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Cervicogenic Headache:
9
Differential Diagnosis
Introduction
Headache is a common complaint in society, with high
personal and socioeconomic impacts.1–3 No age group is
immune from the disorder and headache can present across
the lifespan.4–7 Headache has many causes.8 It may be a
primary disorder such as migraine, tension-type, or cluster
headache or a secondary disorder, in other words, a
symptom complex arising from another recognizable cause.
Cervicogenic headache is a secondary headache, the primary
pathophysiology being in the cervical structures. Patients
often present to musculoskeletal practitioners for manage-
ment of their headaches and, most commonly, for treatment
of cervicogenic, migraine, or tension-type headaches.9, 10
However the evidence is divided for the effect of management
methods such as cervical manipulative therapy and specific
therapeutic exercise for migraine and tension-type
headache.11–22 Yet there is evidence that these methods are
beneficial for cervicogenic headache, the secondary headache
arising from a cervical musculoskeletal disorder.19, 23, 24
It is a reasonable premise that if headache is to be treated
with cervical manipulative therapy and specific therapeutic
exercise, then impairments in the cervical musculoskeletal
system should be major features of the headache syndrome.
Yet migraine and tension-type headache are primary
headaches whose pathogeneses do not lie in cervical
musculoskeletal dysfunction. For example, the biological
markers for the activation of the trigeminovascular system
are present in migraine but not in cervicogenic headache.25
This may be the obvious and simple explanation for the lack
118 Whiplash, Headache, and Neck Pain
of benefit of effect for manipulative and they are not dominant features as they
exercise therapies for many cases of migraine can be in migraine. Both migraine and
and tension-type headache. Further, it has cervicogenic headache are typically (although
been noted that in some studies where not inevitably) a unilateral headache, but
benefits of these therapies were found, migraine can change sides within or between
the headaches were associated with signs attacks, as opposed to cervicogenic headache,
of cervical musculoskeletal impairment,26 which, is side-consistent.30 There is a lack
which could question the original diagnoses of response to drugs such as ergotomine
or subject inclusion criteria in these studies. and sumatriptan in cervicogenic headache,
However it might also point to basic which however, can assist in the diagnosis
problems in differential diagnosis of the of migraine.31–33 Furthermore, cervicogenic
common frequent intermittent headache headache has an unchanged pattern during
types of migraine without aura, tension- pregnancy as opposed to migraine, which
type, and cervicogenic headache because can cease temporarily.34 However reports
of symptomatic overlap or highlight the of headache aggravation with sustained
potential for mixed headache types.27 activities such as computer work are not
This chapter will focus on cervicogenic unique to any headache type, highlighting
headache and its differential diagnosis from the similarity in some activities which
other benign frequent intermittent headache aggravate the different headache types.
types and will discuss some of the factors
which can make this a challenging task in
some patients. The evidence for the nature
Symptomatic overlap
of cervical musculoskeletal impairment in Primary headaches such as migraine with
cervicogenic headache will be presented, aura and cluster headaches have distinct
which also provides the basis for treatment characteristics and are usually reasonably
prescription. readily diagnosed.8, 35 However despite having
characteristic features (Table 9.1), it is well
The clinical diagnosis recognized that there can be difficulties in
of cervicogenic headache differential diagnosis between cervicogenic
headache, the various temporal presentations
The history and clinical presentation of any of migraine without aura, and tension-type
headache contribute in a significant way to headaches because of the considerable
its diagnosis. The International Headache symptomatic overlap between these headache
Society (IHS) has published criteria for types.31, 36, 37 Even though pathophysiological
diagnosis of all recognized headache types.8 processes are different, these headaches
A summary of the main features of the three have a common pathway in the trigeminal
most common benign frequent intermittent system which goes towards explaining this
headache types – migraine without aura, symptomatic overlap.38–42 Studies have been
tension-type, and cervicogenic headache – is conducted examining the reliability of the
presented in Table 9.1 for ready comparison. criteria for differentially diagnosing the
In relation to cervicogenic headache, other three headache types. Those of the IHS8
features in the patient’s history and have been used in studies for migraine
presentation can add to its picture. For and tension-type headache and those of the
example, pain most typically starts in the Cervicogenic Headache International Study
neck in cervicogenic headache whereas it Group (CHISG)33 for cervicogenic headache.
typically starts in the head in migraine.28, 29 In the main, moderate agreement is in evidence
When autonomic symptoms are present, in identifying the headache types.43–46
CHAPTER
Cervicogenic Headache: Differential Diagnosis 119
Table 9.1 A summary of the symptomatic features of cervicogenic, migraine without aura, and tension-type headache
The physical examination cervical flexion test (CCFT), neck flexor and
in differential diagnosis extensor strength, cervical joint position error,
and a measure of cross-sectional area of selected
The criteria for physical impairment in extensor muscles at the C2 level. In agreement
the cervical musculoskeletal system are with previous studies, all individual measures
not defined extensively in the current of physical function in persons reporting a
classification systems. There are two single headache were found to be impaired in
criteria, those of reduced range of neck the cervicogenic headache group when
movement and pain elicited by external compared to the migraine, tension-type
pressure over the occipital or suboccipital headaches, and control groups.58 The excep-
region, ipsilateral to headache.33, 77 While tion was measures of cervical joint position
these are important signs, they lack error where no differences were recorded.
specificity. Tenderness in the occipital or Furthermore there was the expected spread of
suboccipital regions, although present in values in each single measure which indicated
cervicogenic headache, is not unique to the overlap in values between groups. For
the disorder78 and range of movement can example, the measure for sagittal plane range
reduce as a factor of age alone.79 There of motion was 85 ± 11.0° in the cervicogenic
are several studies that have shown the group, 100.5 ± 14.4° in the migraine group,
incidence of cervical musculoskeletal 101.1 ± 14.1° in the tension-type headache
impairment in a cervicogenic headache group, and 98.9 ± 15.1° in the control group.
population using a particular measure of The between-group differences are clear but
impairment.80–86 However if the spread in the magnitude of the standard deviations
values documented for each individual shows, for instance, that a person with 90° of
measure is compared to the spread in sagittal plane motion could be a member of
nonheadache or other headache any group. Thus, of major importance,
populations, there is overlap in values. subsequent analysis revealed that three
This means that a certain absolute value of measures together most strongly separated the
a measure could be recorded in a person groups. Collectively they had 100% sensitivity
with or without cervicogenic headache. and 94% specificity to distinguish cervicogenic
Thus when physical signs (in research or headache. The measures were reduced range
clinical practice) are taken singularly, their of motion (range of extension in this instance)
diagnostic significance is questionable.83, 87 together with the presence of painful joint
Musculoskeletal conditions when con- dysfunction in the upper cervical joints (C0–3)
sidered in their broadest context do not present and with impairment in muscle function as
with an isolated physical sign and usually determined in the CCFT. That is, there was a
present with changes in the articular and pattern of joint, movement, and muscle
muscle systems at the least. We have recently impairment which typified cervicogenic
undertaken a study in which several parame- headache – a pattern that similarly presents in
ters of cervical musculoskeletal function were any musculoskeletal disorder. The histories of
measured concurrently in patients presenting all headache types were prolonged, which
with frequent intermittent headaches to suggests that, even with time, migraine and
investigate whether or not and how well a tension headache sufferers do not automat-
group or pattern of physical features could ically develop secondary neck dysfunction.
distinguish cervicogenic headache.58, 88 The The presentation may sometimes be
measures included range of cervical move- more difficult when a patient reports
ment, manual examination for symptomatic suffering two or more different types of
cervical segment dysfunction, the cranio- headache. Nevertheless it was shown that
CHAPTER
Cervicogenic Headache: Differential Diagnosis 123
that a reduced range of head rotation of the cervical flexor muscles, as measured
was highly sensitive to distinguish in the CCFT, has been demonstrated in
cervicogenic headache subjects with C1–2 cervicogenic headache patients and was
joint dysfunction, determined by manual one of the three impairments that formed
examination, from those with migraine the set of signs that differentiated this
headache and control subjects. This line of headache from migraine and tension-type
research investigating regional movement headache. Commensurate with persons with
restrictions has promise and should be idiopathic neck pain and whiplash,112–114
continued. cervicogenic headache patients have been
shown to have higher levels of activity in
the sternocleidomastoid in the progressive
Manual examination of cervical stages of the test.58, 85, 88 The performances
segmental joint dysfunction of the migraine and tension-type headache
The validity of manual examination as a groups in the CCFT were no different to
clinical test to determine a cervical the control groups.
segmental source of pain is still debated.106 There have not as yet been specific
Nevertheless there are now several studies studies of the activity of the suboccipital
conducted by physiotherapists that have and neck extensors in cervicogenic headache
demonstrated that cervicogenic headache sufferers. There is preliminary evidence
patients can be differentiated from that the semispinalis capitis has reduced
patients with other headache types and cross-sectional area at the C2 level in
nonheadache control subjects through persons with cervicogenic headache,58, 88
the presence of symptomatic upper cervical and degenerative changes (fatty infiltrate)
dysfunction detected by manual have been shown in particularly the
examination.58, 81, 85, 88–90, 107, 108 The presence suboccipital and multifidus muscles in
of dysfunction in the C0–3 segments is patients with chronic whiplash-associated
in accordance with the mechanism for disorders.115 These changes highlight the
cervicogenic headache of convergence need for future investigation of the extensor
of cervical afferents on the trigeminal muscles in the cervicogenic headache
sensory circuit109 and is in line with patient.
the active cervical motion loss in these The pattern of activation in the upper
patients. Relief of cervicogenic headache trapezius muscle has been investigated
with surgical procedures to the lower under the condition of a stressful task.
cervical area have been reported110 and it Elevated activity was found in both
is apparent from clinicians’ patterns of cervicogenic and tension-type headache
treatment that other segments in the upper patients,80, 94 suggesting that both patient
thoracic region may be dysfunctional in groups react to a stressful situation in a
cervicogenic headache sufferers.111 Thus a similar way. To date, the activity of the neck
manual examination should consider all flexors or extensors has not been examined
regions of the cervical and upper thoracic under these conditions.
spines.
Muscle strength and endurance
Alterations in motor control Cervicogenic headache sufferers demonstrate
and cervical muscle properties deficits in the strength of the cervical flexor
There is growing evidence of impaired and extensor muscles whereas the strength
muscle control in cervical musculoskeletal in migraine and tension-type headache
disorders (Chapter 4). Impaired activation groups has not been shown to be different
CHAPTER
Cervicogenic Headache: Differential Diagnosis 125
from control subjects.58, 81, 84, 88 Preliminary headache. There are fibrous connections
data indicate lesser endurance, albeit only between the rectus capitis posterior minor
studied in the neck flexor group in and the cervical dura mater118 and continuity
cervicogenic headache at this time.81, 84, 100 has been observed between the ligamentum
One study has shown that lesser endurance nuchae and the posterior spinal dura at
was not found in patients with migraine.81 the first and second cervical levels.119
Further research is required to investigate Such connections indicate the mechanical
neck muscle strength and endurance and, interdependence of neural, ligamentous,
more specifically, that of the craniocervical and muscular structures in movements and
flexors and extensors now that technology postures of the upper cervical spine, and
is available for this purpose.116 increased activity in cervical muscles has
been demonstrated with noxious stimulation
Muscle length of cervical meningeal tissues.120 It is feasible
Tests of muscle length have been undertaken that changes in movement and attendant
using clinical assessment methods.82, 85, 100 pathophysiological reactions within the
Zito et al.85 compared the incidence of muscle upper cervical region in cervicogenic
tightness in cervical and axioscapular muscles headache could, in some cases, involve the
in persons with cervicogenic headache and upper cervical dura mater.121
migraine as well as those without neck pain Little is known about the sensitivity of
and headache. The incidence of muscle nerve structures to movement in cervicogenic
tightness was significantly higher in the headache. Preliminary clinical observations
cervicogenic headache group (34.9% of all in two cervicogenic headache populations
muscle length tests) than the migraine with suggest an incidence between 7 and 10%.23, 85
aura or control groups, where the incidence These observations were made using the
was low (16.7% and 16.3% respectively). No movement of craniocervical flexion with
one muscle was found to have a higher the patient prepositioned in straight-leg
incidence. What is relevant is that many with raise and brachial plexus provocation test
cervicogenic headache were judged to have positions respectively.122 Further research is
several muscles with normal length, similar required in this field. Nevertheless, when
to migraine and control subjects. This concurs cervical nerve tissues are sensitive to
with the findings of other studies82, 100 and movement, care must be taken in treatment
indicates that some muscle tightness might and especially when retraining the cervical
be present in cervicogenic headache but does flexor muscles, as the movement used may
not strongly characterize this headache type. be provocative of pain (Chapter 14).
might be premature to rule out deficits in symptomatic pattern, they can be confident
joint position sense as a possible impairment of confirming a diagnosis of cervicogenic
in at least some patients with cervicogenic headache with a high degree of certainty.
headache, especially as it was shown that They can be equally certain that if this
the presence of light-headedness was pattern of physical impairment is not
associated with lower odds of achieving present, then the cervical musculoskeletal
long-term relief of headache101 in the clinical impairment is highly unlikely to be
trial testing the effectiveness of manipulative contributing to the cause of the patient’s
therapy and therapy for cervicogenic headache.
headache.23 Further research is needed. Knowledge of the types of musculo-
skeletal impairments associated with
Balance disturbances cervicogenic headache is growing and,
To our knowledge, no studies have studied importantly, they direct the nature of
balance specifically in patients with interventions required (Chapters 13 and
cervicogenic headache. Nevertheless balance 14). There is evidence of the effectiveness
has been studied in patients with migraine of manipulative therapy and specific
and tension-type headache when tested therapeutic exercise for cervicogenic
under various conditions.123, 124 Deficits have headache.19, 23, 24 There are clear indications
been determined in some patients with to use or not use such treatment methods
these headache types, reasoned to reflect in headache management when clear
either dysfunction in the vestibulospinal diagnoses of cervicogenic and migraine
system123 or an impairment in control of and tension-type headache are made.
involuntary oculomotility of central origin.124 Nevertheless, the indications are not so
Research is indicated in patients with clear when patients present with mixed
cervicogenic headache. headache types, with more isolated signs
of cervical musculoskeletal impairment,
or with painful trigger points in the neck or
Conclusion axioscapular muscles in association with
migraine or tension-type headaches. It is
Cervicogenic headache is a distinct possible that manual therapies might assist
secondary headache associated with cervical in headache management in a multimodal/
musculoskeletal impairment. There is a multiprofessional approach to headache
pattern of symptoms that is characteristic management by at least modulating input
of cervicogenic headache, but there can to the trigeminocervical system. However,
be symptomatic overlap with migraine more research needs to be conducted in
without aura and tension-type headaches. this field to provide definitive directives.
If clinicians perform a skilled examination At the present time, such patients should
of the cervical musculoskeletal system and be managed with regular and rigorous
find a pattern of joint, movement, and evaluation of treatment effect to avoid
muscle impairment in conjunction with the prolonged courses of ineffective therapy.