suffer from migraine headache may feel neck pain in the absence of cervical musculoskeletal dysfunction (Anarte et al., 2019). Ac- cording to Getsoian et al. (2020), while neck pain is characteristic of cervicogenic headaches, it is also reported in up to 80% of mi- graine, tension-type, and mixed migraine and tension-type cases. As such, migraine and cervicogenic headaches have a large over- lap of symptoms, which can lead to misdiagnosis and ineffective treatment. The International Headache Society has developed the following diagnostic criteria for cervicogenic headaches (Verma et al., 2021): A. Any headache fulfilling criterion C. B. Clinical and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck, known to be able to cause headache. C. Evidence of causation demonstrated by at least two of the following: 1. Headache has developed in temporal relation to the onset of the cervical disorder or appearance of the lesion. 2. Headache has significantly improved or resolved in paral- lel with improvement in or resolution of the cervical disor - der or lesion. 3. Cervical range of motion is reduced and headache is made significantly worse by provocative maneuvers. 4. Headache is abolished following diagnostic blockade of a cervical structure or its nerve supply. D. Not better accounted for by another ICHD-3 diagnosis. The Cervicogenic Headache International Society (CHISG) has proposed a different set of criteria for diagnosis cervicogenic headaches (Verma et al., 2021): I. Symptoms and signs of neck involvement: A. Precipitation of head pain, similar to the usually occurring headache: i. By neck movement and/or sustained awkward head positioning, and/or ii. By external pressure over the upper cervical or occipi- tal region on the symptomatic side. B. Restriction of the range of motion in the neck. C. Ipsilateral neck, shoulder, or arm pain of a rather vague, nonradicular nature, or, occasionally, arm pain of a radicu - lar nature. II. Confirmatory evidence by diagnostic anesthetic blockades. III. Unilaterality of the head pain, without side shift. Flexion–rotation test Since facet joints at the occiput/C1, C1/C2, and C2/C3 have been found to refer symptoms to the occipital and suboccipital regions, testing of these joints for dysfunction is typically part of confirming a cervical source of headache pain (Bravo Peterson et al., 2015). The flexion–rotation test (FRT) is used to test move- ment at the C1/C2 facet joints. To complete the flexion–rotation test, the therapist passively positions the patient’s neck in full flex- ion to pretension the structures of the middle and lower cervical spine. Next, the patient’s head is passively rotated in both direc- tions while the flexed position is maintained. Since 40%–60% of total cervical rotation comes from C1/C2, this test is meant to isolate motion at that segment. Criteria for a positive test include (1) ROM restriction with firm resistance and (2) a 10-degree differ- ence in motion between painful and nonpainful sides, and pain provocation (Bravo Peterson et al., 2015).
Dysfunction within the cervical structures, especially the upper cervical segments, can cause headache because of the conver- gence of cervical and trigeminal afferents in the trigeminocervi- cal nucleus. This explains how dysfunction in the cervical spine creates referred pain to the head that is perceived by the patient as headache (Anarte et al., 2019). The convergence of cervical and trigeminal afferents in the trigeminocervical nucleus can be bidirectional (Anarte et al., 2019). This means that individuals who Relevant anatomy The atlas is the uppermost vertebrae (C1) and supports the skull. It articulates superiorly with the occiput, forming the atlanto- oc- cipital joint. This joint is responsible for 33% of cervical flexion and extension (Cervical Anatomy, n.d.) Below the atlas is the axis (C2), which allows for rotation of the cervical spine. In fact, 60% of cervi- cal rotation occurs at this joint (Cervical Anatomy, n.d.). The C1–C3 nerves relay pain signals to the nociceptive trigemino- cervical nucleus of the head and neck. This connection is thought to be the cause of referred pain to the occiput and/or eyes when these is dysfunction in the upper cervical spine. Any structure in - nervated by the C1–C3 spinal nerves can be the source of a cer- vicogenic headache, including joints, discs, ligaments, and mus- culature (Cervical Anatomy, n.d.) C1 innervates the short muscles of the suboccipital triangle, while C2 gives sensory supply to the median and lateral atlantoaxial joints; the prevertebral, sternoclei- domastoid, trapezius, semispinalis and splenius muscles; the dura of the posterior cranial fossa; and the upper spinal canal. Both C2 and C3 spinal nerves supply the facet joints of the adjacent seg- ments. The atlantoaxial ligaments and the dura mater of the spinal canal are innervated by the sinuvertebral nerves stemming from C1–C3 (Inan et al., 2005). Through nerve blocking, it has been determined that the facet joints, especially those at C2-C3, are likely the most common source of cervicogenic headache ( Cervi- cal Anatomy, n.d.). Self-Assessment Quiz Question #19 Cervicogenic headaches are sometimes accompanied by dys- function in the upper cervical spine. When assessing upper cer- vical motion, expected motion in the upper cervical spine is: a. 60% of cervical flexion–extension at C1–C2 and 33% of cervical rotation at C2–C3. b. 33% of cervical flexion–extension at C1–C2 and 60% of cervical rotation at C2–C3. c. 33% of cervical flexion–extension at C1–C2 and 33% of cervical rotation at C2–C3. d. 66% of cervical flexion–extension at C1–C2 and 66% of cervical rotation at C2–C3. Differentiating migraine and cervicogenic headaches Anarte-Lazo et al. (2021) conducted a systematic review and me- ta-analysis to determine if physical examination findings could effectively differentiate migraine from cervicogenic headache. Compared with patients with migraine, patients with cervicogenic headache demonstrate a reduction in range of rotation during the flexion–rotation test (FRT) as well as decreased neck flexion strength as measured by the craniocervical flexion test (CCFT). Compared with tension-type headaches, neck movements do not typically aggravate tension-type headaches but often do aggra- vate cervicogenic headaches (physiopedia.com). Also, compared to patients with migraine headaches and control groups, patients with cervicogenic headaches tend to have increased tightness and trigger points in the upper trapezius, levator scapulae, sca- lene, and suboccipital extensor muscles (physiopedia.com). Serious pathologies that can present with symptoms similar to cervicogenic headache include vascular pathologies of the neck, intracranial pathology, cervical instability, cervical myelopathy, and occipital neuralgia (physiopedia.com).
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