Treatment of Headache:

Cervical or cervicogenic headache is a term used to describe headache caused by abnormalities of the joints, muscles, fascia and neural structures of the cervical region. There are a number of classifications for cervical or cervicogenic headache with differing criteria for physical dysfunction.

Mechanism

The mechanism of production of headache from abnormalities in the cervical region is variable. It may be primarily referred pain caused by irritation of the upper cervical nerve roots. This may be due to damage to the atlantoaxial joint or compression of the nerves as they pass through the muscles. Headache emanating from the lower cervical segments probably originates from irritation of the posterior primary rami, which transmit sensation to the spinal portion of the trigeminocervical nucleus.

Commonly, pain may also be referred to the head from active trigger points. Frontal headaches are associated with trigger points in the suboccipital muscles, while temporal headaches are associated with trigger points in the upper trapezius, splenius capiitis and cervicis, and sternocleidomastoid muscles.

Clinical Features

History

A cervical headache is typically described as a constant, steady, dull ache, often unilateral but sometimes bilateral. The patient describes a pulling or gripping feeling or, alternatively, may describe a tight band around the head. The headache is usually in the suboccipital region and is commonly referred to the frontal, retro-orbital or temporal regions.

Cervical headache is usually of gradual onset. The patient often wakes with a headache that may improve during the day. Cervical headaches may be present for days, weeks or even months. There may be a history of acute trauma, such as a whiplash injury sustained in a motor accident, or repetitive trauma associated with work or a sporting activity.

Cervical headache is often associated with neck pain or stiffness and may be aggravated by neck or head movements, such as repetitive jolting when traveling in a car or bus. It is often associated with a feeling of light-headedness, dizziness and tinnitus. Nausea may be present but vomiting is rare. The patient often complains of impaired concentration, an inability to function normally and depression. Poor posture is often associated with a cervical headache. This may be either a contributory factor or an effect of a headache. The abnormal posture typically seen with cervical headache is rounded shoulders, extended neck and protruded chin. This results in tightness of the upper cervical extensor muscles and weakness of the cervical flexor muscles.

Stress is often associated with cervical headache. It may be an important contributory factor to the development of the soft tissue abnormalities causing the headache or may aggravate abnormalities already present. Thus, it is important to elicit sources of stress in the clinical history.

Exercise-Related Causes of Headache

Benign Exertional Headache

Benign exertional headache (BEH) has been reported in association with weightlifting, running and other sporting activities. The IHS criteria include that the headache:

• Is specifically brought on by physical exercise
• Is bilateral, throbbing in nature at onset and may develop migrainous features in those patients susceptible to migraine
• Lasts from 5 minutes to 24 hours
• Is prevented by avoiding excessive exertion
• Is not associated with any systemic or intracranial disorder.

The onset of the headache is with straining and Valsalva maneuvers such as those seen in weightlifting and competitive swimming. The major differential diagnosis is subarachnoid hemorrhage, which needs to be excluded by the appropriate investigations. It has been postulated that exertional headache is due to dilatation of the pain-sensitive venous sinuses at the base of the brain as a result of increased cerebral arterial pressure due to exertion. Studies of weight- lifters have shown that systolic blood pressure may reach levels above 400 mmHg and diastolic pressures above 300 mmHg with maximal lifts.

A similar type of headache is described in relation to sexual activity and has been termed benign sex headache or orgasmic cephalalgia (IHS 4.6). The management of this condition involves either avoiding the precipitating activity or drug treatment, for example, indomethacin (25 mg three times a day). In practise, the headaches tend to recur over weeks to months and then slowly resolve in some cases they may be lifelong.

Treatment

• Treatment of the patient with cervical headache requires correction of the abnormalities of joints, muscles and neural structures found on examination as well as correction of any possible precipitating factors such as postural abnormalities or emotional stress.
• Treatment of cervical intervertebral joint abnormalities involves mobilization or manipulation of the Cl-2 and C2-3 joints.
• Stretching of the cervical extensor muscles and strengthening of the cervical flexor muscles are important.
• Soft tissue therapy to the muscles and the fascia of the cervical region is aimed at releasing generally tight muscles and fascia (commonly the cervical extensors).
• Active trigger points should be treated with spray and stretch techniques or dry needling.
• Cervical muscle retraining has been shown to be beneficial by itself and in combination with manipulative therapy in reducing the incidence of cervicogenic headache.
• This includes retraining of the deep cervical flexors ,extensors and scapular stabilizers.
• Postural retraining is an essential part of treatment. The patient must learn to reduce the amount of cervical extension by retracting the chin.
• Identification and reduction of sources of stress to the patient should be incorporated in the treatment program.