We have mentioned headaches as an associated symptom with injuries such as whiplash and postural-related neck pain in our past blogs, “Whiplash: Can Physio Help?” and “Office work – A Pain in the Neck?”. However, today I would like to take a deep dive into the different types of headaches and how cervicogenic headaches' treatment and management can vary drastically.
Headache has been known for being the most common complaint of humanity, affecting almost 60 to 70% of the population. Imagine having to experience headaches almost every single day of your life and not having a solution. There are different types of headaches, and they can be classified into 7 groups.
Common types of headaches
1. Headache associated with viral illness i.e. sinusitis, influenza
2. Vascular headache (e.g. migraine, cluster headache)
3. Cervical headache (e.g. referred from the joints, muscles, fascia of the neck region)
4. Tension headache or muscle contraction headache
Less common types of headaches
5. Intracranial causes (e.g. tumour, haemorrhage)
6. Exercise-related headache (e.g. benign exertional headache)
7. Other causes e.g. drugs, psychogenic, post-spinal procedure, post-traumatic)
For this blog, we will be focusing on the more common headache called cervicogenic or neck related headache that we see here at the clinic. This headache has some definitive characteristics:
location: occipital, retro-orbital (behind the eye), temporal
side: unilateral (usually one sided and does not spread to both sides)
type of pain: dull ache
constancy: constant rather than episodic
neurological symptoms: occasionally (paraesthesia = numbness or pins and needles)
history of trauma: common in whiplash injury
triggers: posture, trauma (very mechanically based).
However, cervicogenic headache should not be mistaken for vascular headache, which include migraine, cluster headache, toxic headache and exertional headache. To help differentiate these two types of headache, vascular headache usually demonstrates:
location: frontal or temporal
side: unilateral / bilateral (can spread to both sides)
type of pain: throbbing
neurological symptoms or with aura: common (e.g. visual disturbances, nausea, vertigo, hemiplegia, ophthalmoplegia)
history of trauma: rare
triggers: food, drugs, stress.
True migraineurs not only experience headaches, but 20% of them may also experience a mirage of other symptoms including nausea, vomiting, diarrhea, weight gain, fluid retention and flashing lights.
The mechanism of injury
Cervicogenic headache is a term used to describe headache caused by abnormalities of the joints, muscles, fascia and neural structures of the cervical / neck region. Whereas vascular headaches and their symptoms are mainly due to the vasodilatation (the throbbing) and vasoconstriction (the painless sensory neurological symptoms or aura). Therefore, it is very common to develop cervicogenic headache after an acute traumatic incident such as whiplash injury sustained in a moving vehicle accident or repetitive trauma from work or sporting activities.
The mechanism behind the production of cervicogenic headache can be variable.
Irritation of the upper cervical nerve roots resulting in referral pain / headache. This may be due to the damage to the atlantoaxial joint or compression of the nerve as they pass through the muscles.
Irritation of the lower cervical segments where the posterior primary rami is irritated
Referred headache from active trigger points
Frontal headache = suboccipital muscles
Temporal headache = upper trapezius, splenius capitis and cervicis, and sternocleidomastoid muscles
Trigger points (x) and referral pathway (red): suboccipit, upper trapezius, sternocleidomastoid muscle group respectively
Cervicogenic headache usually features neck pain and stiffness which may be aggravated by head or neck movements, such as repetitive jolting when travelling in a car. Poor posture is often associated with this type of headache. This posture can be typically seen with forward head posture, rounded shoulders with protruded chin in which further shortens the cervical muscles and making the headache worse.
Just by looking at the characteristics and the causes of cervicogenic headache, no wonder its treatment and management vary from other types of headaches.
Prognosis and recovery
Cervicogenic headache may present for days, weeks or even months. Thus, it is very important to assess the underlying cause to help determine treatment pathway and achieve good outcomes.
There are common features that often show up during examination:
tenderness/stiffness in C1-3 segments of your neck
increased tone and muscle shortening in suboccipital and erector spinae muscles
weakness in cervical flexors
active triggers points (mentioned previously)
impaired sensorimotor control
neurotension in upper limbs.
treatment of cervicogenic headache is often based on the assessment findings and is directed towards correcting the abnormalities of the joints, muscles, and neural structures. Therefore, treatment options can include:
trigger point release
passive/ active stretching
strengthening weakened muscle groups
sensorimotor exercises (stability and control)
neural mobility exercises.
Joint mobilisation is the application of direction-specific pressure to move a joint. It helps to reduce joint stiffness and improve range of motion, and provides some degree of pain-relief and de-sensitization. Go over to our Instagram page for video on “Acute Neck Pain” on how our physio mobilise the neck to achieve these benefits.
Trigger point release involves:
Applying sustained pressure to the trigger point (myofascial point) in the muscle belly
Stimulate muscle spindles (sensory receptors) leading to relaxation and reduce sensitivity to pressure and tenderness
Reduce headache intensity and frequency
Improve neck range of motion
Passive/ active stretching can address muscle tension and tone. The physiotherapist places your neck in a sustained position (static/ passive) to target specific muscle tightness. They can also assist you with active movement to end of range to reduce tension (dynamic/ active).
Muscle are dynamic structures where they will adapt (in terms of muscle length) to the position you put it through. Therefore, the forward head posture places the suboccipital muscles in a shortened position and tightens over time.
Strengthening exercises is another treatment technique:
Muscle imbalance is common post-injury, meaning that some of the muscle groups can be under-active or not performing as well as they should
Stronger muscles make activities or physical tasks easier to perform
Improve loading capacity and volume
We have an example of a great exercise for neck pain posted on our Instagram called “Bent Over Row for Neck Pain”.
Sensorimotor exercises are important too.
The exercises improve functional joint stability and control by addressing the quality of movement
Common to lose joint-position sense post-injury (ability to gather information from your sensory receptors i.e. tendons/ligaments/ muscle spindles to determine movement and position)
Can reduce potential clicking in the neck.
Postural re-education involves the following.
A neutral spine posture is a position with the least stress and strain on your body structures
People often describe it as a plumb line through your ears-shoulders-hips-knees-ankles
Nerves travel through multiple structures including joints/ ligaments/ tendons and muscle layers, thus, irritation can occur if the nerve tethers due to some degree of restriction.
Neural glide exercises allow you to gently free up this restriction and reduce its symptoms.
For example of a neural glide exercise, go visit our Instagram page for the video and more details!
Overall, cervicogenic headache is a multifactorial condition where proper assessment is critical in developing the right treatment pathway. Without an action plan, the headache may last for a long time or never resolve.