Neck Solutions

Cervicogenic headache

Cervicogenic headache

From: Pol Merkur Lekarski. 2008 Jun;24(144):549-51 Article in Polish

In 2004 cervicogenic headache (neck related headache) was introduced into ICD-10 classification.The reasons of cervicogenic headache are changes within bones, soft tissue and nervous structures of cervical spine section. The pain may spread to the neck, occipital area of skull, area of jaw and eyeballs, and arms. There are many theories trying to explain spreading of the pain outside the area innervated by C1, C2 and C3 cervical roots. Their common denominator is communication between fibres running in those roots and neurons of trigeminal nerve. Many authors describe a possibility of such connection through the jelly-like nucleus of the trigeminal nerve located in the back funiculi of spinal cord. In this mechanism, the pain conducted via occipital nerves may affect activity of neurons of the trigeminal nerve and influence areas innervated by the trigeminal nerve. In general case history and physical examination are sufficient to make a diagnosis. Additional radiological and imaging examinations support this diagnosis. According to some authors, the necessary condition to make a diagnosis of cervicogenic headache is finding the changes of spondylosis nature of the cervical spine section (neck arthritis or degenerative disc disease) in additional examinations. In doubtful cases, diagnostic blockade of greater occipital nerve, resulting in headache relief, supports finally a diagnosis. Any treatment includes pharmacotherapy, rehabilitation, psychotherapy and surgical methods. The purpose of the study is to view literature on cervicogenic headache which causes many diagnostic problems and hence makes it difficult to choose effective treatment.

Neck muscle isometric contractions in chronic tension type headache

Cervical muscle co-activation in isometric contractions is enhanced in chronic tension type headache patients

From: Cephalalgia. 2008 Jul;28(7):744-51. Epub 2008 May 5

The purpose of the study was to compare the co-activation of cervical agonist and antagonist muscles between people with chronic tension type headache and healthy controls during brief isometric neck flexion and extension contractions. Nine women with chronic tension type headache and 10 matched controls participated. Surface electromyographic (EMG) signals were detected from the sternocleidomastoid and splenius capitis muscles bilaterally during neck flexion and extension contractions of linearly increasing force from 0% to 60% of the maximum voluntary contraction in 3 s. Sternocleidomastoid and splenius capitis EMG average rectified values were estimated at 10% maximum voluntary contraction force increments. During cervical extension contraction, sternocleidomastoid (i.e. antagonist muscle) average rectified values was greater for patients than for controls in the force range 20-60% maximum voluntary contraction. During cervical flexion, the left splenius capitis (i.e. antagonist muscle) average rectified values was greater for chronic tension type headache patients regardless of the force level. Maximum neck flexion and extension force was lower for the chronic tension type headache patients compared with controls.

In conclusion, women with chronic tension type headache demonstrated greater co-activation of antagonist musculature during cervical extension and flexion contractions compared with healthy women. Increased co-activation of antagonist musculature may reflect reorganization of the motor control strategy in chronic tension type headache patients, potentially leading to muscle overload and increased nociception.

Chronic pain and comorbidity with depression and anxiety

Common Chronic Pain Conditions in Developed and Developing Countries: Gender and Age Differences and Comorbidity With Depression and Anxiety Disorders

From: J Pain. 2008 Jul 3; [Epub ahead of print]

Although there is a growing body of research concerning the prevalence and correlates of chronic pain conditions and their association with mental disorders, cross-national research on age and gender differences is limited. The present study reports the prevalence by age and gender of common chronic pain conditions (headache, back or neck pain, arthritis or joint pain, and other chronic pain) in 10 developed and 7 developing countries and their association with the spectrum of both depressive and anxiety disorders. It draws on data from 18 general adult population surveys using a common survey questionnaire (N = 42,249).

Results show that age-standardized prevalence of chronic pain conditions in the previous 12 months was 37.3% in developed countries and 41.1% in developing countries, with back pain and headache being somewhat more common in developing than developed countries. After controlling for comorbid chronic physical diseases, several findings were consistent across developing and developed countries. There was a higher prevalence of chronic pain conditions such as; headaches, back pain, neck pain, arthritis or joint pain among females and older persons; and chronic pain was similarly associated with depression and anxiety spectrum disorders in developed and developing countries. However, the large majority of persons reporting chronic pain did not meet criteria for depression or anxiety disorder. We conclude that common pain conditions affect a large percentage of persons in both developed and developing countries.

Chronic pain conditions including headache, back or neck pain, arthritis or joint pain are common in both developed and developing countries. Overall, the prevalence of pain is greater among females and among older persons. Although most persons reporting pain do not meet criteria for a depressive or anxiety disorder, depression and anxiety spectrum disorders are associated with pain in both developed and developing countries.

Whiplash headache

Whiplash headache is transitory worsening of a pre-existing primary headache

From: Cephalalgia. 2008 Jul;28 Suppl 1:28-31

Acute and chronic whiplash headache are new diagnostic entities in the ICHD-2 (5.3, 5.4). In a prospective cohort study, 210 rear-end collision victims were identified consecutively from police records and asked about head and neck pain in questionnaires after 2 weeks, 3 months and 1 year. The results were compared with those of matched controls who were also followed for 1 year. Of 210 accident victims, 75 developed headache within 7 days. Of these, 37 had also neck pain and complied with the criteria for acute whiplash headache. These 37 had the same headache diagnoses, headache features, accompanying symptoms and long-term prognosis as the 38 without initial neck pain who therefore did not comply with the acute whiplash headache diagnosis. Previous headache was a major risk factor for headache both in the acute and chronic stage. Compared with the non-traumatized controls, headache in the whiplash group had the same prevalence, the same diagnoses and characteristic features, and the same prognosis. Both acute and chronic whiplash headache lack specificity compared with the headache in a control group, and have the same long-term prognosis, indicating that such headaches are primary headaches, probably elicited by the stress of the situation.

Exercise and posture modification for cervicogenic headache

A specific exercise program and modification of postural alignment for treatment of cervicogenic headache: a case report.

From: J Orthop Sports Phys Ther. 2005 Jan;35(1):3-15

An intervention approach consisting of a specific active exercise program and modification of postural alignment for an individual with cervicogenic headache. The patient was a 46-year-old male with a 7-year history of cervicogenic headache. He reported constant symptoms with an average intensity of 5/10 on a visual analogue scale where 0 indicated no pain and 10 the worst pain imaginable. Average pain intensity in the week prior to the initial evaluation was 3/10 secondary to trigger point injections. The patient’s headache symptoms worsened with activities that involved use of his arms and prolonged sitting.

The patient was treated 7 times over a 3-month period. Impairments of alignment, muscle function, and movement of the cervical, scapulothoracic, and lumbar regions were identified. Outcome measurements included headache frequency, intensity, and the Neck Disability Index questionnaire. Intervention included modification of alignment and movement during active cervical and upper extremity movements. The patient also received functional instructions focused on diminishing the effect of the weight of the upper extremities on the cervical spine.

The patient reported a decrease in headache frequency and intensity (1 headache in 3 weeks, intensity 1/10) and a decrease in his NDI score from 31 (severe disability) to 11 (mild disability). The patient also demonstrated improvement in upper cervical joint mobility, cervical range of motion, scapular alignment, and scapulothoracic muscle strength.

Interventions that included modification of alignment in the cervical, scapulothoracic, and lumbar region, along with instruction in a specific active-exercise program to address movement impairments in these 3 regions, appeared to have been successful in relieving headaches and improving function in this patient.

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Exercise and manipulative therapy for cervicogenic headache and neck pain

A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache

From: Spine. 2002 Sep 1;27(17):1835-43

A multicenter, randomized controlled trial with unblinded treatment and blinded outcome assessment was conducted. The treatment period was 6 weeks with follow-up assessment after treatment, then at 3, 6, and 12 months. To determine the effectiveness of manipulative therapy and a low-load exercise program for cervicogenic headache (neck related headache) when used alone and in combination, as compared with a control group.

Headaches related to the neck and arising from cervical musculoskeletal disorders are common. Conservative therapies are recommended as the first treatment of choice. Evidence for the effectiveness of manipulative therapy is inconclusive and available only for the short term. There is no evidence for exercise, and no study has investigated the effect of combined therapies for cervicogenic headache.

In patients with cervicogenic headache, manipulative therapy and a low load exercise regimen each reduced headache frequency and intensity more than no physical therapy. A combination of manipulative therapy and exercise was not better than each individual therapy for these outcomes.

200 participants who met the diagnostic criteria for cervicogenic headache were randomized into four groups: manipulative therapy group, exercise therapy group, combined therapy group, and a control group. The primary outcome was a change in headache frequency. Other outcomes included changes in headache intensity and duration, the Northwick Park Neck Pain Index, medication intake, and patient satisfaction. Physical outcomes included pain on neck movement, upper cervical joint tenderness, a craniocervical flexion muscle test, and a photographic measure of posture. The therapeutic exercise used low load endurance exercises to train muscle control of the neck and scapular region.

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Neck exercises and physiotherapy for tension headache

Efficacy of physiotherapy including a cranio cervical neck exercise training programme for tension type headache

From: Cephalalgia, 2006, 26, 983–991

Tension type headache is the most prevalent headache type. Almost 80% of the total population will experience a tension type headache at some time. Headache is one of the 10 major complaints of patients seen in primary care practices and 47% of all headaches are tension type headaches. ‘Tension-type’ labels a headache classification developed in 1988 by the International Headache Society. It can be divided into an episodic and a chronic version and is commonly more experienced by women (female:male ratio 5 : 4). Because of its high prevalence—1-year prevalence in women 86% and in men 63% and its wide spectrum of disability, tension type headache has a greater socioeconomic impact than any other headache type. In spite of this, only 15% of people with tension type headache seek medical attention and 60% of those reporting severe headaches use only over-the-counter medication, standing a chance of analgesic rebound. Instead of self-management, a therapeutic approach, incorporating both non-pharmacological and pharmacological intervention, shows a success rate of greater than 90% in patients with tension headaches.

Physiotherapy consisted of a threefold approach: conventional Western massage techniques, oscillation techniques and instruction on postural correction. Conventional massage techniques included the following modes: ‘effleurage’ (stroking), ‘petrissage’ (kneading) and ‘friction’ (deep pressure). Mode and intensity were determined by the physiotherapist in accordance with the diagnosis and the patient’s condition as a clinical routine. Oscillation techniques included the use of low-velocity, passive cervical joint mobilization, in which the cervical segments are rhythmically moved following a regimen described by Maitland. The two approaches described above are intended to reduce pain and musculotendinous tension.

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Stress in neck and shoulder pain, tension headaches and fibromyalgia

Similarities in stress physiology among patients with chronic pain and headache disorders: evidence for a common pathophysiological mechanism?

From: The Journal of Headache and Pain. 2008 Apr 14 [Epub ahead of print]

One common feature of chronic musculoskeletal pain and headaches are that they are both influenced by stress. Among these, tension headache, fibromyalgia and chronic neck and shoulder pain appear to have several similarities, both with regard to pathophysiology, clinical features and demographics. The main hypothesis of the present study was that patients with chronic pain (tension headache, fibromyalgia and shoulder neck pain) had stress-induced features distinguishing them from migraine patients and healthy controls. We measured pain, blood pressure, heart rate (HR) and skin blood flow (BF) during (1 h) and after (30 min) controlled low-grade cognitive stressor in 22 migraine patients, 18 tension headache patients, 23 fibromyalgia patients, 29 shoulder neck pain patients and 44 healthy controls. fibromyalgia patients had a lower early HR response to stress than migraine patients, but no differences were found among fibromyalgia, tension headaches, shoulder and neck pain patients. Finger skin BF decreased more in fibromyalgia patients compared to migraine patients, both during and after the test. When comparing chronic pain patients (chronic tension headaches, fibromyalgia and shoulder neck pain) with those with episodic pain (episodic tension headache and migraine patients) or little or no pain (healthy controls), different adaptation profiles were found during the test for systolic and diastolic blood pressure, HR and skin BF in the chronic group. In conclusion, these results suggest that tension headache, fibromyalgia and shoulder neck pain patients may share common pathophysiological mechanisms regarding the physiological responses to and recovery from low-grade cognitive stress, differentiating them from episodic pain conditions such as migraine.

Chronic pain and brain structure

Chronic pain may change the structure of the brain

From: Pain. 2008 Apr 12; [Epub ahead of print]

Recently, local morphologic alterations of the brain in areas ascribable to the transmission of pain were detected in patients suffering from phantom pain, chronic back pain, irritable bowl syndrome, fibromyalgia and two types of frequent headaches. These alterations were different for each pain syndrome, but overlapped in the cingulate cortex, the orbitofrontal cortex, the insula and dorsal pons. These regions function as multi-integrative structures during the experience and the anticipation of pain. As it seems that chronic pain patients have a common “brain signature” in areas known to be involved in pain regulation, the question arises whether these changes are the cause or the consequence of chronic pain. The author suggests that the gray matter change observed in chronic pain patients are the consequence of frequent nociceptive input and should thus be reversible when pain is adequately treated.

Chronic neck pain and cervicogenic headaches

Chronic Neck Pain and Cervicogenic Headaches

From: Current Treatment Options in Neurology 2003, 5:493-498

Potential causes of chronic neck pain and cervicogenic headache

Although this review concentrates on chronic neck pain and cervicogenic headache rather than radiculopathy or myelopathy, these patients may also have arm pain that can be radicular or referred. Radiculopathy implies there is loss of motor or sensory function because of nerve root compression or inflammation, and pain is experienced in a dermatomal distribution. Radiculopathy is usually caused by lateral disc herniation, foraminal stenosis, or a combination. Referred pain implies pain is perceived in a part of the body remote from its source and there is no compression or inflammation of nerve roots. Disorders of the neck can refer pain to the shoulders, arms, face, and interscapular area. Cervical myelopathy results from compression of the spinal cord because of narrowing of the central spinal canal caused by osteophyte formation, thickened, buckled; or calcified ligamentum flavum; or a large disc herniation. Many patients with radiculopathy or myelopathy also have axial neck pain.

Facet joint pain: Facet joints alone are the cause of neck pain in at least 23% of patients with chronic axial neck pain caused by trauma. The combination of pain that arises from facet joints and discs are the cause in an additional 41%. It is important to recognize facet joint pain because it is readily treatable. Facet joints are true synovial joints, and they allow smooth motion, but limit excess motion. Facet joints can be injured acutely, such as in whiplash, or can be damaged from chronic overuse. Facet joints are innervated by the medial branches of the dorsal rami of the spinal nerve (medial branches for short). Each joint is innervated by two medial branches.

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