Cervicogenic Headache

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a core concepts musculoskeletal health group newsletter
Cervicogenic Headache                                                                        sufferers. Using a sprained ankle as an
                                                                                             analogy. Proprioception, of a sprained
Physiotherapy Assessment and Managment                                                       ankle is reduced as the sensorimotor
                                                                                             feedback is impaired. This can lead to
Approximately 70% of the people                the head.                                     a high probability of re-injury. Similarly,
who suffer from frequent intermittent                                                        the cervicogenic headache sufferer
headache complain of neck symptoms1.           Poor cervical posture also encourages         will have a deficit in his/her cervical
This proposes the possible relationship        the suboccipital muscles to contribute        joint proprioception, affecting balance
between the cervical spine and                 to the compression of the upper cervical      and possible impairment in the eye
headache. Such cervical spine related          spine. These muscles attach from the          movement control.
headaches are termed as Cervicogenic           base of the skull to the upper cervical
headache. As always, an accurate               spine. The forward head posture places        Physiotherapy Clinical Assessment
diagnosis is important in the effective        the suboccipital muscles in a shortened
treatment of the headache.                     position. If this posture is not corrected,   Apart from subjective assessement1,
                                               over time the suboccipital muscles            there are three main physical tests that
Mechanism                                      adapt and shorten. This can lead to a         will help to determine the diagnosis of
                                               vicious cycle of further compression          Cervicogenic headache.
Cervicogenic headache is characterised         of the upper cervical spine, reducing
by a dull pain that is referred from the       mobility in the spine and accentuating        1. Range of motion
upper cervical spine. This is primarily        the forward head posture.                         Limited in all range of the cervical
contributed by sustained poor                                                                    spine. Specifically the rotation of
cervical position which puts excessive         Forward head posture also leads to                the C1-2.
compressive forces onto the cervical           muscle imbalance in the cervical spine.
structures. Examples of such position          There is a discrepancy between the
include ipsilateral tilt of the neck or        strength and endurance of the smaller         2. Joint mobilization
forward head posture where the head            anterior cervical muscles which are
                                                                                                 Palpation for joint dysfunction
is tilted to one side or is forward relative   thought to be the primary stabilizers
                                                                                                 at C1 to C3 vertebrae. C1-3
to the neck and shoulders. This results        and the larger global muscles, which
                                                                                                 joints are often found to be
in the compression of C1 to C3. The            are thought to be “movers”. Due to
                                                                                                 hypomobile in patients on the
nerves exiting from C1-C3 converge             the weakness of the stabilizers, the
                                                                                                 ipsilateral side of the headache.
into the trigeminocervical nucleus.;           larger cervical muscles are recruited
when irritated can cause a nociceptive         to take over the stabilizing role. The
                                                                                             3. Craniocervical flexion test with Pres-
response to the head resulting in a            sternocleidomastoid muscle is one such
                                                                                                sure biofeedback
headache.                                      muscle and it has found to be overactive
                                               and is riddled with trigger points. On            This measures the endurance of
Compression further causes the                 the other hand, the endurance of the              the deep neck flexors, stabilisers
reduction of C1-3 intervertebrae space.        deep cervical flexor muscles has been             of the cervical spine. In supine
The reduction of the intervertebral            found to have significant deficits when           lying, the pressure biofeedback
space causes the irritation of the             tested using Craniocervical Flexion test.         is placed behind the skull and
respective nerves exiting from C1 to                                                             subject is asked to perform upper
3 which supply sensation to the base           Apart from musculoskeletal problems,              cervical flexion to activate the
of the skull and jaw on the ipsilateral        cervicogenic headache sufferers are               deep flexion in 24-26mmhg. If the
side of the cervical dysfunction. The          found to have sensorimotor deficits.              subject fails to sustain the pressure
trigeminocervical nucleus further              Kinesthetic sense is found reduced                of the biofeedback for 10 sets of 10
amplifies the nociceptive sensation to         when joint position error is measured in          seconds, this indicates weakness
    and poor endurance of the deep            Physiotherapy Management:                             giving a better stabilisation and
    neck flexors. This sustained pressure                                                           control to the cervical spine.
    must be done independently                To manage this condition, a multimodal
    without theassistance of the              approach is required.                           4. Sensorimotor control
    larger superficial muscles like
    Stenocleidomastoid, scalenes etc.         1. Poor Posture                                       A set of exercises targeting on
    Weakness of the deep neck flexors                                                               sensorimotor control is included for
    has been indicated in cervicogenic            After knowing the contribution of                 subjects with or without dizziness.
    headache.                                     cervicogenic headache due to the                  These exercises will rehabilitate
                                                  forward head posture. It is crucial to            subjects suffering from dizziness
                                                  correct the posture by retraining to              and at the same time prevent
The additional tests include                      their neutral neck posture, giving                if the subjects have yet to have
                                                  ergonomic advices and discussing                  dizziness. The exercise programme
4. Joint position error                           strategies to reduce the aggravating              will include training of the head
                                                  factors of the symptoms.                          relocation, balance and oculomotor
    It is a test commonly used to                                                                   practices
    measure the kinesthetic sense of          2. Movement dysfunction of the upper
    the cervical joint. In the test, the         cervical spine
    subject is placed into an ideal head                                                      References:
    position and is asked to relocate the         Several studies4,5 have shown that
    same head position when the vision            manipulative therapy including              1.   Zito G, Jull G, Story I 2006 Clinical tests of mus-
                                                                                                   culoskeletal dysfunction in the diagnosis of the
    is occluded. The test is positive if          high velocity and low velocity                   Cervicogenic headache. Man Ther 11: 118-129
    the subject fails to relocate the ideal       thrust mobilisation as shown to
                                                                                              2.   Headache Classification Subcommittee of the In-
    position as set by the therapist.             reduce the movement impairment                   ternational Headache Society. 2004 The Interna-
                                                  of the upper cervical spine. This                tional Classification of Headache Disorders, 2nd
    This test is greatest in those subjects       encourages better mobility of                    edn. Cephalagia 24(Suppl. 1):1-151
    who complaint of dizziness in                 the spine leading to less painful           3.   Tjell C, Rosenhall U 1998 Smooth Persuit neck tor-
    additional to their neck pain.                movement dysfunction. Active                     sion: A Specific test for cervical dizziness. Amer J
                                                                                                   Otol 19;76-81
                                                  range of motion exercises will
5. Standing Balance                               also be given to promote moblity            4.   Jull G 2002 The use of high and low veloc-
                                                  of the cervical spine. Active                    ity cervical manipulative therapy procedures by
                                                                                                   Australian manipulative physiotherapists. Aust J
    Cervicogenic headache suffers                 exercise is an reinforcement of                  Physiother 48:189-193
    may have impairment in their                  the movement after manipulative
    standing balance but there is                                                             5.   Mulligan B 1995 Manual Therapy ‘NAGs’, ‘SNAGs’,
                                                  therapy as some range of gained                  ‘MWMs’, 5th edn. Plane View Press, Wellington
    no strong evidence to state the               from passive treatments may
    specificity of the test except that           be lost. For example, to cervical
    the sensorimotor system may be                flexion of C1-2 and rotation of C1-
    affected. The standing balance                2 with assisted strap5 (see figure 1).
    consists of 6 tests which gradually
    increases the challenge with              3. Muscle system
    different types of base of support,
    visual feedback and different types                Tight muscles like suboccipital
    of surfaces.                                       and sternocleidomastoid muscles
                                                       are released with deep tissue
                                                                         massage. It is
                                                                         very important
                                                                         to train the
                            Headache Self-SNAG
                                                                         stabiliser muscles
                            1. Secure the mulligan strap around the      like deep neck
                                spinous process of C1 (the rst bony      flexors in their
                                pertrusion that you feel under the
                                                                         strength      and
                                base of your skull).                                                                     MICA (P) 158/10/2010
                                                                         endurance                   This newsletter is produced by Core Con-
                                                                         with the use of                      cepts - Musculoskeletal Health.
                            2. Pull the strap forward equally and
                                                                         exercises and tool
                                sustain the position for at least 10sec. such as pressure                                We can be reached at
                                If headache is relieved, repeat 3-4      biofeedback                                           T: 6226 3632 or
                                times until headache eases.
                                                                         used in CCFT.                        E: enquiry@corecocnepts.com.sg
                                                                         These will help                         W: www.coreconcepts.com.sg
                                                                         to      normalise
                                                                         the        muscle
                              Figure 1                                                                  MUSCULOSKELETAL HEALTH GROUP

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Description: In all sports or activities should not occur after the headache feeling. Headache, should stop their activities, focusing on neurological, cardiovascular and cerebrovascular system checks.