Headache of Cervical Origin Anita Gross McMaster University Part 1 - PDF document

11-03-24 Headache of Cervical Origin Anita Gross McMaster University Part 1 HEADACHE CLASSIFICATION Headache Prevalence Mechanical Headache n Prevalence (44%) q Tension (38%) q Cervicogenic (2.5 - 4.1%) Non-mechanical HA q Migraine 10% q Chronic daily HA 3% 1

11-03-24 Headache “Red Flags” n Sudden onset of a new severe H/A n Worsening pattern of pre-existing H/A in the absence of obvious factors n H/A associated with q fever, neck stiffness, skin rash, q Hx of cancer HIV or other systemic illness q focal neurological signs other than aura n Moderate to severe H/A triggered by cough, exertion or bearing down n New onset of a H/A during or following pregnancy Cervicogenic Headache - International Headache Society - 2004 - A. Pain, referred from a source in the neck and perceived in one or more regions of the head and/or face, fulfilling criteria C and D B. Clinical, laboratory and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck known to be, or generally accepted as, a valid cause of headache C. Evidence that the pain can be attributed to the neck disorder or lesion based on at least one of the following: 1. demonstration of clinical signs that implicate a source of pain in the neck 2. abolition of headache following diagnostic blockade of a cervical structure or its nerve supply using placebo- or other adequate controls D. Pain resolves within 3 months after successful treatment of the causative disorder or lesion Cervicogenic Headache - International Headache Society – 1988, p27 - n Head pain due to mechanical strain of the upper musculoskeletal cervical complex n Major criteria q Symptoms and signs of neck involvement q Precipitation of comparable head pain by: n Neck movement n Awkward postures n External pressure over upper cervical spine on symptomatic side q Restriction of cervical movement q Ipsilateral neck, shoulder or arm pain. Sjaastad (1998) 2

11-03-24 Cervicogenic Headache n Moderate criteria: q Confirmatory evidence by diagnostic blocks q Unilaterality of head pain (no side shift) (NB) q Head pain characteristics of: n Moderate to severe intensity n Non-throbbing, non-lancing pain n Episodes of varying duration n Fluctuating continuous pain. Cervicogenic Headache n Lesser criteria : q Only marginal effect of idomethician, ergotomine and sumatriptan q 3:1 ratio females q Frequent past history of head trauma (50%) q Photophobia, phonophobia q Dizziness, vertigo, blurred vision q Difficulty swallowing (sign of longus coli deficiency) q Ipsilateral perioccular oedema. Diagnostic Validity of criteria n Cervicogenic Headache could be differentiated from Migraine with: q 100% sensitivity and specificity if 7 of the CGHA criteria were present n Cervicogenic Headache could be differentiated from Tension with q 100% sensitivity and 86.2% specificity if 7 of the CGHA criteria were present. Vincent et al 1999 3

11-03-24 Migraine Headache Classification - International Headache Society – 1988, p26 - n Head pain due to intracranial neuro-vascular dysfunction n Characteristics q Headache attacks lasting 4 - 72 hours q Unilateral but may “side shift” (NB) q Pulsating quality q Moderate to severe intensity (limits ADL) q Nausea & vomiting q Photophobia, phonophobia q May or may not be preceded by “aura”. Tension Headache Classification - International Headache Society – 1988, p26 - n Head pain due to mechanical strain of the upper cervical/cranial muscle complex n Characteristics q Headache lasting 30 min – 7 days q Pressing, tightening, non pulsating quality q Bilateral (NB) q Mild to moderate intensity (no ADL limit) q No or minor nausea, vomiting q Photophobia , phonophobia. Subjective Profile of Cervicogenic HA n Area of pain n Quality of pain n Associated symptoms n Neurological signs n Temporal Pattern n Time and mode of onset n Precipitating & relieving factors n History of onset n Family history 4

11-03-24 Outcomes Subjective Evaluation: n Headache Disability Index (0 to 100) n HA severity n HA relief (time) n HA duration Objective Evaluation: n HA frequency (#/month) n Neck Flexion-rotation test n Drug consumption n IHS-classification n Change in HA days per 4w n Change in mean HA severity in 4w n Mean 4w HA relief score n Change in HA duration per day n Change in # of standard doses - symptomatic drugs Headache Disability Index Jarobson et al 1994 – Neruology 1994:44;837-842 n Reliability q Internal consistency – r=0.89 Cronbach alpha between subscale and total HDI q Test-retest reliability n r=0.76 for functional score n r=0.83 for emotional score n Validity q Construct validity – HDI increased with HA severity and frequency; HA classification or gender did not effect the score The Flexion-Rotation Test and Active cervical mobility a Comparative Measurement Study in Cervicogenic Headache Hall & Robinson 2004 – Manual Therapy 2004:9(4) n Manual examination: q 24 subjects to be C1-2 dominant segment q 4 to be C2-3 dominant segment n Active Rotation ROM in neutral: q No significant difference symptomatic vs asymptomatic p>0.05 n Passive Rotation in flexion: q Difference of 17.1 degrees (towards painful side) in symptomatic group p< 0.001 n Inverse relationship in the 24 C1-2 subjects between rotation in flexion and H/A severity (Pearson correlation of r=-0.8. p<0.001) 5

11-03-24 Headache of Cervical Origin Anita Gross McMaster University Part 2 SPECIFIC ISOMETRIC MUSCLE TESTING Isometric Resisted Test – Flex/Ext Extension Flexion RCP Min Superior Oblique RCP Mj Rectus Capitus Anterior Minor Inferior Oblique Rectus Capitus Anterior Major 6

11-03-24 Isometric Resisted Test – SF/Rot Left Rotation Right Side Flexion Part 3 CGH TREATMENT Management of Mechanical Headache n I Pain control q Manual therapy q Postural control n II Recovery of mobility q Self treatment - exercise q Manual therapy n III Dynamic muscular control q Longus coli / capitus q Lower fibers trapezius . 7

11-03-24 Manual Therapy n Mobilizations n Mobilizations with movement n Mobilization using Neuromuscular techniques (NMT) n Manipulation n Soft tissue techniques n Manual traction Therapeutic Exercise Craniocervical Flexion Start with the pressure biofeedback inflated to 20 mm Hg Make sure your chin and forehead line up Nod your head keeping the big neck muscles soft and bringing the reading up to 22 mm Hg. Work up to 10 X 10 second holds. Then progress to 24,26,28 mm Hg. Sets___ Reps___ 8

11-03-24 Head Lift Start with your head in neutral (chin and forehead lined up), do a chin nod and lift your head while maintaining your chin tucked. Hold for a count of 5 – 10 seconds and return smoothly with your chin still tucked. Sets___ Reps___ Resisted Neck CC Flexion & Oblique Flexion ‘Set’ cervical spine, TA and scapulae then 4a. nod head forward 4b. nod head forward at slight oblique angle Sets___ Reps___ Resisted Neck Static dynamic strengthening ‘Set’ cervical spine, TA and scapulae then a. nod head b. step back maintaining the head nod Sets___ Reps___ 9

11-03-24 Active Range - Neck Start with your head in a. c. neutral then a. extend your head b. bend your head c. tilt your head d. turn your head b. d. Sets___ Reps___ Evidence of Benefit n Moderate GRADE evidence supports the use of C1-C2 self-SNAG exercise for acute cervicogenic headache at short and long term follow-up Treatment Control Std. Mean Difference Std. Mean Difference Study or Subgroup Mean SD Total Mean SD Total IV, Random, 95% CI IV, Random, 95% CI 3.2.2 Chronic Cervicogenic H/A: Acute 4 w of treatment Hall 2007 31 9 16 51 15 16 -1.58 [-2.38, -0.77] -10 -5 0 5 10 Favours experimental Favours control Active Range - Shoulders a. b. c. ‘Set’ your cervical spine, TA & scapula a. clasp your hands behind your back and squeeze your scapulae together b. hold your arms out in front of you and reach forward feeling a stretch between your scapulae. e. c. reach your arms over head. d. d & e. Lean into a wall corner to feel a stretch in the front of your chest – elbows first at shoulder then at eye level Hold for 20 seconds. Sets___ Reps___ 10

11-03-24 Scapular Setting a. Single Arm b. Both Arms ‘Set’ your cervical spine, TA and scapulae, then extend your arm backward Sets___ Reps___ Sets___ Reps___ Evidence of Benefit n Low GRADE evidence suggests eye-neck coordination exercises benefit chronic neck pain and function in the short term Treatment Control Std. Mean Difference Std. Mean Difference Study or Subgroup Mean SD Total Mean SD Total IV, Random, 95% CI IV, Random, 95% CI 11.1.1 Chronic Neck Pain:<11 w of treatment Revel 1994 -21.8 25.2 30 -4.3 19.6 30 -0.77 [-1.29, -0.24] -10 -5 0 5 10 Favours treatment Favours control √ Activate √ Video in ER X Pamphlet Education Advice X Rest Medicine ? Pillow X Collar ? Medication • corticosteriod • methelprednisolone • analgesic ? • antiinflammatory ? • muscle relaxant ? 11

11-03-24 √ Laser Therapy (OA) √ Acupuncture Physical Modalities √ Intermittent ? TENS ? PEMF Traction Patient Wishes, Circumstance 12