HEADACHE: cervicogenic (from the neck)

Headache is the most commonly reported physical symptom after a concussion as we have discussed elsewhere.  Cervicogenic headache is a type of headache that arises from structures in the neck (i.e., muscles, joints, bones, nerves, discs, etc.).  Bony structures and soft tissues of the neck can refer pain in the head and face. The pathway by which pain originating from the neck can be referred to the head is the trigeminocervical nucleus. [1]

 

The trigeminocervical nucleus or complex (TCC) is a region in the brainstem where sensory fibers in the descending tract of the trigeminal nerve are believed to interact with sensory fibers from the upper cervical spine (neck).  Convergence of the two pathways makes it possible for the referral of pain signals from the neck to the trigeminal sensory receptive fields. In other words, pain from the upper cervical spine can refer to regions of the head innervated by the cervical nerves 1-3 (ear and back of the head or occiput) and areas innervated by the trigeminal nerve (eyes, forehead and parietal region). [1] The TCC is an important structure in the development of migraine headaches.

 

Dr. Molly Johnston, from UCLA, made a discovery while doing interventional nerve blocks. When she would stimulate patients’ C1 sensory nerve roots, patients would complain of pain around their eyes radiating to the back of their heads (like patients with migraine get) on the same side on which they received the stimulation in their necks. Not everyone has a sensory nerve root at C1; only about  50% of people. And, it’s asymmetric in patients, that is they may have a big sensory nerve root on one side and not the other. They are now investigating to see those with C1 sensory nerve roots experience pain or migraines differently; and if there are new techniques to treat neck-related headaches using this information (Charles, A., 2019).

 

However, migraine and neck pain is a two-way street, and more often, the neck pain is caused by migraine than the other way around. We have discussed this in another article.

People with cervicogenic headache often have decreased range of motion in their neck.  Headaches are aggravated by certain neck positions. For example, turning your head to the left will trigger headaches whereas turning to the right will not.  Headaches are often unilateral (on one side) and are reproducible with pressure to certain areas on the neck.

Numerous pain sensitive structures exist in the upper cervical spine and occiput, including:

• Upper cervical facets [1]
• Cervical muscles[1] including upper trapezius, sternocleidomastoid and scalenes [2]
• C2-3 intervertebral disc [1]
• Vertebral artery [1]
• Nerve roots [3]
• Dura matter of the upper spinal cord [1]

 

Technically, to diagnose a cervicogenic headache, there needs to be physical exam evidence or imaging evidence of a neck disorder and at least two of the following criteria, for example:

• Headache has developed in temporal relation to the onset of the cervical disorder or the appearance of the lesion;
• headache has significantly improved or resolved with improvement or in the resolution of the cervical disorder or lesion;
• or cervical range of motion is reduced and the headache is made significantly worse by provocative maneuvers or certain positions of the head;
• and headache could be abolished by doing a pain block injections of the cervical structures.

 

In any cause of neck pain, red flags need to be looked for to rule out more serious causes of neck pain. These generally involve worrisome signs like:

• neurological dysfunction like weakness of an arm or wasting of muscle in an arm
• problems with walking or urinating
• sharp stinging pain radiating down an arm
• night sweats, fevers and/or unintentional weight loss
• problems swallowing or speaking
• dizziness associate with neck pain
• problem stabilizing your vision (it seems to be jumping or double vision)
• drop attacks (just falling, without loss of consciousness, without any apparent external cause for falling)

Physiotherapy approach to cervicogenic headache foremost includes a thorough assessment of the neck. This includes assessing for cervical range of motion, cervical segmental movement, myofascial trigger points (sensitive points in the muscles), deep neck stabilizer strength and endurance, and scapular (shoulder blade) stabilizer strength. An ergonomic assessment is also a good idea as most of us spend at least a quarter of our time at the office, and poor posture may lead to chronic muscle tension that can contribute to neck pain and headaches, including migraine. 

Rehabilitation for cervicogenic headache should include both manual therapy and exercise interventions. [6]

Evidence-based treatments include:

• Cervical spine mobilization (movement of spinal segment through range) and manipulation (adjustment to the spine) [4]
• C1-2 Self-sustained apophyseal glides (SNAG). Pressure is applied to a spinal segment while the patient performs the symptomatic movement (for example left neck rotation). [5]
• Deep neck flexor (deep neck muscles that stabilizes and supports the neck) activation, strengthening and endurance training [6]
• Deep neck extensor (deep neck muscles that stabilizes and supports the neck) activation, strengthening and endurance training [6]
• Upper quarter (middle trapezius, lower trapezius) strengthening and endurance training [7]
• Sensory motor training (for example, balance training) [8]
• Cervical proprioceptive training (for example, eye-neck coordination training) [9]

One of the main treatments we have found to be helpful is neuromuscular control retraining.

What this means is retraining your body so that you use your body (including your neck) more efficiently, just like an athlete would do.

 

In effect, and to put it simply, it’s training you to be more powerful.

Nowadays the influence of technology is so pervasive in our lives that the younger generation is starting to have musculoskeletal ailments that were more typical of middle-aged or older people. Many are starting to have neck issues, shoulder issues, visual issues and more. It is apparent that the more we are allowed to develop the way nature intended for us, the healthier for us.

Take for example, wild animals don’t need any formal training, they just learn how to move.

 

Can you imagine what it was like to learn how to toddle for the first time?

• Can you imagine how you would have experienced the ground?
• What was the spirit with which you encountered the steps that lay ahead?
• One of adventure and curiosity?
• Or one of fear and hurting yourself and having to go to the doctor to have it checked?

 

The last question is a bit facetious, but it is meant to express a point:

• That our movement is basically a function of habitual ways of moving and thinking.
• If you’ve trained a certain posture, even inadvertently, you will probably use this strategy.
• If you are afraid to use specific movement strategy, or don’t know how, you probably won’t.

Often, we find, that in adults, it’s difficult for them to be mindful of their movement the same way they were when they were children; they know too much now, or they have other (movement) skills that are very developed (relative to children) that they use to compensate for a lack of fundamentals in the way they move.

 

What does this have to do with neck patients?

We find a successful way to treat necks is to retrain them to move the way Mother Nature intended for them to move, by leveraging their biomechanics to improve power:

• or another way to think of power is to decrease the amount of input (effort/force) for the amount of output (power)

 

Just like in Judo, a small opponent can learn to flip and throw around a big opponent by leveraging their body, we can do the same for every day movements we do.

• We find that teaching people how to breath with appropriate diaphragmatic form goes a long way to helping them stabilize their core and offload accessory muscles (those muscles around your neck) from doing the breathing.
  • The diaphragm is a very strong, big, flexible muscle that is stuck to the lungs and can expand the lungs directly.
  • The accessory muscles of breathing are many muscles around the neck and chest wall that are designed to help “crank” out a little bit more breath if you really need it (e.g., if you’re huffing and puffing), but it’s not efficient (the way the diaphragm is) in breathing for us.
  • However, most of us use accessory muscles to breath, although we used to use the diaphragm as babies and younger and/or fitter people. There are many reasons for this:
    • decreased exercise
    • social norms with the way we project body images (i.e., sucking in the tummy)
    • tight clothing
    • stress
    • poor ergonomics
    • lots of talking
  • Keep in mind that we breath about 25,000 times per day. If you can give your accessory muscles (including neck muscles) a break from all this work, they will thank you. Remember, they were designed to crank out a little extra breath when and if you need it, not to replace the primary breathing muscle, the diaphragm. Using your accessory muscles to breath could be compared to using your calves more to run a marathon – it wouldn’t be an ideal strategy.
  • Also, when you learn to breath diaphragmatically, you learn to activate the Transverse Abdominis, a large corset-like muscle that spans from the bottom of the ribs to the top of the pelvis, and wraps around your torso in a cylindrical shape. Activating this muscles gives you a lot of strength and helps offload your neck muscles.

 

• Then we find it useful to teach people how to use the main neck muscles the way they would have learned to use them (from interacting with the ground when they were babies) when they were babies and children:
  • while they are lying down on their backs, stomachs, and turning their necks.
  • People are often impressed at this point that pain starts to just melt away and they feel more powerful,
  • And they notice that they are using so much more of their body to do the movements.

 

• Then after that, there is not much more fundamentals to neck neuromuscular control other than learning to integrate these lessons in the context of any of the movements you may do in day-to-day life.
  • sitting
  • standing
  • running
  • reaching
  • swinging

 

• Just like there is an ideal neuromuscular control strategy to move the neck, there are also ideal ones for these other movements, and ideal neck neuromuscular control is then integrated into ideal “whole body” neuromuscular control.

 

You can learn more about this by watching our YouTube videos, also accessible through our webpage “Concussion Rehab Video Series“, section on Neuromuscular Control.

[1] Bogduk, N & Govind, J. Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. The Lancet Neurology. 2009, 8(10), 959-68

Charles, A., (2019, Mar 23). Neck Pain and Migraine. Migraine World Summit 2019. https://migraineworldsummit.com/

[2] Hall, T., Briffa, K. & Hopper, D. Clinical Evaluation of Cervicogenic Headache. A Clinical Perspective. Journal of Manual and Manipulative Therapy. 2008, 16 (2), 73-80

[3] Haldeman, S. &  Dagenais, S. Cervicogenic headaches: a critical review.  The Spine Journal 2001, 1 (1), 31-46

[4] Gross. A., Miller, J., D’Sylva, J., Burnie, S.J., Goldsmith, C.H.,…Hoving, J.L. Manipulation or mobilisation for neck pain: a Cochrane review. Manual Therapy. 2010, 15(4), 315-33

[5] Hall, T., Chan, H.T., Christensen, L., Odenthal, B., Wells, C. & Robinson, K. Efficacy of a C1-C2 Self-sustained Natural Apophyseal Glide (SNAG) in the management of cervicogenic headache.  The Journal of Orthopaedic and Sports Physical Therapy. 2007, 37(3), 100-107

[6] Jull, G. & Stanton, W. Predictors of responsiveness to physiotherapy management of cervicogenic headache. Cephalalgia. 2005,25,101-108

[7] Page, P. Cervicogenic headaches: An evidence-led approach to clinical management. The International Journal of Sports Physical Therapy. 2011, 6(3), 254-66

[8] Kristjansson, E., & Treleaven, J. Sensorimotor function and dizziness in neck pain: implications for assessment and management. The Journal of Orthopaedic and Sports Physical Therapy. 2009, 39 (5), 364-77

[9] Jull, G., Falla, D., Treleaven, J., Hodges, P. & Vicenzo, B. Retraining cervical joint position sense: the effect of two exercise regimes. Journal of Orthopaedic Research. 2007; 25 (3): 404-12