitioners invest their time in treating patients with significant involvement of the musculoskeletal system in their clinical presentation and avoid treating patients that are not likely to respond to a musculoskeletal based intervention. Furthermore, this framework incorporates medical screening for dangerous medical conditions, and profiling the psychosocial aspects of each patient; thus follows the biopsychosocial rehabilitation paradigm.

A perspective on the use of the cervical flexion rotation test in the physical therapy management of cervicogenic headaches

BACKGROUND

The Cervical Flexion-Rotation Test (CFRT) is widely used in the assessment of upper cervical spine mobility impairments and in the diagnosis of cervicogenic headache (CGH) by physiotherapist. Many studies investigated its different properties, and the results show that the CFRT has good construct validity in the measurement of C1-C2 rotation as well as good to excellent reliability.

PURPOSE

In this theoretical paper, we explore the value and point out two methodological issues associated to the CFRT, one related to the procedures and another related to its diagnostic accuracy.

RESULTS

Our analysis indicate that there are many confounding factors that could affect the CFRT cut-off's accuracy, which are likely to overestimate the diagnosis properties of CFRT. Potential solutions are discussed. Moreover, the gold standard (manual examination) used to examine the validity of the CFRT for the diagnosis of CGH appears to be far from perfect - we could argue that the diagnostic properties of the CFRT for CGH might be biased and the likelihood ratios are likely to be overestimated. However, it could be relevant to explore if results of the CFRT could be considered as a treatment-effect modifier. Maybe the CFRT could be more valuable as a prognostic factor?

CONCLUSION

The quality of evidence supporting the validity of the CFRT is most likely biased. In the absence of a better gold standard, maybe the CFRT could be a more valuable test to establish the patient's prognosis and help the clinician to choose the most appropriate treatment options.

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.

Inter-individual variability in mechanical pain sensation in patients with cervicogenic headache: an explorative study

Currently, evidence for effective physiotherapy interventions in patients with cervicogenic headache (CeH) is inconsistent. Although inter-individual variability in pain response is predictive for successful physiotherapy interventions, it was never explored in patients with CeH. Therefore the objective of the current study was to explore inter-individual variability in mechanical pain sensation, and its association with biopsychosocial-lifestyle (BPSL) characteristics in patients with CeH. A cross-sectional explorative analysis of inter-individual variability in mechanical pain sensation in 18 participants with CeH (29-51 years) was conducted. Inter-individual variability in mechanical pain sensation (standard deviations (SDs), F-statistics, Measurement System Analysis) was deducted from bilateral pressure pain thresholds of the suboccipitals, erector spine, tibialis anterior. BPSL-characteristics depression, anxiety, stress (Depression Anxiety Stress Scale-21), quality of life (Headache Impact Test-6), sleep-quality (Pittsburgh Sleep Quality Index), and sedentary time (hours/week) were questioned. Inter-individual variability in mechanical pain sensation explained 69.2% (suboccipital left), 86.8% (suboccipital right), 94.6% (erector spine left), 93.2% (erector spine right), 91.7% (tibialis anterior left), and 82% (tibialis anterior right) of the total variability in patients with CeH. The significant p-values and large F-statistic values indicate inter-individual differences in SDs. Significant associations between (1) lower quality of life and lower SDs of the suboccipital left PPT (p .005), and (2) longer sedentary time and higher SDs of the suboccipital left PPT (p .001) were observed. Results from our explorative study could suggest inter-individual variability in mechanical pain sensation at the left suboccipitals which associates with quality of life and sedentary time. These novel findings should be considered when phenotyping patients and 'individually' match interventions.

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.

Computed tomography-guided radiofrequency ablation of cervical intervertebral discs for the treatment of refractory cervicogenic headache: A retrospective chart review

OBJECTIVE

To evaluate the feasibility and efficacy of computed tomography (CT)-guided radiofrequency ablation (RFA) of cervical intervertebral discs for the treatment of discogenic cervicogenic headache (CEH).

BACKGROUND

Some patients with CEH experience no obvious therapeutic effect after conventional therapy, particularly patients with refractory CEH originating from abnormal cervical intervertebral discs. Treatment for this type of CEH remains poorly characterized.

METHODS

Using a single intervention arm, pretest/posttest design, we retrospectively analyzed the data of patients who underwent CT-guided RFA of cervical intervertebral discs for CEH at the Pain Medicine Center of Zhejiang Provincial People's Hospital from January 2017 to April 2021. If conservative treatment failed in patients with discogenic CEH, we classified the patients as having refractory CEH and performed RFA of cervical intervertebral discs. We used a numeric rating scale (NRS) to assess pain intensity for 6 months. We also compared therapeutic outcome of patients with different characteristics.

RESULTS

A total of 44 patients who underwent CT-guided RFA of cervical intervertebral discs were enrolled and 41 of them were analyzed in the present study. The preoperative median (25th, 75th) NRS score was 4 (4, 5), and it was significantly reduced to 1 (0, 4) 6 months after RFA (p < 0.001). The number of patients with ≥50% of their pain relieved after 6 months was 28 of 41 (68%). No serious treatment-related complications occurred in this study. Compared with single-level RFA, multi-level RFA shows greater effects on pain intensity reduction (p = 0.032) and pain relief rate (p = 0.047) of patients.

CONCLUSION

In patients who have discogenic CEH, CT-guided RFA of the cervical intervertebral discs appears to be a promising treatment with no serious complications.

Efficacy of Physiotherapy Interventions for The Management of Adults With Cervicogenic Headache: A Systematic Review and Meta-Analyses of Randomized Controlled Trials

OBJECTIVE

To update and appraise the efficacy of physiotherapy for adults with cervicogenic headache.

LITERATURE SURVEY

Bibliographic searches were conducted up to September 2021 for randomized controlled trials, assessing the efficacy of physiotherapy interventions for adults with cervicogenic headache, in five databases: CINAHL, PEDro, PubMed, Sage Journals and Wiley Online Library.

METHODS

Data extraction of included trials was conducted by two reviewers according to a standardized extraction form. The PEDro tool and the GRADE approach were used for grading evidence. Results from trials with similar interventions and with similar outcome measures were pooled into separate meta-analyses. A qualitative synthesis was performed for studies that were not pooled into meta-analyses.

SYNTHESIS

Fourteen trials were included. Moderate-certainty evidence indicates that manual therapy significantly reduces headache frequency (MD: -0.93 episodes/week; 95%CI: -1.40 to -0.46; 2 RCTs; n=265) compared to sham manual therapy, and headache frequency (MD: -1.23 episodes/week; 95%CI: -1.55 to -0.91; 3 RCTs; n=126) and intensity (MD: -1.63/10; 95%CI: -2.15 to -1.10; 4 RCTs; n=208) compared to no treatment in the short term. At 12-month follow-up, moderate-certainty evidence indicates that manual therapy did not lead to greater reduction in headache intensity (MD VAS 0-10: -0.12; 95%CI: -0.49 to 0.26; 2 RCTs; n=265) nor frequency (MD: -0.32 episodes/week; 95%CI: -0.91 to 0.28; 2 RCTs; n=265) when compared to a sham manual therapy. In the long-term, in one high quality trial, neck exercise significantly reduces headache intensity compared to no treatment (MD: -1.51/10; 95%CI: -2.52 to -0.50; n=100) or to aerobic exercises in another trial of moderate quality (MD: -1.15/10; 95%CI: -2.1 to -0.20; n=180).

CONCLUSIONS

Manual therapy in the short term and neck exercise in the long term may be efficacious to treat adults with cervicogenic headache. More high quality evidence is needed and future results may change the current conclusions. This article is protected by copyright. All rights reserved.

Effectiveness of manual therapy in the treatment of cervicogenic headache: A systematic review

OBJECTIVE

The aim of this study was to identify the manual therapy (MT) methods and techniques that have been evaluated for the treatment of cervicogenic headache (CH) and their effectiveness.

BACKGROUND

MT seems to be one of the options with the greatest potential for the treatment of CH, but the techniques to be applied are varied and there is no consensus on which are the most indicated.

METHODS

A systematic search in Scopus, Medline, PubMed, Cinahl, PEDro, and Web of Science with the terms: secondary headache disorders, physical therapy modalities, musculoskeletal manipulations, cervicogenic headache, manual therapy, and physical therapy. We included articles published from 2015 to the present that studied interventions with MT techniques in patients with CH. Two reviewers independently screened 365 articles for demographic information, characteristics of study design, study-specific intervention, and results. The Oxford 2011 Levels of Evidence and the Jadad scale were used.

RESULTS

Of a total of 14 articles selected, 11 were randomized control trials and three were quasi-experimental studies. The techniques studied were: spinal manipulative therapy, Mulligan's Sustained Natural Apophyseal Glides, muscle techniques, and translatory vertebral mobilization. In the short-term, the Jones technique on the trapezius and ischemic compression on the sternocleidomastoid achieved immediate improvements, whereas adding spinal manipulative therapy to the treatment can maintain long-term results.

CONCLUSIONS

The manual therapy techniques could be effective in the treatment of patients with CH. The combined use of MT techniques improved the results compared with using them separately. This review has methodological limitations, such as the inclusion of quasi-experimental studies and studies with small sample sizes that reduced the generalizability of the results obtained.

Acupuncture plus massage for cervicogenic headache: A protocol for systematic review and meta-analysis

BACKGROUND

Cervicogenic headache (CGH), one of the most common headaches. It is characterized by pain starting from the neck and gradually involving the eyes, frontal and temporal regions. Acupuncture and massage therapy has been widely used in the treatment of CGH, the purpose of this study was to evaluate the effectiveness and safety of acupuncture combined with massage in the treatment of CGH.

METHODS

The databases of PubMed, Embase, Cochrane library, Medicine, Web of Science, China National Knowledge Infrastructure, Wan-Fang Database, China Biomedical Literature Service System, and Chongqing VIP Chinese Science will be searched. This study will include randomized controlled trials of acupuncture combined with massage in the treatment of CGH published before November 2021. The primary outcomes included the overall efficiency, visual simulation score, neck activity score, quality of life score, and adverse reactions as secondary outcomes were assessed. Cochrane bias risk assessment tool will be used for literature data screening and quality evaluation, and using RevMan5.4 to collect data for statistical analysis. We then will use the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the overall quality of evidence supporting the primary outcomes.

RESULTS

This systematic review will provide a high-quality synthesis to evaluate the efficacy and safety of acupuncture combined with massage therapy in the treatment of CGH, providing a reference for the safe and effective treatment plan.

CONCLUSION

This study provides evidence that acupuncture combined with massage is effective and safe for patients with CGH.

SYSTEMATIC REVIEW REGISTRATION

INPLASY2021120049U1.

Effectiveness of different physiotherapy interventions in the management of cervicogenic headache: a pilot randomized controlled trial

BACKGROUND

Cervicogenic headache is a secondary headache which leads to decreased functional activity, quality of life and functional disability.

OBJECTIVE

To determine the feasibility and acceptability of different physiotherapy interventions in the management of cervicogenic headache and to determine sample size for a full trial.

TRIAL DESIGN

A pilot randomized controlled trial.

SETTINGS

Various physiotherapy outpatient department.

METHODS

Participants suffering from cervicogenic headache with age 20- 60 years were randomly allocated into four groups. Sessions were given over 4 weeks 4 times a week (16 sessions). The primary outcomes were feasibility of participant recruitment, assessment procedure, retention, adherence, and acceptability. The secondary outcomes were headache impact test-6 for a headache disability, headache diary for headache intensity, frequency, duration, and neck disability index for neck pain, disability measured at baseline, 4th week, and follow up after 1 month.

RESULT

178 subjects were screened based on selection criteria. Out of them, 93 (52%) were eligible and 80 (86%) participated in the study. 96.25% of participants completed the final 8-week assessment. Overall 93.75% of participants completed the entire assessment item across all time points. 95% completed all treatment sessions. 97.5-100% of participants were satisfied with the treatment protocol. No adverse effects were reported by participants. Based on the data obtained from the pilot trial, sample size was determined as 35 participants in each group.

CONCLUSION

The results indicate that the trial methodology and intervention are feasible for implementing a full-powered randomized controlled trial to determine the effectiveness of physiotherapy intervention in the management of cervicogenic headache.

Thoracic spine thrust manipulation for individuals with cervicogenic headache: a crossover randomized clinical trial

Objective: To determine if thoracic spine manipulation (TSM) improves pain and disability in individuals with cervicogenic headache (CeH).Methods: A randomized controlled crossover trial was conducted on 48 participants (mean age: 34.4 years) with CeH symptoms. Participants were randomized to 6 sessions of TSM or no treatment (Hold) and after 4-weeks, groups crossed over. Outcomes were collected at 4, 8 and 12 weeks and included: headache disability inventory (HDI), neck disability index (NDI), and the global rating of change (GRC). Outcomes were analyzed using a linear mixed-effects model with Bonferroni correction. Odds of achieving the minimal clinically important difference (MCID) on the GRC of +4 or greater were also calculated. Scores at 4 weeks represent the only timepoint where 1 group is fully treated and other group has not received any treatment.Results: Comparing hold to active treatment, HDI were not significantly different between groups (mean difference = 7.39, 95 CI: -4.39 to 19.18; P = 0.214) at any timepoint; the NDI was significant (mean difference = 6.90, 95 CI: 0.05 to 13.75; P = 0.048) at 4 weeks. Odds of achieving the +4 MCID on the GRC (OR = 38.0, 95 CI: 6.6 to 220.0; p < 0.001) favored TSM at 4 weeks.Conclusion: TSM had no effect on headache-related disability but resulted in significant improvements in neck-related disability and participant reported perceived improvement. Future studies are needed to examine the long-term impact of TSM in this population.

The association between specific temporomandibular disorders and cervicogenic headache

BACKGROUND AND AIMS

Upper neck signs, symptoms and hypomobility have been shown to present with a higher prevalence in patients with temporomandibular disorders (TMDs). However, there is currently no evidence of an association between specific TMDs and cervicogenic headache (CGH). Therefore, the aim of this study was to evaluate the odds ratio and the relative risk of CGH in patients with specific TMDs.

METHOD

116 participants, including 74 patients with TMD (pain-related/intraarticular/mixed TMD) and 42 healthy controls took part in this study. The TMD diagnosis was made by senior faculty members of the Dental School according to the Diagnostic Criteria for TMD, while the cervical diagnosis was made by a qualified senior physical therapist. The analysis comprised the evaluation of the odds ratio of CGH among patients with TMD and the relative risk (RR) for CGH during 14-24 months of follow-up.

RESULTS

Significantly higher odds ratios of cervicogenic headache were found among pain-related and mixed TMD (12.17 and 10.76, respectively) versus healthy controls. During the 14-24 months of follow-up, there was no significant difference of relative risk for CGH among patients with TMD versus healthy controls.

SUMMARY AND CONCLUSIONS

The results support a clear clinical association between painful TMD (pain-related and mixed TMD) and cervicogenic headache.

Consensus among musculoskeletal experts for the management of patients with headache by physiotherapists? A delphi study

BACKGROUND

Though a large amount of research on the management of headache has been conducted, the clinical effectiveness of these treatments remains unclear.

OBJECTIVES

To reach consensus among international musculoskeletal experts on what the most appropriate management is in patients that suffer from headache.

DESIGN

Expert group and Delphi-study.

METHODS

A total of 11 experts participated in the expert panel groups, where the role of physiotherapy in the management of headache was discussed. Afterwards, 14 of the initial 25 participants in the field of headache completed the whole Delphi study, which was conducted over 4 rounds. The first round aimed to identify clinical indicators and treatments that are useful in patients with headache. These questions were then categorized and ranked during the second, third, and fourth rounds. Consensual agreement was set at ≥ 80%.

RESULTS

After the final round, 9 interventions were rated as useful by the participants. In the final extra round, 14 clinical indicators were retrieved as important to decide whether or not to start one of the consensual treatments. The top 3 management strategies were (1) upper cervical spine mobilisations in cervivogenic headache, (2) active mobilisation exercises of the cervical spine in cervivogenic headache, and (3) lifestyle advice in tension-type headache and migraine.

CONCLUSION

International experts agreed that most scientifically established effective treatments are useful in cervicogenic headache. Consensual agreement on treatments for migraine and tension-type headache were only reached for specific treatments. Their recommendations provide a framework for further research and the clinical management of headache.

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).

The Effectiveness of Sternocleidomastoid Muscle Dry Needling in Patients with Cervicogenic Headache

BACKGROUND

Cervicogenic headache (CGH) is a secondary headache with a cervical source that radiates pain to the head or face. Accordingly, one reason of CGH is myofascial trigger points. The purpose of this study was to investigate the effect of one session dry needling (DN) of myofascial trigger points of the sternocleidomastoid (SCM) muscle in patients with CGH.

MATERIALS AND METHODS

In this before-and-after clinical trial, 16 females aged 18-60 years with a clinical diagnosis of CGH were enrolled. All of the patients received one session DN into the myofascial trigger points of the SCM muscle. Headache index (HI), headache duration, headache frequency, and headache disability index (HDI) were assessed at 2 weeks before and 2 weeks after the intervention. This study was registered in Clinical Trials as IRCT20181109041599N1.

RESULTS

One session DN into myofascial trigger points of the SCM muscle showed a significant improvement in HI (P < 0.001). Duration and frequency of headache as well as HDI significantly reduced after intervention (P < 0.001).

CONCLUSION

One session DN into myofascial trigger points of the SCM muscle was effective on improvement of HI, headache duration, headache frequency, and HDI in patients with CGH.

Pragmatic application of manipulation versus mobilization to the upper segments of the cervical spine plus exercise for treatment of cervicogenic headache: a randomized clinical trial

BACKGROUND

The effectiveness of manipulation versus mobilization for the management of spinal conditions, including cervicogenic headache, is conflicting. However, a pragmatic approach comparing manipulation to mobilization has not been examined in a patient population with cervicogenic headache.

OBJECTIVES

To evaluate the effectiveness of manipulation compared to mobilization applied in a pragmatic fashion for patients with cervicogenic headache.

METHODS

Forty-five (26 females) patients with cervicogenic headache (mean age 47.8 ± SD 16.9 years) were randomly assigned to receive either pragmatically selected manipulation or mobilization. Outcomes were measured at baseline, the second visit, discharge, and 1-month follow-up and included the Neck Disability Index (NDI), Numeric Pain Rating Scale (NPRS), the Headache Impact Test (HIT-6), the Global Rating of Change (GRC), the Patient Acceptable Symptoms Scale (PASS). The primary aim (effects of treatment on disability and pain were examined with a mixed-model analysis of variance (ANOVA), with treatment group (manipulation versus mobilization) as the between subjects variable and time (baseline, 48 hours, discharge and follow-up) as the within subjects variable.

RESULTS

The interaction for the mixed model ANOVA was not statistically significant for NDI (p = 0.91), NPRS (p = 0.81), or HIT (p = 0.89). There was no significant difference between groups for the GRC or PASS.

DISCUSSION AND CONCLUSION

The results suggest that manipulation has similar effects on disability, pain, GRC, and cervical range of motion as mobilization when applied in a pragmatic fashion for patients with cervicogenic headaches.

CLINICALTRIALS.GOV

NCT03919630.

Fluoroscopy-Guided Blockade of the Greater Occipital Nerve in Cadavers: A Comparison of Spread and Nerve Involvement for Different Injectate Volumes

Background

Fluoroscopy-guided blockade of the greater occipital nerve (GON) is an accepted method for treating the symptoms of cervicogenic headaches (CGHs). However, the spread patterns among different injectate volumes of fluoroscopy-guided GON blocks are not well defined.

Objective

A cadaveric study was established to determine the spread patterns of different volumes of dye injectate within a fluoroscopic GON block. Study Design. Cadaveric study. Setting. Xingtai Institute of Orthopaedics; Orthopaedic Hospital of Xingtai.

Methods

15 formalin-fixed cadavers with intact cervical spines were randomized in a 1 : 1 : 1 ratio to receive a fluoroscopy-guided GON injection of a 2, 3.5, or 5 ml volume of methylene blue. The suboccipital regions were dissected to investigate nerve involvement.

Results

The suboccipital triangle regions, including the suboccipital nerves and GONs, were deeply stained in all cadavers. The third occipital nerve (TON) was stained in 7 of 10 administered 2 ml injections and in all the 3.5 ml and 5 ml injections. Compared to the 3 ml injectate group, the 5 mL cohort consistently saw injectate spreading to both superficial and distant muscles. Limitations. Given that cadavers were used in this study, cadaveric soft tissue composition and architecture can potentially become distorted and consequently affect injectate diffusion.

Conclusions

A 3.5 or 5 mL fluoroscopy-guided GON injection of methylene blue successfully stains the GON, TON, and suboccipital nerves. This suggests that such an injection would generate blockade of all three nerve groups, which may contribute to the efficacy of the block for CGH. A volume of 3.5 ml may be enough for the performance of a fluoroscopy-guided GON block for therapeutic purposes.

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.

Spinal manipulation for the management of cervicogenic headache: A systematic review and meta-analysis

BACKGROUND

Spinal manipulative therapy (SMT) is frequently used to manage cervicogenic headache (CGHA). No meta-analysis has investigated the effectiveness of SMT exclusively for CGHA.

OBJECTIVE

To evaluate the effectiveness of SMT for CGHA.

DATABASES AND DATA TREATMENT

Five databases identified randomized controlled trials comparing SMT with other manual therapies. The PEDro scale assessed the risk-of-bias. Pain and disability data were extracted and converted to a common scale. A random effects model was used for several follow-up periods. GRADE described the quality of evidence.

RESULTS

Seven trials were eligible. At short-term follow-up, there was a significant, small effect favouring SMT for pain intensity (mean difference [MD] -10.88 [95% CI, -17.94, -3.82]) and small effects for pain frequency (standardized mean difference [SMD] -0.35 [95% CI, -0.66, -0.04]). There was no effect for pain duration (SMD - 0.08 [95% CI, -0.47, 0.32]). There was a significant, small effect favouring SMT for disability (MD - 13.31 [95% CI, -18.07, -8.56]). At intermediate follow-up, there was no significant effects for pain intensity (MD - 9.77 [-24.21 to 4.68]) and a significant, small effect favouring SMT for pain frequency (SMD - 0.32 [-0.63 to - 0.00]). At long-term follow-up, there was no significant effects for pain intensity (MD - 0.76 [-5.89 to 4.37]) and for pain frequency (SMD - 0.37 [-0.84 to 0.10]).

CONCLUSION

For CGHA, SMT provides small, superior short-term benefits for pain intensity, frequency and disability, but not pain duration, however, high-quality evidence in this field is lacking. The long-term impact is not significant.

SIGNIFICANCE

CGHA are a common headache disorder. SMT can be considered an effective treatment modality, with this review suggesting it providing superior, small, short-term effects for pain intensity, frequency and disability when compared with other manual therapies. These findings may help clinicians in practice better understand the treatment effects of SMT alone for CGHA.

Involvement of cervical disability in migraine: a literature review

Background

The trigeminal nerve theory has been proposed as a pathophysiological mechanism of migraine; however, its association with the triggers of migraine remains unclear. Cervical disability such as neck pain and restricted cervical rotation, have been associated with not only cervicogenic headaches but also migraine. The presence of cervical disability could worsen of the migraine, and also the response to pharmacologic treatment may be reduced. The aim in this review is to highlight the involvement of cervical disability in migraine, considering contributing factors.

Findings

In recent years, evidence of neck pain complaints in migraine has been increasing. In addition, there is some recent evidence of cervical musculoskeletal impairments in migraine, as detected by physical assessment. However, the main question of whether neck pain or an associated cervical disability can act as an initial factor leading to migraine attacks still remains. Daily life imposes heavy loads on cervical structures (i.e. muscles, joints and ligaments), for instance, in the forward head position. The repetitive nociceptive stimulation initiating those cervical skeletal muscle positions may amplify the susceptibility to central migraine and contribute to chronicity via the trigeminal cervical complex.

Conclusion

Further studies are needed to explain the association between cervical disability as a source of pain and the development of migraine. However, evidence suggests that cervical disability needs to be considered in the prevention and treatment of migraine.

The Feasibility and Efficacy of Ultrasound-Guided C2 Nerve Root Coblation for Cervicogenic Headache

OBJECTIVE

The cervicogenic headache is a syndrome caused by dysfunction of the upper cervical spine and its component bony, disc, and/or soft tissue elements. The C2 nerve root may play a pivotal role in cervicogenic headache. In this retrospective study, we evaluated the feasibility and efficacy of ultrasound-guided C2 nerve root coblation in managing 26 patients with cervicogenic headache.

DESIGN AND SETTING

The data were collected retrospectively by reviewing the patient's medical records and pain questionnaires.

SUBJECTS AND METHODS

A total of 109 patients with cervicogenic headache sustained for at least six months were identified. Of those patients, 26 had a visual analog scale score ≥6 and subsequently underwent an ultrasound-guided C2 nerve root coblation.

RESULTS

All 26 patients had >50% pain relief one day after coblation. Twenty-three of the 26 patients (92.31%) had a decrease in their pain score of 50% or more at 24-week follow-up. The mean pain score was 7.38 ± 1.13 before coblation and 1.85 ± 0.83 one day after coblation (Bonferroni-adjusted P < 0.001). At 12 and 24 weeks after coblation, the mean pain scores were 2.96 ± 0.96 (P < 0.001) and 3.08 ± 1.38 (P < 0.008), respectively.

CONCLUSIONS

C2 nerve coblation may provide the majority of patients with a pain relief period as long as 24 weeks. And ultrasound guidance is an efficient method with which to perform coblation.

Diagnostic Value of Single-Photon Emission Computed Tomography/Computed Tomography Scans with Tc-99m HDP in Cervicogenic Headache

A cervicogenic headache (CEH) is difficult to diagnose due to its varied pathology. We evaluated the usefulness of single-photon emission computed tomography/computed tomography (SPECT/CT) in diagnosing CEH and its interventional treatment. Retrospectively, 23 patients diagnosed with CEH between March 2016 to August 2018 were allocated to SPECT/CT (n = 11) and control (n = 12) groups. The SPECT/CT group was further stratified into SPECT/CT(+) and SPECT/CT(-) groups according to the presence of positive findings. Patients in the SPECT/CT group underwent an intra-articular injection at a radiologically verified lesion site, whereas those in the control group underwent third occipital nerve block. Clinical outcomes were evaluated with the visual analog scale (VAS), neck disability index (NDI), and global perceived effect (GPE) scale at baseline, and at one, three, and six months postoperatively. The SPECT/CT group showed less VAS, NDI, and GPE scores at six months postoperatively (2.91 ± 2.30 vs. 4.42 ± 1.62, p = 0.08; 38.00 ± 16.54 vs. 48.7 ± 12.40, p = 0.093; 2.00 ± 1.41 vs. 3.17 ± 1.11, p = 0.039). Successful responders at six months postoperatively were higher in the SPECT/CT(+) group than in the control group (75% vs. 0%). SPECT/CT can identify arthritic changes and accurately define therapeutic targets.

Exercise, headache, and factors associated with headache in chronic whiplash: Analysis of a randomized clinical trial

BACKGROUND

Almost 40% of individuals with chronic whiplash-associated disorders (WAD) report headache after 5 years, making it one of the most common persistent symptoms besides neck pain, but randomized treatment studies are lacking. This study aimed to evaluate the effect of 3 different exercise approaches on headache in chronic WAD grades 2 and 3, and to identify potential factors associated with such headache, and whether they differ depending on 3 different aspects of such headache (current headache, maximum headache, or headache bothersomeness).

METHODS

This was an analysis of a randomized clinical trial of people with chronic WAD and headache (n = 188), who were randomized to either 12 weeks of neck-specific exercise without (NSE) or with a behavioral approach (NSEB) or physical activity prescription (PPA). Data were collected at baseline and at 3, 6, and 12 months. Physical and psychosocial factors were tested for association with headache. Multivariate regression models and linear mixed models were used.

RESULTS

The NSE/NSEB groups reported reduced headache both over time and compared to PPA. Up to 51% (NSE) and 61% (NSEB) reported at least 50% reduction in their headache at 12 months. The PPA group was not improved over time. Neck pain and dizziness were associated with headache regardless of aspect of headache. The only associated psychosocial factor was anxiety, which was associated with headache bothersomeness. Other factors were mainly physical, and up to 51% of the variance was explained.

CONCLUSION

Headache in chronic WAD, may be reduced with neck-specific exercise with or without a behavioral approach. Chronic headache was associated with neck pain and dizziness regardless of aspect tested. Other factors associated with headache in chronic WAD were mainly physical rather than psychosocial.

TRIAL REGISTRATION NUMBER

Clinical Trials.gov, no: NCT015285.

Prevalence and factors associated with the use of primary headache diagnostic criteria by chiropractors

Background

The diagnosis of primary headaches assists health care providers in their decision-making regarding patient treatment, co-management and further evaluation. Chiropractors are popular health care providers for those with primary headaches. The aim of this study is to examine the clinical management factors associated with chiropractors who report the use of primary headache diagnostic criteria.

Methods

A cross-sectional survey was distributed between August and November 2016 to a random sample of Australian chiropractors who are members of a practice-based research network (n = 1050) who had reported ‘often’ providing treatment for patients with headache disorders to report on practitioner approaches to headache diagnosis, management, outcome measures and multidisciplinary collaboration. Multiple logistic regression was conducted to assess the factors that are associated with chiropractors who report using International Classification of Headache Disorders (ICHD) primary headache diagnostic criteria.

Results

With a response rate of 36% (n = 381), the majority of chiropractor’s report utilising ICHD primary headache diagnostic criteria (84.6%). The factors associated with chiropractors who use ICHD primary headache diagnostic criteria resulting from the regression analysis include a belief that the use of ICHD primary headache criteria influences the management of patients with primary headaches (OR = 7.86; 95%CI: 3.15, 19.60); the use of soft tissue therapies to the neck/shoulders for tension headache management (OR = 4.33; 95%CI: 1.67, 11.19); a belief that primary headache diagnostic criteria are distinct for the diagnosis of primary headaches (OR = 3.64; 95%CI: 1.58, 8.39); the use of headache diaries (OR = 3.52; 95%CI: 1.41, 8.77); the use of ICHD criteria improves decision-making regarding primary headache patient referral/co-management (OR = 2.35; 95%CI: 1.01, 5.47); referral to investigate a headache red-flag (OR = 2.67; 95%CI: 1.02, 6.96) and not referring headache patients to assist headache prevention (OR = 0.16; 95%CI: 0.03, 0.80).

Conclusion

Four out of five chiropractors managing headache are engaged in the use of primary headache diagnostic criteria. This practice is likely to influence practitioner clinical decision-making around headache patient management including their co-management with other health care providers. These findings call for a closer assessment of headache characteristics of chiropractic patient populations and for further enquiry to explore the role of chiropractors within interdisciplinary primary headache management.

Neck and headache—Do we see paths through the jungle? An overview and an hypothesis

Background and overview:

It is widely accepted that cervicogenic headache (CEH) originates in the neck. In many circles, it is also accepted that neck–tongue syndrome belongs to the headaches that have their origin in the neck. For many headache researchers, the list: “headaches stemming from the neck” ends here. The objective of this overview was to explore the field and to determine whether there are grounds for adding other headaches to this list.

Discussion:

We suggest that headaches stemming from the neck possibly consist of five different subgroups: CEH, neck–tongue syndrome, tractor drivers’ headache, posterior headache subsequent to protracted neck-ache, and chronic paroxysmal hemicrania with mechanical attack precipitation. An overview of the clinical characteristics of each putative subgroup with comments is given.

The Chinese Association for the Study of Pain (CASP): Expert Consensus on the Cervicogenic Headache

Cervicogenic headache is a relatively common but unique form of headache, and in China, as well as in several other countries, both diagnosis and a clear evidence-based treatment plan remain controversial. Therefore, the Chinese Association for the Study of Pain organized a meeting of pain management experts and created an expert consensus on the diagnosis and treatment of cervicogenic headache in China. This article summarizes the conclusions of the consensus group regarding the epidemiology, etiology, clinical features, diagnosis, differential diagnosis, treatment, and rehabilitation of cervicogenic headache in China.

Occipital Neuralgia and Cervicogenic Headache: Diagnosis and Management

PURPOSE OF REVIEW

Occipital neuralgia (ON) and cervicogenic headache (CGH) are secondary headache disorders with occipital pain as a key feature. Due to significant phenotypic overlap, differentiating ON and CGH from primary headache disorders such as migraine or tension-type headache, or other secondary headache disorders, can be clinically challenging. This article reviews the anatomy, clinical features, unique diagnostic considerations, and management approaches relating to ON and CGH.

RECENT FINDINGS

Conservative therapeutic approaches are considered first-line. Anesthetic nerve blocks may have a dual role in both supporting diagnosis and providing pain relief. Newer minimally invasive procedures, such as pulsed radiofrequency (PRF) and occipital nerve stimulation (ONS), represent an exciting therapeutic avenue for severe/refractory cases. Surgical interventions should be reserved for select patient populations who have failed all other conservative and minimally invasive options, to be weighed against potential risk. ON and CGH represent an ongoing diagnostic challenge. Further studies are required to consolidate efficacy regarding the comprehensive management of ON and CGH.

Trigger Point Sensitivity Is a Differentiating Factor between Cervicogenic and Non-Cervicogenic Headaches: A Cross-Sectional, Descriptive Study

Purpose: A common factor in all forms of headache is the presence of myofascial trigger points (TrPs). The aim of this study was to compare the presentation of patients with cervicogenic headaches and patients with non-cervicogenic headaches in the sensitivity of TrPs in their upper trapezius, sternocleidomastoid, temporalis, and posterior cervical muscles. Method: This was a descriptive, cross-sectional study. The following variables were compared between patients with cervicogenic (n=20) and patients with non-cervicogenic (n=20) headaches: sensitivity (pain-pressure threshold) of TrPs in the upper trapezius, sternocleidomastoid, posterior cervical, and temporalis muscles (using a handheld, digital algometer); level of disability (using the Henry Ford Hospital Headache Disability Inventory questionnaire); demographics (age, sex); anthropometrics (BMI); and clinical presentation (duration and intensity of symptoms). The independent Student t-test and χ² test were used to determine the differences between the two groups. Effect sizes (Cohen's d) were calculated when relevant. Results: The two groups were similar in level of disability, demographic and anthropometric data, and clinical presentation. However, TrP sensitivity in the right upper trapezius (p=0.006; Cohen's d=0.96) and the left upper trapezius (p=0.003; Cohen's d=1.06) muscles was higher in the cervicogenic group. Conclusions: Increased sensitivity of TrPs in the upper trapezius muscle may be used as a differentiating factor in the diagnosis of cervicogenic headaches. This finding emphasizes the importance of integrating this muscle into the rehabilitation programs of patients with cervicogenic headache.

Increased mechanosensivity of the greater occipital nerve in subjects with side-dominant head and neck pain - a diagnostic case-control study

Objectives: To investigate differences in pressure pain thresholds (PPTs) and longitudinal mechanosensitivity of the greater occipital nerve (GON) between patients with side-dominant head and neck pain (SDHNP) and healthy controls. Evaluation of neural sensitivity is not a standard procedure in the physical examination of headache patients but may influence treatment decisions. Methods: Two blinded investigators evaluated PPTs on two different locations bilaterally over the GON as well as the occipitalis longsitting-slump (OLSS) in subjects with SDHNP (n = 38)) and healthy controls (n = 38). Results: Pressure pain sensitivity of the GON was lower at the occiput in patients compared to controls (p = 0.001). Differences in pressure sensitivity of the GON at the nucheal line, or between the dominant headache side and the non-dominant side were not found (p > 0.05). The OLSS showed significant higher pain intensity in SDHNP (p < 0.001). In comparison to the non-dominant side, the dominant side was significantly more sensitive (p = 0.004). Discussion: Palpation of the GON at the occiput and the OLSS may be potentially relevant tests in SDHNP. One explanation for an increased bilateral sensitivity may be sensitization mechanisms. Future research should investigate the efficacy of neurodynamic techniques directed at the GON. Level of Evidence: 3b.

Pericranial Tenderness in Females With Episodic Cervical Headache vs Asymptomatic Controls: A Cross-sectional Study

OBJECTIVES

The purpose of this study was to compare pericranial tenderness of females with episodic cervical headache vs matched asymptomatic controls.

METHODS

Through a single-blind, cross-sectional study, pericranial tenderness was compared between 20 females with episodic cervical headaches (29.4 ± 13.2 years) and 20 age-matched female asymptomatic controls (30.1 ± 13.7 years). Pericranial tenderness was bilaterally measured in a headache-free period with the "total tenderness score" (TTS) in the suboccipital, temporal, frontal, masseter, upper trapezius (UT), levator scapula, and sternocleidomastoid (SCM) muscle insertions. Passive cervical mobility, headache intensity, frequency, and duration were secondary outcomes. Analysis was done with a 95% confidence level (SPSS version 22). The Mann-Whitney U-test was used to compare pericranial, cephalic, cervical, and muscle-specific tenderness between groups. Correlations between passive cervical mobility and headache characteristics and the TTS were estimated with Spearman's ρ.

RESULTS

The headache group (1.25 ± 0.89) showed a 2 times higher (P < .05) pericranial TTS compared to the control group (0.62 ± 0.70). Higher (P < .05) scores were observed for the left suboccipital, temporal, masseter, UT, levator scapula, and SCM muscles and the right suboccipital, frontal, UT, and levator scapula muscles. Grouping the tenderness scores into cervical (suboccipital, UT, levator scapula, SCM) and cephalic (frontal, temporal, masseter) regions revealed greater scores (P < .05) in the headache group. In the latter, the TTS was significantly positively correlated with passive cervical extension (ρ = 0.78).

CONCLUSION

Consistent higher tenderness scores were observed and suggest involvement of sensitization in patients with episodic cervical headaches. A positive correlation was seen between passive cervical extension and sensitivity.

Dystonic Head Tremor and the Coexistence of Headache

BACKGROUND

Head tremor may be observed in the presence of cervical dystonia and sometimes coexists with headache. We wished to investigate the presence of headache in dystonic head tremor.

METHODS

We studied the files of 19 patients from our outpatient clinic (1997-2017) with dystonic head tremor and assessed the co-occurrence of headache. We also performed a literature search of the topic.

RESULTS

Cervicogenic headache was present in nearly 37% of patients with dystonic head tremor. More than 85% of our patients presented with a "no-no" head tremor.

DISCUSSION

Headache is common in dystonic head tremor. Cervicogenic headache seems to be more frequent in patients with dystonic head tremor than in the general population. Future studies should compare the presence of cervicogenic headache in essential head tremor patients with that in patients suffering from dystonic head tremor.

Stratifying migraine patients based on dynamic pain provocation over the upper cervical spine

Background

Migraine patients usually report a high prevalence of neck pain preceding or during the migraine attack. A recent investigation of musculoskeletal dysfunctions in migraine patients concluded that neck pain is not simply a symptom of the migraine attack but corresponds to identifiable muscle and joint alterations. Particularly pain provocation using palpation of the joints in the upper cervical spine was significantly more prevalent in patients with migraine than in headache-free participants.

Methods

One hundred seventy-nine migraineurs (diagnosed according to IHS classification criteria version III beta) and 73 age- and gender-matched healthy controls were examined by a physiotherapist blinded towards the diagnosis, using a palpation technique over the upper cervical spine. The palpation combined oscillating movements and sustained pressure.

Findings

Using simple palpation of the upper cervical spine, migraine patients can be stratified into three groups: painfree (11%), local pain only (42%), and pain referred to the head during sustained pressure (47%). Combining both test components (palpation and sustained pressure) has a high sensitivity and specificity for migraine.

Conclusions

The response to palpation of the upper cervical spine may indicate migraine subtypes. The presence of musculoskeletal dysfunctions of the upper cervical spine should be identified and treated to avoid ongoing nociceptive input into the trigeminocervical complex.

Trial registration

German Clinical Trial Register DRKS-ID: DRKS00009622.

Chiropractic spinal manipulative therapy for cervicogenic headache: a single-blinded, placebo, randomized controlled trial

Objective

Cervicogenic headache is a disabling headache where pharmacological management have limited effect. Thus, non-pharmacological management is warranted. Our objective was therefore to investigate the efficacy of chiropractic spinal manipulative therapy versus placebo (sham manipulation) and control (continued usual but non-manual management) for cervicogenic headache in a prospective 3-armed single-blinded, placebo, randomized controlled trial of 17 months’ duration.

Results

Nineteen participants were equally randomized into the three groups, and 12 participants completed the randomized controlled trial. Headache frequency improved at all time points in the chiropractic spinal manipulative therapy and the placebo group. Headache index improved in the chiropractic spinal manipulative therapy group at all time points, while it improved at 6 and 12 months’ follow-up in the placebo group. The control group remained unchanged during the whole study period. Adverse events were few, mild and transient. Blinding was concealed throughout the RCT. Thus, our results suggest that manual-therapy might be a safe treatment option for participants with cervicogenic headache, but data need to be confirmed in a randomized controlled trial with sufficient sample size and statistical power.

Trial registration ClinicalTrials.gov identifier: NCT01687881, 11 September 2012

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2651-4) contains supplementary material, which is available to authorized users.

The Clinical Features, Risk Factors, and Surgical Treatment of Cervicogenic Headache in Patients With Cervical Spine Disorders Requiring Surgery

OBJECTIVE

To clarify the clinical features and risk factors of cervicogenic headache (CEH; as diagnosed according to the International Classification of Headache Disorders-Third Edition beta) in patients with cervical spine disorders requiring surgery.

BACKGROUND

CEH is caused by cervical spine disorders. The pathogenic mechanism of CEH is hypothesized to involve a convergence of the upper cervical afferents from the C1, C2, and C3 spinal nerves and the trigeminal afferents in the trigeminocervical nucleus of the upper cervical cord. According to this hypothesis, functional convergence of the upper cervical and trigeminal sensory pathways allows the bidirectional (afferent and efferent) referral of pain to the occipital, frontal, temporal, and/or orbital regions. Previous prospective studies have reported an 86-88% prevalence of headache in patients with cervical myelopathy or radiculopathy requiring anterior cervical surgery; however, these studies did not diagnose headache according to the International Classification of Headache Disorders criteria. Therefore, a better understanding of the prevalence rate, clinical features, risk factors, and treatment responsiveness of CEH in patients with cervical spine disorders requiring surgery is necessary.

METHODS

We performed a single hospital-based prospective cross-sectional study and enrolled 70 consecutive patients with cervical spine disorders such as cervical spondylotic myelopathy, ossification of the posterior longitudinal ligament, cervical spondylotic radiculopathy, and cervical spondylotic myeloradiculopathy who had been scheduled to undergo anterior cervical fusion or dorsal cervical laminoplasty between June 2014 and December 2015. Headache was diagnosed preoperatively according to the International Classification of Headache Disorders-Third Edition beta. The Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire, Neck Disability Index, and a 0-100 mm visual analog scale (VAS) were used to evaluate clinical features, and scores were compared between baseline (ie, preoperatively) and 3, 6, and 12 months post-surgery.

RESULTS

The prevalence of CEH in our population was 15/70 (21.4%, 95%CI: 11.8% to 31.0%). The main clinical features were dull and tightening/pressing headache sensations in the occipital region. Headache severity was mild (VAS, 32 ± 11 mm) and only one patient reported use of an oral analgesic. Compared to patients without CEH, patients with CEH had higher frequencies of neck pain (86.7% vs. 50.9%; P = .017), cervical range of motion limitation (ROM) (66.7% vs. 38.2%; P = .049), and higher Neck Disability Index scores (14 vs. 3; P < .001). Among the different cervical spine disorders, the prevalence of CEH was highest in cervical spondylotic myeloradiculopathy patients (60%), being ≤ 20% for all other disorders. Surgical treatments including cervical laminoplasty to relieve abnormal pressure on the spinal cord via a posterior approach, were associated with initial improvements in headache VAS that slightly diminished by 12 months post-surgery (P < .001).

CONCLUSIONS

We report a lower prevalence of CEH in patients with cervical spinal disorders requiring surgery than that reported previously. The main clinical features of CEH were mild, dull, and tightening/pressing headache sensations in the occipital region. Potential risk factors for CEH included neck pain, limited cervical ROM, high Neck Disability Index score, and a diagnosis of cervical spondylotic myeloradiculopathy. The further accumulation of patients in a multi-institutional study may be required in order to discuss the diagnostic criteria and pathophysiology of this condition.

Cervicogenic headache alleviation after cervical coblation nucleoplasty: A prospective cohort study

A degenerative cervical disc is a pain generator for headaches, and headaches can benefit from cervical prolapse surgery. However, as an alternative intervention for open cervical surgery, no study has reported whether headaches can benefit from cervical nucleoplasty.The objective of this study was to evaluate the efficacy of cervical coblation nucleoplasty in the treatment of cervicogenic headaches.In a prospective cohort study performed between December 2013 and August 2015, 20 patients with cervicogenic headaches undergoing cervical nucleoplasty for shoulder-arm pain were recruited into group C, and 20 patients with cervicogenic headaches undergoing lumbar nucleoplasty for low back pain, matched for age and sex, were recruited into group L. Cervicogenic pain was diagnosed according to the International Headache Society criteria. During the 24-month follow-up, pain visual analog scale (VAS) scores were collected as the primary outcomes, and significant pain relief rate, Neck Disability Index (NDI) headache scores, and Patients Satisfaction Index (PSI) scores were recorded as secondary outcomes to evaluate headache severity and physical function postoperatively.During the 24-month follow-up, a significant decrease in headache VAS scores was observed in group C but not in group L. NDI and PSI scores in group C were better than those in group L. In comparison with the final follow-up, no significant differences in the NDI and PSI scores were found in all observations after surgery. In comparison to group L, ≥50% pain relief was significantly better in group C. No serious complications were observed except for ≤20% of ecchymoma at the needle insertion site.This prospective study indicated that cervicogenic headaches may benefit from nucleoplasty.

Chiropractic spinal manipulative therapy for cervicogenic headache: a study protocol of a single-blinded placebo-controlled randomized clinical trial

Cervicogenic headache (CEH) is a secondary headache which affects 1.0–4.6 % of the population. Although the costs are unknown, the health consequences are substantial for the individual; especially considering that they often suffers chronicity. Pharmacological management has no or only minor effect on CEH. Thus, we aim to assess the efficacy of chiropractic spinal manipulative therapy (CSMT) for CEH in a single-blinded placebo-controlled randomized clinical trial (RCT). According to the power calculations, we aim to recruit 120 participants to the RCT. Participants will be randomized into one of three groups; CSMT, placebo (sham manipulation) and control (usual non-manual management). The RCT consists of three stages: 1 month run-in, 3 months intervention and follow-up analyses at the end of intervention and 3, 6 and 12 months. Primary end-point is headache frequency, while headache duration, headache intensity, headache index (frequency × duration × intensity) and medicine consumption are secondary end-points. Primary analysis will assess a change in headache frequency from baseline to the end of intervention and to follow-up, where the groups CSMT and placebo and CSMT and control will be compared. Due to two group-comparisons, the results with p values below 0.025 will be considered statistically significant. For all secondary end-points and analyses, the significance level of 0.05 will be used. The results will be presented with the corresponding p values and 95 % confidence intervals. To our knowledge, this is the first prospective manual therapy three-armed single-blinded placebo-controlled RCT to be conducted for CEH. Current RCTs suggest efficacy in headache frequency, duration and intensity. However a firm conclusion requires clinical single-blinded placebo-controlled RCTs with few methodological shortcomings. The present study design adheres to the recommendations for pharmacological RCTs as far as possible and follows the recommended clinical trial guidelines by the International Headache Society.

Trial registration ClinicalTrials.gov identifier: NCT01687881, 2 December 2012

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.

Pericranial tenderness in chronic tension-type headache: the Akershus population-based study of chronic headache

Background

Most knowledge on chronic tension-type headache (CTTH) is based on data from selected clinic populations, while data from the general population is sparse. Since pericranial tenderness is found to be the most prominent finding in CTTH, we wanted to explore the relationship between CTTH and pericranial muscle tenderness in a population-based sample.

Methods

An age- and gender-stratified random sample of 30,000 persons aged 30-44 years from the general population received a mailed questionnaire. Those with a self-reported chronic headache were interviewed and examined by neurological residents. The questionnaire response rate was 71% and the interview participation rate was 74%. The International Classification of Headache Disorders II was used. Pericranial muscle tenderness was assessed by a total tenderness score (TTS) involving 8 pairs of muscles and tendon insertions. Cross-sectional data from the Danish general population using the same scoring system were used for comparison.

Results

The tenderness scores were significantly higher in women than men in all muscle groups. The TTS was significantly higher in those with co-occurrence of migraine compared with those without; 19.3 vs. 16.8, p = 0.02. Those with bilateral CTTH had a significantly higher TTS than those with unilateral CTTH. The TTS decreased significantly with age. People with CTTH had a significantly higher TTS compared to the general population.

Conclusions

People with CTTH have increased pericranial tenderness. Elevated tenderness scores are associated with co-occurrence of migraine, bilateral headache and low age.

Whether the increased muscle tenderness is primary or secondary to the headache should be addressed by future studies.

Therapeutic options for cervicogenic headache

The term cervicogenic headache (CeH) describes a syndrome originating from the cervical spine. There are a variety of therapeutic approaches used for the management of CeH, but scientific evidence of their effectiveness is scarce. No medication drug has proven to be effective. The evidence for greater occipital nerve blocks, cervical nerve blockades, facet joint injections and surgical procedures is limited. Several physical therapy interventions are proposed for CeH, with spinal manipulation and soft tissue interventions being the most commonly used. However, the lack of solid evidence of positive effects and risks of serious complications for spinal manipulation should be considered in favor of other physical therapy interventions associated with less risk. The inconsistent results in the literature can be related to the fact that maybe not all therapeutic interventions are appropriate for all patients with CeH or maybe not all patients with CeH will benefit from particular interventions.

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.