Neck Solutions Blog

Physical Examination and Self-Reported Pain Outcomes From a Randomized Trial on Chronic Cervicogenic Headache.

From: J Manipulative Physiol Ther. 2010 Jun;33(5):338-348.

Objective clinical measures for use as surrogate markers of cervicogenic headache pain have not been established. In this analysis, the authors investigate relationships between objective physical examination measures with self-reported cervicogenic headache outcomes.

This was an exploratory analysis of data generated by attention control physical examination from an open-label randomized clinical trial. Of 80 subjects, 40 were randomized to 8 treatments (spinal manipulative therapy or light massage control) and 8 physical examination over 8 weeks. The remaining subjects received no physical examination. Physical examination included motion palpation of the cervical and upper thoracic regions, active cervical range of motion and associated pain, and algometric pain threshold evaluated over articular pillars.

Self-reported outcomes included cervicogenic headache and neck pain and disability, number of cervicogenic headaches, and related disability days. Associations between physical examination and self-reported outcomes were evaluated using generalized linear models, adjusting for sociodemographic differences and study group.

At baseline, number of cervicogenic headache and disability days were strongly associated with cervical active range of motion. Neck pain and disability were strongly associated with range of motion-elicited pain but not later in the study. After the final treatment, pain thresholds were strongly associated with week 12 neck pain and disability and cervicogenic headache disability and disability days.

Cervical range of motion was most associated with the baseline headache experience. However, 4 weeks after treatment, algometric pain thresholds were most associated. No one physical examination measure remained associated with the self-reported headache outcomes over time.

Effect of neck exercises on cervicogenic headache: a randomized controlled trial.

From: J Rehabil Med. 2010 Apr;42(4):344-9

This study compared the efficacy of three 12-month training programmes on headache and upper extremity pain in patients with chronic neck pain. A total of 180 female office workers, with chronic, non-specific neck pain were randomly assigned to 3 groups. The strength group performed isometric, dynamic and stretching exercises. The endurance group performed dynamic muscle and stretching exercises. The control group performed stretching exercises. Pain was assessed with a visual analogue scale. Each group was divided into 3 subgroups according to headache intensity.

At the 12-month follow-up headache had decreased by 69% in the strength group, 58% in the endurance group and 37% in the control group compared with baseline. Neck pain diminished most in the strength group with the most severe headache. In the dose analysis, one metabolic equivalent per hour of training per week accounted for a 0.6-mm decrease in headache on the visual analogue scale. Upper extremity pain decreased by 58% in the strength group, 70% in the endurance group and 21% in the control group.

All of the training methods decreased headache. However, stretching, which is often recommended for patients, was less effective alone than when combined with muscle endurance and strength training. Care must be taken in recommending the type of neck exercises to be undertaken by patients with severe cervicogenic headache.

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Cervicogenic headache: evidence that the neck is a pain generator.

From: Headache. 2010 Apr;50(4):699-705

This review was developed as part of a debate, and takes the “pro” stance that abnormalities of structures in the neck can be a significant source of headache. The argument for this is developed from a review of the medical literature, and is made in 5 steps. It is clear that the cervical region contains many pain-sensitive structures, and that these are prone to injury. The anatomical and physiological mechanisms are in place to allow referral of pain to the head including frontal head regions and even the orbit in patients with pain originating from many of these neck structures. Clinical studies have shown that pain from cervical spine structures can in fact be referred to the head. Finally, clinical treatment trials involving patients with proven painful disorders of upper cervical zygapophysial joints have shown significant headache relief with treatment directed at cervical pain generators. In conclusion, painful disorders of the neck can give rise to headaches, and the challenge is to identify these patients and treat them successfully.

The con noted: Cervicogenic headache is a well-recognized headache syndrome, distinguishable from other primary and secondary headaches. Although in some cases a cervical lesion may be detected in connection with the headache, many cervicogenic headache patients have no demonstrable lesion. Besides, most of the frequent cervical diseases, such as spondylosis and disc herniations, do not present with headache of the cervicogenic type. This suggests that the neck is not an independent headache generator. Cervicogenic headache may depend in addition on a central predisposition counterpart, leading to the activation of the trigeminovascular system and pain generation.

The Prevalence of Neck Pain in Migraine

From: Headache. 2010 Jan 20. [Epub ahead of print]

To determine the prevalence of neck pain at the time of migraine treatment relative to the prevalence of nausea, a defining associated symptom of migraine. This is a prospective, observational cross-sectional study of 113 migraineurs, ranging in attack frequency from episodic to chronic migraine. Subjects were examined by headache medicine specialists to confirm the diagnosis of migraine and exclude both cervicogenic headache and fibromyalgia. Details of all migraines were recorded over the course of at least 1 month and until 6 qualifying migraines had been treated. For each attack, subjects recorded the presence or absence of nausea as well as the intensity of headache and neck pain (graded as none, mild, moderate, or severe).

Subjects recorded 2411 headache days, 786 of which were migraines. The majority of migraines were treated in the moderate pain stage. Regardless of the intensity of headache pain at time of treatment, neck pain was a more frequent accompaniment of migraine than was nausea. Prevalence of neck pain correlated with chronicity of headache as attacks moved from episodic to chronic daily headache.

In this representative cross-section of migraineurs, neck pain was more commonly associated with migraine than was nausea, a defining characteristic of the disorder. Awareness of neck pain as a common associated feature of migraine may improve diagnostic accuracy and have a beneficial impact on time to treatment.