Differential diagnosis of cluster headaches Cluster headaches share some common symptoms with other types of headache, but the following characteristics can be used to differentiate a cluster headache from other types: 1. Migraine —more common in women versus men and typically starts younger, in puberty or young adulthood. In addition, migraine often displays nausea and vomiting, phonophobia, and photophobia as distinguishing characteristics. 2. Paroxysmal hemicrania —a unilateral headache last 2 to 30 minutes. It is more common in women, with onset typically at age 34 to 41 years. 3. Tension-type headache —symptoms develop more gradually and are bilateral with a squeezing, bandlike headache. These headaches often start around midday. 4. Trigeminal neuralgia —involves a paroxysmal, electrical, stabbing pain in the trigeminal nerve distribution that last a few seconds. It is often triggered by cold air or light touch in the nerve distribution area. (Weaver-Agostini, 2013). Cervicogenic headaches Cervicogenic headaches are thought to arise from musculoskeletal impairment(s) in the neck. They are described as a lateralized nonthrobbing headache that result from a nociceptive source in cervical spine (Verma et al., 2021). Cervicogenic headaches are commonly associated with suboccipital neck pain but can also be associated with ipsilateral arm discomfort (Racicki et al., 2020). Onset of these headaches may be due to postural strain or chronic tension, acute whiplash injury, intervertebral disc disease, or progressive facet joint arthritis (Carvallo Goodman et al., 2018). Mean age of onset is age 33– 43 years, and the mean duration of symptoms is 7 to 17 years (Hall et al., 2008). The conditions that share symptoms with cervicogenic headaches and which must be differentiated Relevant anatomy The atlas is the uppermost vertebrae (C1) and supports the skull. It articulates superiorly with the occiput, forming the atlanto- occipital 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 cervical rotation occurs at this joint (Cervical Anatomy, n.d.). The C1–C3 nerves relay pain signals to the nociceptive trigeminocervical 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 innervated by the C1–C3 spinal nerves can be the source of a cervicogenic headache, including joints, discs, ligaments, and musculature (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, sternocleidomastoid, 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 segments. 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 ( Cervical Anatomy, n.d.).
during physical therapy assessment include migraine, cervical spondylosis, and tension-type headache. Typical signs and symptoms of cervicogenic headache include: ● Pain starting in the occipital region that spreads anteriorly toward the frontal area. ● Typically bilateral location of symptoms. ● Mild to severe pain intensity. ● Often made worse by neck movements or sustained positions. ● Decreased neck range of motion. ● Trigger or tender points in the cervical muscles. ● Cervical muscle dysfunction or weakness, especially the suboccipital muscles. ● Can have accompanying nausea or light/sound sensitivity. ● History of trauma, disc disease, or arthritis. Dysfunction within the cervical structures, especially the upper cervical segments, can cause headache because of the convergence of cervical and trigeminal afferents in the trigeminocervical 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 suffer from migraine headache may feel neck pain in the absence of cervical musculoskeletal dysfunction (Anarte et al., 2019). According to Getsoian et al. (2020), while neck pain is characteristic of cervicogenic headaches, it is also reported in up to 80% of migraine, tension-type, and mixed migraine and tension-type cases. As such, migraine and cervicogenic headaches have a large overlap of symptoms, which can lead to misdiagnosis and ineffective treatment. Self-Assessment Quiz Question #19 Cervicogenic headaches are sometimes accompanied by dysfunction in the upper cervical spine. When assessing upper cervical 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. 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 parallel with improvement in or resolution of the cervical disorder 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:
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