Cervicogenic headache

Cause of pathology

Pain occurs because the muscular skeletal apparatus of the neck does not function optimally. As a result, normal movements of the cervical vertebrae are disturbed. Therefore, headaches often start together with neck pain, are movement-related and improve when the mobility of the cervical vertebrae improves. The headache itself originates in the nerve structures of the upper part of the cervical spine (the upper three vertebrae) (Bogduk 2014). Due to disturbed spinal movement, the nerve structures cannot work normally and this manifests itself in headaches. In addition, the muscles may also show increased sensitivity and tension and be linked to the intensity and location of the headache. Cervicogenic headaches are often also accompanied by tension and sensitivity in the muscles of the neck and shoulder on the side where the headache manifests itself.

Evolution of the pathology

Cervicogenic headaches may manifest suddenly or repeatedly and sometimes resemble migraine-like or tension-related headaches (Suijlekom et al. 2003). Often, patients have already tried to reduce the complaint with analgesic medication. This is often not effective, as the pain signals originate from a neurological basis. The cervicogenic headache recurs more often in patients if the disorder of the musculoskeletal apparatus is caused by daily activities (e.g. repetitive physical work or a static job with poor ergonomic posture). The duration and recurrence thus strongly depend on the patient's living and working environment and his/her active participation in recovery and prevention.

Articular

Cervicogenic headaches are often caused by restriction of the rotation and/or the forward/backward movement of the cervical vertebrae. These movements will therefore be painful both actively and passively (when your physiotherapist moves the vertebrae) and may provoke or worsen the headache.

Neurologic

Cervicogenic headaches result from a strain on the nerve structures in the area of the upper cervical vertebrae and are therefore primarily a neurological symptom. It is the result of a blockage of these nerve structures, which prevents them from working optimally.

Muscular

The muscles around the cervical vertebrae and shoulders may also feel painful or tense. If the muscles are excessively tense, they can also cause radiating pain to the head. This radiating pain differs from cervicogenic headaches in that it is less motion-related.

Other symptoms

Other causes of headache should be excluded, e.g. tension headache, migraine, infectious disease or extreme dehydration.

Physiotherapeutic examination

During the examination, your physiotherapist will first check whether the headache is cervicogenic. This means that the clinical examination or clear imaging indicates that there is a disturbance near the cervical vertebrae. Your physiotherapist will also determine which structures are most and directly responsible for an overload of the nerve structures of the upper cervical vertebrae. In the case of cervicogenic headache there is typically a limitation of movement around the three upper cervical vertebrae. The most important tests are the passive motion tests, in which the mobility of the upper cervical vertebrae is evaluated very specifically. If the rotation and/or forward-backward movement of the upper vertebrae is limited, this is indicative of cervicogenic headache (Anarte et al. 2019; Howard et al. 2015).

After the interview and examination, your physiotherapist will assess with you which treatment is best suited to relieve the symptoms in the short term and prevent them in the long term. A multidisciplinary physiotherapist team can be of great benefit in cervicogenic headaches by providing a wide range of treatment strategies to accompany recovery (Côté et al. 2019).

Manual therapy

Spinal manual techniques are most effective in the short-term for treating cervicogenic headaches as they quickly relieve the blockage of the nerve structure. These techniques often provide immediate but short-term reduction of pain intensity and frequency (Fernandez et al. 2020). In addition, softer techniques, such as mobilisation/manipulation and traction of the upper three cervical vertebrae, are also relevant (Chaibi and Russell 2012) and are equally effective in the long term. These manual techniques are intended to guide the cervical vertebrae back to their normal position. As a result, neck movements can return to normal and surrounding structures can be relieved. In the long term, it is therefore important to remove the cause of the problem by means of posture corrections that relieve the neck. Finally, soft tissue techniques or dy needling are effective in reducing muscle tone, helping to normalise the functioning of the musculoskeletal apparatus and possibly reducing radiating pain from excessive muscle tension. It is thus an indirect way of improving the mobility of the cervical vertebrae.

Physiotherapeutic treatment

After the interview and examination, your physiotherapist will assess with you which treatment is best suited to relieve the symptoms in the short term and prevent them in the long term. A multidisciplinary physiotherapist team can be of great benefit in cervicogenic headaches by providing a wide range of treatment strategies to accompany recovery (Côté et al. 2019).

Pain control

In order to reduce the headache, your physiotherapist will try to relieve the nerve structures around the upper three cervical vertebrae. In the first phase this will be done mainly through manual techniques and later through posture correction exercises.

Exercise therapy

Since the cause of cervicogenic headaches is a disturbed position and/or mobility of the upper cervical vertebrae, good posture and control of the neck is important. This means that exercise therapy is aimed at normalising the position and function of the cervical vertebrae. There are two forms of exercise: exercises to normalise the mobility: These exercises are intended to normalise the mobility of one or more joints. In cervicogenic headaches, the focus will be on exercises for the cervical vertebrae and the shoulder region. These aim, for example, to improve the gliding movements of the vertebrae. An example are sustained apophysiological glides. Exercises to improve movement control: During these exercises, the aim is to learn a normal pattern of movement so that the load on the different structures (mainly muscles, joints, ligaments and nerves) is optimally distributed. The aim is to automate and integrate these into daily life so that the risk of relapse is minimised. This includes corrections to the position of the head, neck, shoulders (Côté et al. 2019) and, if necessary, the lower back. To ensure that the postural correction can be maintained, the strengthening of the strength and endurance of the muscles around the neck and shoulder is also a point of attention. This is essential to avoid relapse (Zronek et al. 2016). If there are limitations due to shortened muscles, stretching exercises will be included in the recovery programme.

Short term

In the short term, the aim of the physiotherapist is to relieve the headache by improving the local mobility of the cervical vertebrae. The pain is relieved because the blockage of the nerve structures is partly or completely removed.

Long term

In the long run, relapse cannot be ruled out and therefore it is extremely important to break bad exercise habits. If not, the risk of relapse is high. Awareness and active participation of the patient are extremely important to achieve normalisation of the musculoskeletal system.