Cervicogenic headache is characterised by headache pain that is associated with cervical stiffness and/or pain with neck movement or sustained postures. Pain often starts in the neck and back of the head, with the potential to radiate over the head and to the face. It is usually unilateral but can on occasion be bilateral, particularly in those with professions that require sustained position e.g. hairdressing, truck driving. The facet joints, intervertebral discs and muscles of the upper cervical spine are the most likely cause of cervicogenic headache, with presentations in children and following a trauma the exception. In this case, the lower cervical spine may also be involved.
Incidence and Prevalence
Approximately 15-20% of all headache pain can be attributed to a cervical cause. Females are four times more likely to experience cervicogenic headache than males. 44% of sufferers of cervicogenic headache also have temporomandibular joint dysfunction.
A comprehensive assessment of the cervical spine is essential in determining the underlying cause of cervicogenic headache. This should include assessment of the following:
- Posture: a “poked-neck” posture increases the load on the upper cervical spine and can suggest weakness of the deep neck flexors.
- Range-of-motion: stiffness may be correlated to overall cervical dysfunction.
- Muscle length: tightness of the upper trapezius, levator scapulae, sub-occiptals, pectorals, scalenes and sternocleidomastoid are all associated with headache pain.
- Muscle strength/activation: weakness of the deep neck flexors, rhomboids and lower trapezius is usually coupled with tightness of the above muscles.
- Palpation: stiffness and headache pain is often reproduced with mobilisation of upper cervical segments or palpation of the upper cervical musculature.
- Atlanto-axial rotation: lack of mobility at the atlanto-axial joint is strongly linked to cervicogenic headache.
- Breathing pattern: overuse of accessory muscle and under-recruitment of the diaphragm can contribute to tightness and hyperactivity of the neck muscles.
Once accurately diagnosed and after the primary cause of headache is identified physiotherapy can be aimed at correcting the specific underlying cervical dysfunction.
Manual therapy to reduce joint stiffness in combination with a home exercise program comprising of stretching tight superficial muscles and strengthening deep stabiliser muscles is effective in reducing intensity, duration and frequency of headache pain in the majority of patients. Medication is often of little or no help.
Education regarding work ergonomics, postural habits and a generalised upper quadrant strengthening program are also important to correct any postural abnormalities and assist with prevention of future episodes.