HEADACHES AND MIGRAINES
Cervicogenic headaches (neck related headaches)
These headaches are of cervical spine origin (the neck). These headaches were historically difficult assess and manage because their aetiology and pathophysiology were not fully understood. They maybe related to posture, whiplash, previous concussion injuries with neck pain and related to repeated loading. Notably, headaches that develop 3 months or greater following a concussion event are more likely to be related to be related to the cervical spine and not generally a result of brain or head injury at that point. Generally, headaches may stem from vascular origin (potentially migraineurs), in addition to muscular (tension-type headaches), or inflammation related to head or neck injuries.
Characteristics of cervicogenic headache
• Unilateral pain potentially radiating from a facet “lock” back of the head
• Evidence of cervical spine involvement during manual examination with your physiotherapists
• Can be reproduced with palpation and manual application to specific points in the head/neck region
• Generally aggravated with sustained neck positions
• Normal imaging (most of the time!)
There is a common pathway proposed for cervicogenic headache, with underlying pathophysiology related to the convergence of sensory input from the upper segments of the cervical through the trigeminal spinal nucleus. Input from upper cervical facets, cervical muscles, vertebral and internal carotid arteries, C2-3 discs, dura mater or the upper spinal cord and input from the posterior cranial fossa. Furthermore 44 % of patients with CGH have concurrent temporomandibular joint (TMJ) influence in addition to this. Evaluation of the jaw AND the neck is important in each case to ensure appropriate diagnosis and management upon examination.
Patient may have symptoms that mimic a migraine including nausea (plus minus vomiting), photophobia, blurred vision and phonophobia. They may be triggered by sustained neck postures or neck movement and can refer into the frontal, temporal, orbital (eye areas) and base of skull. Importantly some migraines (upon ruling out vascular origin) can be related to the musculoskeletal system with involvement from the upper neck/jaw region. It is critical for thorough and safe screening to take place with your physiotherapist to assess this if you have not already been to your GP and they will refer on if they suspect your symptoms are not musculoskeletal in origin.
Red flags
Your physiotherapist will be experienced in assessing for red flags and indications in your history that may warrant further medical assessment or imaging and referral onwards. A thorough subjective assessment is carried out to ensure there is no indication from the assessment that there is potential vascular involvement or sinister pathology that warrants further investigation. Notably, vertebral artery dissection presents with concomitant neck pain and headaches, so it is crucial to identify early on and refer on for further medical evaluation. Other red flags include:
1. Headaches that get worse over time
2. Sudden onset of severe head pain
3. Headaches in combination with high fever, rash and neck stiffness
4. Headache following a head injury
5. Profound dizziness and visual disturbances (though some people may have benign visual disturbances in combination with their headaches)
Physiotherapy Treatment
Your therapist will assess muscle length, range of joint movement, patterns of activation and strength of the spinal muscles and postural stabilizers to evaluate underlying structural causation and form a treatment plan. The history determines the aetiology and likely response and therefore expectations from the treatment plan. And following the initial assessment it is important to have an open discussion about the potential need for multidisciplinary involvement which is person dependent. Other disciplines that may need to be involved include neurology, psychology, or maxillofacial input and dental expertise.
References:
Page P. (2011). Cervicogenic headaches: an evidence-led approach to clinical management. International journal of sports physical therapy, 6(3), 254–266.
Zhou, Y. (2010). Cervicogenic headache: It is time to call for more attention. BJMP, 3(3).
These headaches are of cervical spine origin (the neck). These headaches were historically difficult assess and manage because their aetiology and pathophysiology were not fully understood. They maybe related to posture, whiplash, previous concussion injuries with neck pain and related to repeated loading. Notably, headaches that develop 3 months or greater following a concussion event are more likely to be related to be related to the cervical spine and not generally a result of brain or head injury at that point. Generally, headaches may stem from vascular origin (potentially migraineurs), in addition to muscular (tension-type headaches), or inflammation related to head or neck injuries.
Characteristics of cervicogenic headache
• Unilateral pain potentially radiating from a facet “lock” back of the head
• Evidence of cervical spine involvement during manual examination with your physiotherapists
• Can be reproduced with palpation and manual application to specific points in the head/neck region
• Generally aggravated with sustained neck positions
• Normal imaging (most of the time!)
There is a common pathway proposed for cervicogenic headache, with underlying pathophysiology related to the convergence of sensory input from the upper segments of the cervical through the trigeminal spinal nucleus. Input from upper cervical facets, cervical muscles, vertebral and internal carotid arteries, C2-3 discs, dura mater or the upper spinal cord and input from the posterior cranial fossa. Furthermore 44 % of patients with CGH have concurrent temporomandibular joint (TMJ) influence in addition to this. Evaluation of the jaw AND the neck is important in each case to ensure appropriate diagnosis and management upon examination.
Patient may have symptoms that mimic a migraine including nausea (plus minus vomiting), photophobia, blurred vision and phonophobia. They may be triggered by sustained neck postures or neck movement and can refer into the frontal, temporal, orbital (eye areas) and base of skull. Importantly some migraines (upon ruling out vascular origin) can be related to the musculoskeletal system with involvement from the upper neck/jaw region. It is critical for thorough and safe screening to take place with your physiotherapist to assess this if you have not already been to your GP and they will refer on if they suspect your symptoms are not musculoskeletal in origin.
Red flags
Your physiotherapist will be experienced in assessing for red flags and indications in your history that may warrant further medical assessment or imaging and referral onwards. A thorough subjective assessment is carried out to ensure there is no indication from the assessment that there is potential vascular involvement or sinister pathology that warrants further investigation. Notably, vertebral artery dissection presents with concomitant neck pain and headaches, so it is crucial to identify early on and refer on for further medical evaluation. Other red flags include:
1. Headaches that get worse over time
2. Sudden onset of severe head pain
3. Headaches in combination with high fever, rash and neck stiffness
4. Headache following a head injury
5. Profound dizziness and visual disturbances (though some people may have benign visual disturbances in combination with their headaches)
Physiotherapy Treatment
Your therapist will assess muscle length, range of joint movement, patterns of activation and strength of the spinal muscles and postural stabilizers to evaluate underlying structural causation and form a treatment plan. The history determines the aetiology and likely response and therefore expectations from the treatment plan. And following the initial assessment it is important to have an open discussion about the potential need for multidisciplinary involvement which is person dependent. Other disciplines that may need to be involved include neurology, psychology, or maxillofacial input and dental expertise.
References:
Page P. (2011). Cervicogenic headaches: an evidence-led approach to clinical management. International journal of sports physical therapy, 6(3), 254–266.
Zhou, Y. (2010). Cervicogenic headache: It is time to call for more attention. BJMP, 3(3).