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Cervicogenic Headache: Evaluation of the Original Diagnostic Criteria
Abstract and Figures
A variety of headaches are frequently associated with the occurrence of neck pain. The purpose of this paper was to describe the adherence to diagnostic criteria of a series of patients enrolled on the basis of two clinical criteria: (1) unilateral headache without side-shift, and (2) pain starting in the neck and spreading to the fronto-ocular area. One hundred and thirty-two patients (36 male and 96 female) entered the study. Sixty-two patients were assigned to Group A (patients fulfilling criteria 1 and 2), 40 to Group B (criterion 2 only) and 12 to Group C (criterion 1, only). Eighteen subjects were excluded because X-rays of the neck were not available. Patients were evaluated regardless of whether or not they fell into one or more of the following diagnostic categories: cervicogenic headache (CEH), migraine without aura (M) and headache associated with disorders of the neck (HN) (IHS definitions). Fulfillment of the diagnostic criteria for CEH was found to be particularly frequent in Group A. A higher frequency of CEH diagnosis was found when two criteria were used (Group A) than in Group B (P = 0.001); in the former group a higher mean number of diagnostic criteria for CEH were also present (P = 0.001). Group A patients more frequently presented pain episodes of varying duration or fluctuating, continuous pain and moderate, non-excruciating, non-throbbing pain than Group B patients (P = 0.04 and P = 0.08, respectively). In Group C patients, the frequency of these two criteria was relatively low (17%) especially of the first mentioned variable. The presence of at least five of the seven 'pooled' CEH criteria (present in > or = 50% of the patients) might be deemed a reliable cut-off point, allowing the headache to be diagnosed as 'probable' CEH. If patients fulfilling M or HN criteria in addition to the CEH criteria are added to the 'pure' CEH group a total of 74% of Group A patients may have a CEH picture. The temporal pattern of pain and the quality of pain in Group A showed good sensitivity and specificity (> or = 75) when compared with Group B; therefore, the chances of diagnosing a definite CEH are significantly more frequent in patients presenting with unilateral pain that also begins as a neck pain. Head/neck trauma and radiological abnormalities in the cervical spine were not significantly associated with CEH, M or HN diagnoses. An improvement of the current diagnostic IHS criteria might make it possible to avoid the existing, partial overlap of CEH with HN and M. Extensive use should be made of the GON, and other, blockades in the routine work-up of CEH, both in the differential diagnosis and in the mixed forms (CEH + M, and CEH + HN), in order to improve the efficiency of the current diagnostic system.
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... Во-первых, такая клиническая характеристика ЦГБ, как односторонняя локализация, выделенная Международной группой по изучению ЦГБ в качестве одного из ее основных диагностических критериев, не уникальна для ЦГБ; односторонняя локализация ГБ свойственна и мигрени без ауры (см. табл. 1) [13][14][15][16]. Во-вторых, фотофобия или фонофобия, сопровождающие приступ мигрени, а также такие описательные характеристики ГБ, как «пульсирующий характер» и «сопровождается тошнотой» (см. ...
... Original articles мы руководствовались диагностическими критериями 3-го издания Международной классификации головных болей (МКГБ-3) и отечественными клиническими рекомендациями по диагностике и лечению мигрени [2,3,7]. При постановке диагноза ЦГБ мы учитывали как диагностические критерии МКГБ-3 [7], так и клинические характеристики ЦГБ, неоднократно опубликованные Международной группой по изучению ЦГБ [14,16,20]. У пациентов с ЦГБ головная боль должна была удовлетворять как минимум двум диагностическим критериям: 1) ГБ развилась в непосредственной временной связи с патологией ШОП (критерий C.1); 2) подвижность ШОП ограниченна, а проведение специальных маневров провоцирует приступ ГБ (критерий C.3). Что касается первого диагностического критерия (C.1), то у всех пациентов ЦГБ имелась на фоне обострения неспецифической боли в шее. ...
... Во-первых, ЦГБ и мигрень имеют такую общую клиническую характеристику, как односторонняя локализация ГБ. Эта характеристика стоит на первом месте в диаг ностических критериях ЦГБ, опубликованных Международной группой по изучению ЦГБ [14,16,35]; она же стоит на первом месте в диагностических критериях мигрени без ауры, опубликованных в МКГБ-3 [7,14,16,20]. Во-вторых, такие симптомы, как боль и напряжение в шее -одни из основных клинических признаков ЦГБ, -достаточно часто сопутствуют и мигрени. ...
... Antonaci et al. proposed seven criteria for cervicogenic headache: (1) Unilateral headache without side-shift, (2) symptoms and signs of neck involvement: pain triggered by neck movement or sustained awkward posture and/or external pressure of the posterior neck or occipital region; ipsilateral neck, shoulder, and arm pain; reduced range of motion, (3) pain episodes of varying duration or fluctuating continuous pain, (4) Moderate, non-excruciating pain, usually of a non-throbbing nature, (5) pain starting in the neck, spreading to oculo-fronto-temporal areas, (6) anesthetic blockades abolish the pain transiently provided complete anesthesia is obtained, or occurrence of sustained neck trauma shortly before onset [106]. Satisfying criteria 1 and 5 qualify for a diagnosis of possible cervicogenic headache. ...
... Satisfying criteria 1 and 5 qualify for a diagnosis of possible cervicogenic headache. Satisfying any additional three criteria advances the diagnosis to a probable cervicogenic headache [106]. ...
... Patience is important for obtaining a detailed and valid and reliable medical history of the patient (anamnesis). For COP, the most reliable features are previous neck trauma, pain that starts in the neck and radiates to the fronto-temporal region, pain that radiates to the ipsilateral shoulder and arm, and provocation of pain by neck movement [106][107][108]. ...
(1) Background and Objectives: The aim of this narrative review was to analyze the neuroanatomical and neurophysiological basis of cervicogenic pain in cervico-cranial pain syndromes, focusing particularly on cervico-orofacial syndromes as a background for the proper diagnosis and non-surgical treatment. Relevant literature on the topic from past 120 years has been surveyed. (2) Material and Methods: We surveyed all original papers, reviews, or short communications published in the English, Spanish, Czech or Slovak languages from 1900 to 2020 in major journals. (3) Results: The cervicogenic headache originates from the spinal trigeminal nucleus where axons from the C1–C3 cervical spinal nerves and three branches of the trigeminal nerve converge (trigeminocervical convergence) at the interneurons that mediate cranio-cervical nociceptive interactions. The role of the temporomandibular joint in the broad clinical picture is also important. Despite abundant available experimental and clinical data, cervicogenic orofacial pain may be challenging to diagnose and treat. Crucial non-surgical therapeutic approach is the orthopedic manual therapy focused on correction of body posture, proper alignment of cervical vertebra and restoration of normal function of temporomandibular joint and occlusion. In addition, two novel concepts for the functional synthesis of cervico-cranial interactions are the tricentric concept of mouth sensorimotor control and the concept of a cervicogenic origin of bruxism. (4) Conclusions: Understanding the basis of neuroanatomical and neurophysiological neuromuscular relations enables an effective therapeutic approach based principally on orthopedic manual and dental occlusal treatment.
... For example, it has been shown that neck pain and disability measured in people with headache (notably primary headache) does not always relate to the presence of cervical musculoskeletal dysfunction (Liang et al., 2022). In contrast, the presence of neck pain can be highly associated with the presence of cervical musculoskeletal impairments in cervicogenic headache (Antonaci et al., 2001). Luedtke et al. (2016) developed a consensus between physiotherapy headache experts on the most useful physical examination tests to examine cervical musculoskeletal impairments in headache patients (Luedtke et al., 2016). ...
Background:
Office workers are specifically vulnerable to headache conditions. Neck pain is reported by almost 80% of patients with headaches. Associations between currently recommended tests to examine cervical musculoskeletal impairments, pressure pain sensitivity and self-reported variables in headache, are unknown. The aim of this study is to evaluate whether cervical musculoskeletal impairments and pressure pain sensitivity are associated with self-reported headache variables in office workers.
Methods:
This study reports a cross-sectional analysis using baseline data of a randomized controlled trial. Office workers with headache were included in this analysis. Multivariate associations, controlled for age, sex and neck pain, between cervical musculoskeletal variables (strength, endurance, range of motion, movement control) and pressure pain threshold (PPT) over the neck and self-reported headache variables, such as frequency, intensity, and the Headache-Impact-Test-6, were examined.
Results:
Eighty-eight office workers with a 4-week headache frequency of 4.8 (±5.1) days, a moderate average headache intensity (4.5 ± 2.1 on the NRS), and "some impact" (mean score: 53.7 ± 7.9) on the headache-impact-test-6, were included. Range of motion and PPT tested over the upper cervical spine were found to be most consistently associated with any headache variable. An adjusted R2 of 0.26 was found to explain headache intensity and the score on the Headache-Impact-Test-6 by several cervical musculoskeletal and PPT variables.
Discussion:
Cervical musculoskeletal impairments can explain, irrespective of coexisting neck pain, only little variability of the presence of headache in office workers. Neck pain is likely a symptom of the headache condition, and not a separate entity.
... Mechanical precipitation of headache is characteristic of CeH, but it is not specific and can happen in migraine [71]. Also, migraine may coexist with CeH [72] and the cooccurrence may increase the number of migraine episodes and analgesic use [73]. Pain location itself may not be enough to distinguish between migraine and CeH as migraine patients can have pain concentrating on occipital and neck regions, and up to 50-72% of patients with CeH report pain in the frontotemporal area [74]. ...
Cranial autonomic symptoms and neck pain have been reported to be highly prevalent in migraine, although they are rarely considered in clinical evaluation. The aim of this review is to focus on the prevalence, pathophysiology, and clinical characteristics of these two symptoms, and their importance in the differential diagnosis between migraines and other headaches. The most common cranial autonomic symptoms are aural fullness, lacrimation, facial/forehead sweating, and conjunctival injection. Migraineurs experiencing cranial autonomic symptoms are more likely to have more severe, frequent, and longer attacks, as well as higher rates of photophobia, phonophobia, osmophobia, and allodynia. Cranial autonomic symptoms occur due to the activation of the trigeminal autonomic reflex, and the differential diagnosis with cluster headaches can be challenging. Neck pain can be part of the migraine prodromal symptoms or act as a trigger for a migraine attack. The prevalence of neck pain correlates with headache frequency and is associated with treatment resistance and greater disability. The convergence between upper cervical and trigeminal nociception via the trigeminal nucleus caudalis is the likely mechanism for neck pain in migraine. The recognition of cranial autonomic symptoms and neck pain as potential migraine features is important because they often contribute to the misdiagnosis of cervicogenic problems, tension-type headache, cluster headache, and rhinosinusitis in migraine patients, delaying appropriate attack and disease management.
... Neck pain (NP) is frequently associated with headache conditions (Ashina et al., 2014;Al-Khazali et al., 2022), although the role of the cervical spine as either the source, coexisting factor, or an area of referred pain is controversial (Antonaci et al., 2001;Liang et al., 2021). The anatomical explanation for a reciprocal influence refers to convergence of afferences from upper cervical structures with trigeminal afferents within the trigeminocervical nucleus (Edvinsson et al., 2020). ...
Background:
Movement control tests (MCTs) are clinical tests to evaluate impairment of movement and associated neuromuscular control and are commonly used to evaluate people with neck pain or headache conditions. The aim of this study was to establish inter-rater
reliability as well as discriminatory and predictive validity for seven MCTs of the upper (UCS) and lower cervical spine (LCS) in office workers with headache or neck pain.
Methods:
Seven MCTs of the UCS (3) and LCS (4) were performed at baseline on 140 office workers which were included in a cluster randomized controlled trial. The occurrences of headache and neck pain were established at baseline (discriminatory validity) and at a 15-month follow-up (predictive validity). Inter-rater-reliability was established in a separate cross-sectional study.
Results:
MCTs showed slight to almost perfect inter-rater reliability but limited discriminatory (baseline) and limited to small predictive validity (15-month follow up) for different subgroups of office workers with headache and/or neck pain. MCTs of the UCS
showed limited discriminatory validity, especially for rotation in participants with headache and neck pain compared to those with headache only (Negative Likelihoodratio: 0.82, 95% CI: 0.69–0.98). Participants with neck pain only and ≥1/4 positive MCTs for the sagittal plane had an increased risk for future neck pain (Relative risk: 3.33, 95% CI: 1.05-10.56).
Discussion:
MCTs of the UCS and LCS are reliable but have only limited to small validity to predict future headache events in office workers. Insufficient sagittal plane movement control may predict neck pain relapses in the future.
Objective:
The main aim of this systematic review is to evaluate the effectiveness of therapeutic exercise for managing pain and disability in patients with cervicogenic headache (CEH).
Methods:
A protocol for this systematic review was published in PROSPERO (CRD42019122703). PRISMA and AMSTAR2 standards were followed. Based on an extensive systematic search in five databases (EMBASE, MEDLINE, CINHAL, PsychInfo and SportDISCUS) and the CENTRAL trial register, two reviewers carefully and independently assessed, selected results, collected data, rated the risk of bias (RoB) of included studies with the Cochrane risk of bias tool, synthesized the available evidence, and rated it using GRADE methodology.
Results:
A total of 12 manuscripts, reporting on 11 studies were included. Most studies showed a high risk of bias (63,63%). Additionally, a great deal of heterogeneity was observed regarding interventions, comparisons, and outcomes and thus, results could not be synthesized in meta-analyses. The quality of the evidence was found to be from low to very low. Significant differences with large effect sizes were found when comparing multimodal exercise vs. control groups on headache outcomes (SMD = 0.73; 95%CI [0.31, 1.14] for headache intensity and SMD = 0.98; 95%CI [0.56, 1.41], for headache frequency).
Conclusions:
Findings indicate that therapeutic exercise may be effective to achieve clinically relevant reductions in headache intensity and frequency as well as disability for patients suffering from cervicogenic headache. However, more high-quality research is needed to gain confidence in this finding and possibly determine optimal types and dosage of therapeutic exercise.
Background:
In 2020, a revised version of the International IFOMPT Cervical Framework was published. This framework provides both physical therapists and educators the necessary information to guide the assessment of the cervical spine region for potential vascular pathologies of the neck in advance of planned Orthopaedic Manual Therapy (OMT) interventions.
Objective:
The objective was to develop a framework flowchart which is useful in clinical practice and education to assist physical therapists to improve the safety of OMT, and apply this in a case report.
Methods:
The framework was developed in co-creation with manual therapy experts, researchers, educators in manual therapy, patients, medical specialists and the Manual Therapy Association in The Netherlands and Belgium. Manual therapists and patients tested the framework for intelligibility and usefulness.
Results:
A framework flowchart is developed and presented, that is easy to use in both clinical practice and education. It is a visual representation of the sequence of steps and decisions needed during the process. A case description of a patient with neck pain and headache is added to illustrate the clinical usefulness of the framework flowchart.
Conclusion:
The framework flowchart helps physical therapists in their clinical reasoning to provide safe OMT interventions.
Objetivo: Contextualizar a cefaleia cervicogênica descrevendo sua etiologia, fisiopatologia, quadro clínico, critérios diagnósticos e tratamentos, para nortear a sociedade médica diante da patologia que está em crescente aumento de sua incidência. Métodos: O presente estudo realizou buscas nas bases de dados PubMed, Nature, Scielo e Wiley, utilizando os descritores cefaleia cervicogênica, e foram analisados trabalhos publicados entre os anos de 1980 e 2022, em todos os idiomas, além das respectivas traduções em inglês. Como fator de inclusão foi considerado: “trabalhos publicados dentro do escopo do estudo dentro do intervalo de tempo citado e relacionados a cefaleia cervicogênica e como fator de exclusão foi considerado: “trabalhos não relacionados ao tema de estudo e com relatos já ultrapassados de acordo com a literatura atual”. Resultados: Foram encontrados 1.319 artigos, após leitura e análise dos artigos foram selecionados 27 artigos, e de acordo com a relevância no assunto fazem parte do escopo do trabalho. Em relação a cefaleia cervicogênica é possível classifica-la como uma cefaleia secundária, atribuída a transtornos cervicais, com sintomatologia heterogênea, geralmente apresentando-se como uma cefaleia unilateral, não latenjante e não excruciante, podendo ser desencadeada por pontos gatilhos em região cervical podendo ainda se apresentar com pródomos autonômicos. Sua etiologia e fisiopatologia tem ligação direta com transtornos cervicais e irritação das fibras aferentes de C1-C2-C3, além da convergência para o núcleo trigêmeo-cervical aumentando a variabilidade de sintomas. Seu diagnóstico é baseado em critérios diagnósticos e existem uma grande variedade de tratamentos com eficácia limitada. Conclusão: A cefaleia cervicogênica pode se apresentar de formas heterogêneas dificultado seu diagnóstico e sendo subdiagnosticada e tratada erroneamente em até 50% dos casos, seu aumento em decorrência da pandemia alerta para a melhoria no diagnóstico e tratamento da cefaleia cervicogênica e os distúrbios osteomusculares associados.
Eleven patients with cervicogenic headache took part in a radiological diagnostic workup related to the head and neck.All the patients were female with a mean age of 43 years (range 25-59) at the onset of the study.Cerebral and cervical computer tomography as well as standard X-ray of the spine were carried out in all patients.Six patients underwent cerebral angiography and six cervical myelography.The different investigations showed no typical characteristic pathology in the group.No indication of a common therapeutic approach in this group of patients could therefore B.E. derived from these investigations.
Patients suffering from migraine, cluster headache and atypical cluster headache, including patients with chronic paroxysmal hemicrania, were studied with respect to corneal temperature, intraocular pressure and corneal indentation pulse amplitude changes during pain attacks. Significant rises in these three parameters were demonstrated during attacks of cluster headache and atypical cluster headache, indicating that intraocular vasodilatation with increased ocular blood flow occurs during attacks. No definite changes were found in migraine. The results strongly suggest that significant pathophysiological differences exist between migraine and cluster headache. The point is stressed that these disorders probably represent separate pathogenetic entities and should be classified as such, and not be grouped together within an ill-defined group of “vascular headache”.
The interval between indomethacin administration and clinical response may be clinically relevant in the assessment of chronic paroxysmal hemicrania and hemicrania continua and other unilateral headache disorders with which they can be confounded. Eight patients with chronic paroxysmal hemicrania (6 women and 2 men) and 12 patients with hemicrania continua (8 women and 4 men) were entered into the study. The patients were given 50 mg of indomethacin intramuscularly (IM) on day 1 and some of them 100 mg IM on day 2 in an open fashion. The usual attack pattern was reestablished prior to the second test.
The mean interval between attacks before the two injections (51 ± 18 minutes) in chronic paroxysmal hemicrania was significantly shorter than the mean after each of the two indomethacin injections (50 mg = 493 ± 251 minutes; 100 mg = 668 ± 211 minutes; P 0.001; Mann‐Whitney test).
In every patient, there was a clear refractory period after indomethacin. Since the first “expected” attack after indomethacin administration did not occur, it can, with reasonable certainty, be assumed that the protective phase was initiated already prior to the time of the next “anticipated” attack. The mean attack duration was 22 minutes (last three attacks prior to test). The mean interval between the onset of two consecutive pretest attacks was 73 minutes. Since the interval between attacks was rather stable, one is, therefore, probably allowed to assume that the absolute protective effect of indomethacin on average had begun somewhere between 22 (mean attack duration) and 73 minutes after indomethacin injection.
Similarly, in hemicrania continua, the time between 50‐mg indomethacin injection and complete pain relief was 73 ± 66 minutes. The pain‐free period after indomethacin injection was around 13 hours (ie, 13 ± 8 hours after 50 mg and 13 ± 10 hours after 100 mg).
The use of a test dosage of 50 mg of indomethacin IM (‘indotest’) gives a clear‐cut answer and may be a useful tool in the diagnostic arsenal in every unilateral headache for a proper clinical assessment. A diagnosis of chronic paroxysmal hemicrania or hemicrania continua is a serious matter because it may imply life‐long treatment with a potentially noxious drug. It is, therefore, of the utmost importance that an ‘indotest’ is carried out in a standard fashion. In the future, the rules set forth in the present context should be followed, at least in scientific studies.
Pain pressure thresholds at cranial and extracranial levels were not significantly modified after indomethacin injection in any of the headaches.
SYNOPSIS
Eighty-one patients were diagnosed as having migraine, tension headache or both according to previously used criteria. Then we performed a standardized interview to determine the frequency and severity of headache characteristics used in the new operational diagnostic criteria of the International Headache Society (IHS). In every patient the original diagnosis fulfilled also the IHS criteria, but in 9 patients the criteria were only fulfilled in half or less of the attacks, and applying the IHS criteria they also achieved an additional diagnosis. In one patient these attacks did not fulfill the pain criteria and in 8 (4 migraine, 4 tension headache) they did not fulfill the criteria for accompanying symptoms. Overall the HIS criteria are sensitive and specific, but they may possibly be improved with regard to accompanying symptoms. The present study suggests that recording of frequency and graded severity of characteristics using a headache diary may further improve the distinction between the different types of headache.
"Chronic daily headache" should not include cervicogenic headache, which in its typical form is a unilateral headache that can be precipitated mechanically; in other words, probably an organic disorder. Chronic daily headache as such should not be included in the IHS classification.
