So You’re Telling Me the Problem Isn’t in my Head?
To conclude my series of posts on headaches, I’ll be discussing cervicogenic headaches. Much like tension headaches, these have some very distinct characteristics and are easier to diagnose than migraines or other types of headaches. In my opinion, this is the easiest headache to treat of the three types that I have discussed, but if the treatment isn’t specifically matched to the correct type of headache, no one will like the results. So let’s dig in and discuss the unique features of cervicogenic headaches and what an effective treatment plan looks like for those who are suffering from these headaches.
As you might guess from the name, cervicogenic headaches are caused by an issue with the cervical spine itself, particularly the first two cervical vertebrae and the occiput (base of the skull). These joints account for roughly 50% of the range of motion of the cervical spine, so they are meant to be highly mobile. Thus, when mobility deficits arise (for a variety of reasons), these joints are no longer able to function at an optimal level, and one of the primary symptoms of these mobility restrictions is a headache, This headache has some very specific characteristics. First of all the headache is usually felt on only one side of the head, neck, or face, and the side is consistent (headache symptoms do not change sides). The pain is usually triggered by neck movements such as cervical rotation, or turning your head. The most common way I have heard a patient describe this is an onset of a headache every morning after turning her head to back her car out of her driveway. The final and most distinguishable characteristic of cervicogenic headaches is a significant restriction in cervical rotation range of motion, typically toward the same side as the headache symptoms. In other words, an individual whose symptoms are on the right will usually have a significant loss of rotation toward that side. There is a clinical test known as the “cervical flexion rotation test” that has been studied and validated in several studies as being useful for distinguishing cervicogenic headaches from migraines. This test involves maximally flexing the cervical spine and then performing rotation to each side, looking for a significant difference of asymmetry between the two sides (Source). It is important to note that just because someone has cervicogenic headaches with these characteristic mobility restrictions, that does not necessarily imply that he or she has neck pain. Neck pain may or may not be present and is not indicative of the type of headache that an individual is experiencing. These symptoms (headache only on one side, pain triggered by neck movement, and restricted range of motion to one side) are so distinct that we can reasonably conclude that someone is not suffering from a true cervicogenic headache if these symptoms don’t exist.
Cervical Flexion-Rotation Test
Cervicogenic headaches are not quite as common as tension headaches or migraines, but they are frequently seen in medical practice. Approximately 14-18% of people will experience a cervicogenic headache in their lifetime, while 2.2% of people are suffering from cervicogenic headaches at any given time (Source). Common treatments for cervicogenic headache include epidural steroid injections, botox injections, and medication (tri-cyclic antidepressants and/or muscle relaxers). There is little to no evidence of good long-term outcomes with any of these treatments for those suffering from cervicogenic headaches. In extreme cases, nerve blocking or nerve cutting procedures are sometimes performed, but research has shown poor results with high complication rates including worsening headaches after these procedures (Source). So if common medical management is largely ineffective, we are led to the same place we have ended up in our last two posts – conservative management focused on manual techniques and exercise to address the impairments that are ultimately causing the headache rather than masking the symptoms with medications or injections.
The treatment for a cervicogenic headache should look different than the treatment for a migraine or tension headache. As I discussed before, cervicogenic headaches feature a specific motion restriction that is not caused by trigger points, but rather by stiffness of the joints of the spine itself. Thus, the hallmark interventions that are most supported by evidence are mobilizations or manipulations targeting the upper cervical spine (Source). Without the use of these techniques, it is highly unlikely that an individual will achieve any semblance of lasting relief from these headaches. I know the idea of “adjustments” or “manipulations,” particularly of the neck, make some people nervous, despite very low risk of any type of serious side effects or adverse events (Source). Here is the good news – although these “thrust” techniques may be more effective (Source), “non-thrust” techniques involving less force and pressure can still help facilitate significant reductions in severity of headache symptoms (Source). In other words, a “pop” is not necessary in order to get some significant relief from these headaches, but it is usually associated with a better outcome, particularly if repeated over several sessions. Once headache symptoms are resolved, aerobic exercise and exercises focused on strength and mobility of the neck and shoulders are highly effective at helping prevent recurrences of cervicogenic headaches by continuing to address underlying causes and triggers (Source).
I fully recognize that these 3 posts do not encompass all types of headaches, or even all of the common types of headaches. As I’ve discussed in this post and my previous posts, headaches are extremely common and frequently misdiagnosed, so the purpose of these posts has been to demonstrate that there are several common types of headaches that are highly responsive to non-pharmacologic, conservative interventions centered around manual therapy and exercise. I also hope that these posts have been an encouragement to some of you who have been suffering from headaches with no clear diagnosis and no hope for relief. I plan on producing some free video content with exercise ideas and deeper discussion of these topics in the very near future. In the meantime, if you have questions about your headaches and what can be done to start getting them under control, reach out via email, phone, or social media. I would be glad to start a conversation about what life without headaches could look like for you.