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. 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 is a region of the upper cervical spinal cord 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]
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]
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.
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]
[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
[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
Research & writing: Donna Chan
Last update: February 2019