Generally, it may appear on any area of the head
Frequent: frontal, retro-orbital, occipital, temporal

Patient Profile

• Female > Male
• All ages
• 15-20% of all relapsing headaches are cervicogenic

Pathophysiology

Trigger

• Stress
• Sustained postures (sleeping, sitting activity)
• Movements into painful direction: e.g. rotation-extension

Cause

• Cervical dysfunction
• Convergence of N. Trigeminus and spinal nerves of upper cervical spine segments. Irritation of structures innervated by the first three cervical spinal nerves (muscles, discus, vertebral arteries, internal carotid artery, facets)
• Exact identification of the affected structure causing the headache is not possible due to the close proximity of the trigeminal nerves
• Contributing factors can play a major role in the etiology: Disturbed sleep, stress, psychological factors, diet, allergies, etc.

Pain Mechanisms

• Mechanical nociceptive: Movement dependent, direction specific, on/off characteristic
• Ischemic nociceptive: Pain elicited during prolonged static postures
• Maladaptive central sensitization: Contributing factors influence pain perception
• Motor output: Change in muscle tone and movement

Course

Headache onset is preceded by neck pain. Duration of painful period varies from hours to days. Improvement of symptoms within 3 months after end of treatment. Moderate to good effectiveness

History

History varies (usually long), head/C-spine trauma (WAD, fall) in history4, neck pain preceding headache, patient describes postural load during ADLs but often fails to describe a specific trigger (<50%), other concordant headache types, pain got progressively worse + other (migraine-like) symptoms

• Unilateral/bilateral with a dominant side: pain does not switch sides
• Gnawing, pulsating, throbbing
• Narrow band around head
• Limited ROM in C-Spine: especially high cervical rotation
• Radiating pain: referred pain
• Not sharp shooting
• Moderate to severe
• Starts in the neck
• May have migraine like symptoms: nausea, photophobia, dizziness, etc.

Physical Examination

Inspection
Cranio-cervical angle (line of spinous process C7 to tragus of the ear) is <51° (normal): Ø 44.5% in symptomatic population (± 2.3 SD)

Active Examination
Assess movement both qualitatively and quantitatively

Functional Assessment
Patient is able to demonstrate provoking movements

Special Testing

Neurological
no abnormal findings

Passive Examination
PPIVMs & PPAVMs C0-C2: local stiffness in rotation/extension centrally and laterally; possible protective muscle spasm down to CTJ

Further Testing
CCFT, Eye-Head Coordination

Differential Diagnosis

1. Tension-type headache
2. Migraine
3. Meningitis
4. Cranial arteritis
5. Subarachnoid hemorrhage
6. Tumor
7. Fracture

Strategy

Start with patient education. Manual interventions at the C-Spine, training motor control, stretching and strengthening of cervical muscles, as well as eliminating contributing factors.Goal: Pain reduction, improve function, adapt ADLs, and elimination of possible contributing factors

Interventions

Patient has to understand trigger and source of pain to understand their situation and treatment strategy

Reduction of contributing factors: Lifestyle modifications

Stress: Relaxation exercises, endurance training 3-4x/week as part of a hobby

Sleep: Monitor sleeping cycles and adapt: sufficient hours, regular pattern

Work ergonomics: Adapt working place and daily tasks

Diet: Consult with dietician to adapt eating habits

Mobilization / Manipulation of C/T-Spine

Deep neck flexor exercises, general strengthening upper quarter, stretching

Headache diary: Get individual insight into correlation between headache and specific activities

1. Antonaci, F., Bono, G., & Chimento, P. (2006). Diagnosing cervicogenic headache. J Headache Pain, 7(3), 145-148. doi:10.1007/s10194-006- 0277-3
2. Bogduk, N. (2001). Cervicogenic headache: anatomic basis and pathophysiologic mechanisms. Curr Pain Headache Rep, 5(4), 382-386.
3. Fredriksen, T. A., Antonaci, F., & Sjaastad, O. (2015). Cervicogenic headache: too important to be left un-diagnosed. J Headache Pain, 16(1), 6. doi:10.1186/1129-2377-16- 6
4. Frese, A., Schilgen, M., Husstedt, I. W., & Evers, S. (2003). [Pathophysiology and clinical manifestation of cervicogenic headache]. Schmerz, 17(2), 125-130. doi:10.1007/s00482-002- 0194-6
5. Piekarz, H. v. (2011). Zervikogener Kopfschmerz. In P. Westerhuis, R. Wiesner (Eds.), Klinische Muster in der Manuellen Medizin (Vol. 2, pp. 269-279). Stuttgard: Thieme Verlag.
6. Sargent, J. D., Baumel, B., Peters, K., Diamond, S., Saper, J. R., Eisner, L. S.; Solbach, P. (1988). Aborting a migraine attack: naproxen sodium v ergotamine plus caffeine. Headache, 28(4), 263-266.Stovner, L. J., Zwart, J. A., Hagen, K., Terwindt, G. M., & Pascual, J. (2006). Epidemiology of headache in Europe. Eur J Neurol, 13(4), 333-345. doi:10.1111/j.1468-1331.2006.01184.x