Cervicogenic Headaches: A Real Pain in the Neck

Cervicogenic headaches (CGH) are quite literally a pain in the neck! They are considered a secondary form of headache which develops from somatic referred pain from the upper cervical spine. More precisely, C1-3 nerves as they converge with trigeminal afferents, forming the trigeminocervical nucleus (15). CGH is a rarer form of headache which occurs insidiously in 1-2.5% of adults aged 30-40 years but has a much higher prevalence of approximately 53% in post whiplash-associated disorders (WAD) (4). For an excellent, in-depth review, check out Dr. Toby Hall’s Masterclass, The Physical Management of Headache.

The management of CGH is challenging for both clinicians and patients alike (so conveniently I’m attempting to summarise it) despite its existence being recognised back in the 1980’s. A multimodal approach which encompasses exercise with or without manual therapy is recommended for initial conservative management (24, 8, 15, 4).

Education

Clinicians should aim to understand concerns or expectations from the patient and address any misinterpretations through advice and reassurance (8). There are mixed reviews regarding the effectiveness of educational interventions, due to low quality evidence and heterogeneity amongst studies (12). However, when used in conjunction with physiotherapy it may provide short-term benefits for individuals post-WAD, irrespective of its method of delivery via handout or verbal communication (26). Although these studies are not exclusive to CGH’s, we can hypothesise that education may offer some benefit considering cervical pain precedes headache symptoms and the prevalence of CGH is far greater post-WAD (4).

One method is reassurance. Discussing that neck pain is common amongst the general population and between 33-65% of episodes will resolve within a year and headaches often tend to coexist may offer some relief (18, 7). Interestingly, our trauma-related demographic are dealt a slightly more favourable outcome. In the absence of poor prognostic factors (e.g. psychosocial factors etc) symptoms often recover within three months (3). Education about the risk factors associated with chronic headaches is also important, these include; obesity, caffeine, medication overconsumption and sleep disturbances (9).

Manual Therapy

Mobilisation and manipulation (MM) are frequently used by therapists for CGH with the former consisting of repetitive, passive oscillatory movement, whereas the latter involves high velocity, low amplitude movement at, or beyond end of range (6). Previous systematic reviews have shown conflicting findings on the efficacy of MM for CGH. Their clinical utility is further questioned because of the multimodal treatment designs, high risk of bias or lack of meta-analysis to quantitatively assess the effect size (19, 11).

Recent meta-analyses have illustrated MM offers short-term relief in symptoms for CGH patients whilst spinal manipulation therapy (SMT) appeared superior in comparison to other manual therapies (6, 10). To further complicate matters, there is little evidence regarding the minimal clinically important change score for CGH’s; making it difficult to ascertain whether poking or prodding someone’s neck offers much clinical benefit.

MM should consist of a maximum of ten sessions over six weeks and be used alongside exercise therapy (8, 9, 19, 24). The exact mechanisms to which MM works is not fully understood, yet it is thought to alter central processing and provide descending inhibition to ease symptoms (15). What it certainly doesn’t do is release fascial tissue, ‘trapped nerves’ or realign vertebrae. Therefore, communicating these findings to patients as part of the shared decision-making process coupled with the potential adverse effects associated with MM is integral to ensure it aligns with their values and preferences (5).

Exercise

In the context of CGH’s, research focused on exercise therapy runs fairly thin. To create more of a headache (pardon the pun), there is little consensus on what constitutes a ‘good’ exercise for this condition as a recent Delphi Survey concluded that 30% of the expert reviewers were unsure regarding the effectiveness of exercise for CGH due to the paucity of evidence (9). To shed some optimism, recommendations surrounding strengthening for cervical pain have illustrated promising results (1, 8, 17, 4).

To fit my bias, just two minutes of theraband resistance training targeting the shoulder girdle five days a week for ten weeks improved symptoms for office workers with cervical pain (1). This was supported more recently where participants performed two sets of four shoulder/neck exercises for eight weeks which led to greater pain relief and health-related quality of life (21). However, it is hard to envisage the load provided from a theraband would be sufficient for younger, more athletic patients suffering with neck pain.

Although these studies are not exclusive to CGH, the condition itself is caused by upper cervical spine disorders and with neck pain believed to affect approximately 30-50% of the population annually (with a greater predisposition in office workers) we can hypothesise these results may offer some benefit (15, 1, 21). Exercises targeting the shoulder girdle also helps integrate global muscles to aid with neck function whilst reducing repeated movements of the cervical spine; a known aggravating factor for CGH (17, 22).

Neck-specific exercises have generated positive results (13). Isometric or endurance-based strengthening with stretching led to similar improvements in headache, neck and arm pain; with the former being more efficacious for patients with severe headache symptoms (25). Although promising, this study was not exclusive to CGH’s. Also, their training interventions were intensive and I’m sceptical towards adherence rates if administered amongst the general population. The results were also obtained at twelve month follow-up, which raises the question whether these improvements were secondary to natural history?

Sensorimotor Training

Neck pain may alter proprioception and postural control due to impairment of cervical and suboccipital muscles secondary to injury. These deficits may lead to symptoms such as dizziness due to their central and reflex connections with vestibular, visual and postural control systems (14, 20, 23). Studies include progressive cervical and oculomotor movements with head repositioning and provide promising results for sensorimotor function and postural control (14). Interestingly, progressive balance training has also elicited improvements (2, 20). Other studies recommend utilising laser pens and unstable surfaces. So if your manager questions why you have someone balancing on a wobble board pointing lasers around the department; explain that the research supports it (17, 23).

Pharmacology & Injections

Epidural corticosteroid injection around the C2/3 facet joint (a dominant nociceptive driver for this condition) has gained popularity due to it being innervated by the third occipital nerve. An interlaminar approach is deemed relatively safe and the mix of local anaesthetic and steroid is likely to elicit an analgesic effect whilst reducing nerve root irritation secondary to inflammation, helping to reduce headache symptoms (15, 17). With regards to medication, there is limited research and the conclusion was that pharmacology appears to offer minimal to no benefit for this condition (17).

Wrapping Up

There remains lots of uncertainty surrounding effective treatments for CGH. Clinicians should incorporate a multimodal programme consisting of manual therapy and exercise with an air of caution recommended for the former; particularly on patients who rely on passive modalities. There appears to be no gold standard with regards to exercise prescription but resistance training with high or low loads seems promising. Finally, for those with particularly irritable symptoms, epidural steroid injections may offer pain relief and reduce reliance on medication. If you are interested in learning more about headache management, check out Dr. Toby Hall’s Masterclass, The Physical Management of Headache.