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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Predictors of disability in migraineurs referred to a tertiary clinic: neck pain, headache characteristics, and coping behaviors
From: Headache. 2008 Apr;48(4):523-8
The aim of this study was to determine if neck pain, select headache characteristics, and migraine related coping response predicted disability in migraineurs referred to a tertiary headache clinic.
Patients seeking treatment at a neurology-based headache clinic were included if they met diagnostic criteria for migraine with or without aura according to the International Headache Society. Subjects completed a self-report headache history form and a detailed headache and neurologic examination. The headache history form assessed: 1) weekly headache frequency; 2) number of weekly severe headaches; 3) presence of migraine-related neck pain; 4) photophobia; 5) phonophobia; 6) headache duration; 7) vomiting; 8) monthly headache-free days; and 9) behavioral coping style. Disability was assessed using a self-report inventory (HIT-6).
Self-reported headache severity, frequency, and headache-free days were strongly associated with disability. The presence of neck pain during migraine and one’s coping response to migraine significantly predicted disability independent of headache characteristics.
These data suggest the need for prospective research exploring the causal mechanisms by which neck pain and coping response influence disability and underscores the importance of multidisciplinary approaches to headache management.
Approach to imaging the patient with neck pain
From: Journal of Neuroimaging 2003;13:5-16
Neck pain is a common complaint of patients seeking care in the outpatient setting, and the cases seen vary widely in severity and cause. A careful history and physical exam, followed by appropriate imaging studies, are essential for the orderly workup and management of neck pain in the ambulatory patient. Available imaging studies include plain film radiography, computed tomography (CT), magnetic resonance, and CT myelography. The general considerations necessary to select the appropriate imaging study are discussed for a broad spectrum of common disorders.
A careful history is key to placing a patient in a preliminary diagnostic category for further evaluation. A patient’s occupation, postural habits, onset of pain, character of pain, and stress at work and/or home should be discussed. The patient should be questioned regarding the presence of associated symptoms, such as gait or bladder dysfunction. Certain symptom groups are suggestive or even diagnostic of certain disease processes.
Acute pain with limited motion, especially in a younger person, is likely to follow trauma or a persistent new activity. Often, the neck muscles are tender in these patients. Middle-aged patients may present with recurrent or persistent pain, sometimes accompanied by tingling in the arms or fingers and/or pectoral pain from an affected C6 nerve root. Extension or lateral gaze may aggravate the pain. This constellation of symptoms, usually without history of trauma, suggests cervical degenerative arthritis or cervical spondylosis. Rheumatoid arthritis of the cervical spine usually occurs after a decade of peripheral joint disease and is characterized by severe neck pain followed by arm pain and progressive radiculopathy or myelopathy.
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Prevalence of cervicogenic headache: Vågå study of headache epidemiology
From: Acta Neurologica Scandinavica Volume 117 Issue 3 Page 173-180, March 2008
OBJECTIVES: To describe the prevalence and various clinical characteristics of cervicogenic headache in the population at large.
METHODS: Cervicogenic headache was searched for in Vågå, Norway, where 1838 18 to 65-year-old citizens, i.e. 88.6% of this age group, underwent an interview/clinical examination. The Cervicogenic Headache International Study Group criteria include: (I) unilaterality of head pain, (II) reduction, range of movement, neck, (III/IV) ipsilateral shoulder/arm discomfort, (V/VI) mechanical provocation of similar pain, objectively or subjectively.
RESULTS: A prevalence of 4.1% was found. In 41 cases with the highest number of cervicogenic headache criteria (’core’ cases), there was a male preponderance (F/M: 0.71). While cervicogenic traits (mechanical precipitation etc.) were frequently present in cervicogenic headache, ‘migraine traits’, like nausea, vomiting, and throbbing seemed to be rarely present. In 97% of the cases, pain exacerbations began in the neck/occipital region.
CONCLUSIONS: Cervicogenic headache may be one of the three large, recurrent headaches. In this series, there was no female preponderance. Nuchal onset of pain is a characteristic trait of cervicogenic headache.
Effectiveness of an educational and physical programme in reducing headache, neck and shoulder pain: a workplace controlled trial.
From: Cephalalgia. 2008 Mar 3
This study was an 8-month controlled trial to evaluate the effectiveness of a workplace educational and physical programme in reducing headache and neck and shoulder pain.
Central registry office employees (n = 192; study group) and 192 peripheral registry office and central tax office employees (controls) in the city of Turin, Italy were given diaries for the daily recording of pain episodes. After 2 months, the study group only began the educational and physical programme.
The primary end-point was the change in frequency of headache and neck and shoulder pain expressed as the number of days per month with pain, and as the proportion of subjects with a >/= 50% reduction of frequency (responder rate). The number of days of analgesic drug consumption was also recorded. Diaries completed for the whole 8 months were available for 169 subjects in the study group and 175 controls.
The baseline frequency of headache (days per month) was 5.87 and 6.30 in the study group and in controls; frequency of neck and shoulder pain was 7.12 and 7.79, respectively. Mean treatment effects [days per month, 95% confidence interval (CI)] on comparing the last 2 months vs. baseline were: headache frequency -2.45 (-3.48, -1.43); frequency of neck pain -2.62 (-4.09, -1.16); responder rates (odds ratio, 95% CI) 5.51 (2.75, 11) for headache, 3.10 (1.65, 5.81) for neck and shoulder pain, and 3.08 (1.06, 8.90) for days with analgesic drug consumption.
The study suggests that an educational and physical programme reduces headache and neck and shoulder pain in a working community.
Predictors of adverse events following chiropractic care for patients with neck pain
From: Journal of Manipulative and Physiological Therapeutics. 2008 Feb;31(2):94-103.
Neck pain is a common and costly complaint in Western society. Studies of neck pain have suggested that manipulation is an effective therapy, particularly when combined with exercise. However, as with other interventions, such as nonsteroidal
anti-inflammatory drug use, cervical manipulation is not without side effects. Although the rare cases of stroke after cervical manipulation are well documented, there is much less known about the more common adverse, but benign events.
Previous observational studies have described the type, frequency, duration, and intensity of adverse events after manipulative treatment of the neck and/or back, but much less is known about the predictors of these events. Only one of these studies has specifically examined cervical manipulation by chiropractors, which found headache and neck disability to be significantly associated with an adverse event. Given this, it remains to be verified whether these or other socio-demographic and/or clinical factors can be identified which are predictive of adverse events after treatment to the neck by chiropractors.
OBJECTIVE: This study examines which variables may predict adverse events in subjects undergoing chiropractic treatment for neck pain.
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Prevalence of Chronic Pain in a Representative Sample in the United States
From Pain Medicine Published article online: 11-Mar-2008
Objective. Chronic pain is a common reason for seeking medical care. We estimated the prevalence of chronic regional and widespread pain in the United States population overall, and by age, sex, and race/ethnicity.
Setting. We examined the data from 10,291 respondents who participated in the 1999–2002 NHANES (National Health and Nutrition Examination Survey) and completed a pain questionnaire. Items allowed classification of chronic (≥3 months) pain as regional or widespread. We used regression models to test the association of sex and race/ethnicity with each pain outcome, adjusting for age.
Results. Chronic pain prevalence estimates were 10.1% for back pain, 7.1% for pain in the legs/feet, 4.1% for pain in the arms/hands, and 3.5% for headache. Chronic regional and widespread pain were reported by 11.0% and 3.6% of respondents, respectively. Women had higher odds than men for headache, abdominal pain, and chronic widespread pain. Mexican-Americans had lower odds compared with non-Hispanic whites and blacks for chronic back pain, legs/feet pain, arms/hands pain, and regional and widespread pain.
Conclusion. The population prevalence of chronic pain in the United States was lower than previously reported, with smaller sex-related differences and some variation by race/ethnicity.
Lower cervical disc prolapse may cause cervicogenic headache: prospective study in patients undergoing surgery
From: Cephalalgia Volume 27 Issue 9 Page 1050-1054, September 2007
In 1983 Sjaastad published for the first time diagnostic criteria for cervicogenic headache. Until now there have been no prospective studies investigating whether cervical disc prolapse can cause cervicogenic headache.
Between July 2002 and July 2003 50 patients with cervical disc prolapse proven by computed tomography, myelography or magnetic resonance imaging were recruited and prospectively followed for 3 months. Patients were asked at different time points about headache and neck pain by questionnaires and structured interviews. These data were collected prior to and 7 and 90 days after surgery for the disc prolapse.
Fifty patients with lumbar disc prolapse, matched for age and sex, undergoing surgery were recruited as controls. Headache and neck pain was diagnosed according to International Headache Society (IHS) criteria. Twelve of 50 patients with cervical disc prolapse reported new headache and neck pain. Seven patients (58%) fulfilled the 2004 IHS criteria for cervicogenic headache.
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The role of cervical dysfunction in migraine: a systematic review
From: Cephalgia 3-Mar-2008
This systematic review evaluates the strength of the evidence for the role of cervical musculoskeletal dysfunction in migraine. In this review, cervical musculoskeletal dysfunction will refer to the abnormal sensory afferentation from cervical region structures contained within the receptive field of the trigeminocervical nucleus.
Electronic database searches using MEDLINE, PubMed and CINAHL were performed, and 17 studies investigating cervical musculoskeletal dysfunction in people with migraine were selected for review. The methodological quality of the included studies was assessed by two independent reviewers using a customized checklist.
The review found that intersubject differences were inadequately reported and controlled, which resulted in grouping of participants with varying pathologies and symptoms. A diverse range of assessment procedures was used by the reviewed studies, which made comparison of their findings difficult. The assessment procedures were mainly used to quantify the degree of cervical musculoskeletal dysfunction, rather than to identify a cause and effect relationship between cervical structure and migrainous pain.
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