Beneficial treatments and optimal care strategies
As a doctor of chiropractic, you know it can be difficult to keep track of new evidence as it emerges. However, this difficulty does not diminish the importance of doing so; DCs must continue to learn and update their expertise as new information appears. This professional insight is meant as a bridge between the frontier of cutting-edge research and its day-to-day application in clinical practice.
Although headaches are an extremely common ailment, patient presentations can vary greatly from person to person, or even between visits. Indeed, “headache” itself is a large category that contains many smaller, distinct types. One type in particular, cervicogenic headache (CGHA), accounts for as many as 20% of all headaches. Cervicogenic headaches are characterized by unilateral pain that starts in the neck, often after movement or injury. Research in this area has made incredible progress in understanding the mechanisms behind CGHA, as well as highlighting beneficial treatments and optimal care strategies.
An overview of CGHA
Broadly speaking, CGHA is classified as unilateral head pain that can be modified by neck or shoulder movement, as well as pressure over the neck and head. It is pain secondary to cervical spine dysfunction, and there is evidence CGHA can be characterized by pain originating in the neck or occipital area, which extends or moves into the face and head.
CGHA is often found concurrently with reduced cervical range of motion, poor neck and head ergonomics, as well as ipsilateral shoulder and arm pain. Symptoms associated with other headache types, such as photophobia or nausea, are rare, and, if present, mild. However, while common symptoms and the basic mechanisms underlying cervicogenic headaches are reasonably well–understood, the exact methodology for diagnosis remains divided between the use of manual examinations and fluoroscopically guided diagnostic blocks. Similarly, the overlap between CGHA and other conditions can make clinical diagnosis difficult.
Patient experience and pain patterns
Although diagnostic criteria help with diagnosis, patients will likely communicate their symptoms using terms they understand. Patients may commonly complain their headaches become worse with neck movement, are provoked by sustained head positions or increase with external pressure over the symptomatic side. Understanding these common descriptions is critical in order for clinicians to differentiate CGHA from other headache subtypes.
Patients may also complain of stiffness or reduced range of motion in their neck, which can be assessed clinically with both passive and active movements. It is not uncommon for patients suffering from cervicogenic headache to experience extensive range–of–motion deficits, often upward of 25% or more of their individual baseline.
How common are CGHA?
A study conducted in Norway investigating prevalence found 4.1% of the population between ages 18 and 65 were experiencing CGHA; however, other investigations have found prevalence as low as 0.4%, though accounting for as many as 15-20% of all headache complaints. Females have been reported to be four times as likely to suffer from CGHA as their male counterparts. Though the prevalence of CGHA can vary widely, likely depending on the population examined, CGHA is a substantial global burden and significantly decreases quality of life.
Having any two of the following four criteria is diagnostic for CGHA:
- Headache developed in temporal relation to the onset of the cervical disorder or lesion.*
- Headache significantly improved or resolved in parallel with improvement in or resolution of the cervical disorder or lesion.
- Cervical range of motion is reduced, and headache is made significantly worse by provocative movements.
- Headache is abolished following diagnostic blockade of a cervical structure or its nerve supply.
*Clinical and/or imaging findings may indicate a cervical spine lesion. Imaging findings are commonly found in asymptomatic patients; they are not indicative of headache causation.
Red flags and referral
When a patient presents with neck pain and headache, DCs must differentiate the associated symptoms as musculoskeletal or pathological to determine if conservative care is appropriate. It is imperative providers identify any red flags during the history and examination, and, if necessary, refer to a specialist.
CGHA can present similarly to a vertebral artery dissection. It is of paramount importance DCs view headache and/or neck pain accompanied by vertigo or unilateral facial paraesthesia as vital warning signs that may precede the onset of stroke by several days or even a few hours. These patients must be sent for emergency care immediately. In addition to the above, there are several red flags that may arise during a history or exam as well as several notable risk factors clinicians must keep in their consideration.
Best-known care options for CGHA
People suffering from CGHA regularly consult providers of manual therapy as part of their headache management. Various options have been proposed for conservative management of CGHA, including joint manipulation and mobilization, massage and endurance-based cervico-scapular exercises. Many of the studies in the most recent overview of systematic reviews included multiple studies with chiropractic spinal adjustments as the intervention, which were classified as manipulations by the authors. A chiropractic spinal adjustment is a manually applied, high velocity and low amplitude (HVLA) force, directed at specific dysfunctional spinal segments to create joint movement at or beyond the normal joint end-range. Neurophysiologically, this is by some seen as distinct from a manipulation, as manipulation is used to refer to HVLA thrusts applied to “healthy” or random spinal segment.
A number of contemporary systematic reviews have shown this kind of HVLA adjustment might be a beneficial option for reducing pain associated with CGHA. Other studies have also suggested this kind of care can also reduce CGHA frequency and disability. In conclusion, there is leading evidence mobilization and HVLA chiropractic adjustments of the cervical spine, either alone or in combination, appear to reduce the pain intensity of, frequency of and disability stemming from cervicogenic headaches.
The possibility of adverse events
As with any medical intervention, adverse events can occur. An adverse event is any unexpected problem that happens during a health care intervention. Adverse events may be mild, moderate or severe and may be caused by something other than the therapy being given. However, whatever the etiology of these events, it is important to be aware of them and take them into consideration during clinical evaluation and care. In favor of best practice guidelines and patient-centered care, sharing possible patient experiences and adverse events when discussing spinal adjustments as part of your care plan for practice members with CGHA is imperative.
Note: This article is based on research compiled by the Chiropractic Future Strategic Plan (CFSP). For more information, view the complete document along with references at . Learn more about the CFSP at chiropracticfuture.org.
MARK SANNA, DC, ACRB LEVEL II, FICC, is the CEO of Breakthrough Coaching. He is a Board member of the Foundation for Chiropractic Progress, a member of the Chiropractic Summit and a member of the Chiropractic Future Strategic Plan Leadership Committee. His recent book, “Cracking the Code: Marketing Chiropractic,” is the number one chiropractic best-seller on Amazon.com. To learn more about Sanna, visit mybreakthrough.com
