Kristin Stockham, SPT
Regis University
Objectives
The learner will be able…
 To state the criteria necessary for a diagnosis of
cerviogenic headache;
 To provide information assessed in the
examination and evaluation for cervicogenic
headache;
 To apply current evidence in development of an
intervention for cervicogenic headache.
This 17 year old female
was referred with the
following information:
Dx: Neck pain & HA
Rx: Evaluate & Treat
S: 2 year hx of R sided
headaches that can be
brought on by too
much reading.
What We Know
Diagnostic Criteria
International Headache Society1
1.
2.
3.
4.
Pain localized in the neck and occiput, which can spread to other areas in
the head, such as forehead, orbital region, temples, or ears, usually
unilateral.
Pain is precipitated or aggravated by specific neck movements or
sustained posture.
At least one of the following:
i.
Resistance to or limitation of passive neck movements.
ii.
Changes in neck muscle contour, texture, tone, or response to active
and passive stretching and contraction.
iii.
Abnormal tenderness of neck musculature.
Radiological examination reveals at least one of the following:
i.
Movement abnormalities in flexion/extension.
ii.
Abnormal posture.
iii.
Fractures, congenital abnormalities, bone tumors, RA, or other distinct
pathology (not spondylosis or osteochondrosis).
Cervicogenic Headache Facts
 Incidence (up to 20% of all headaches)2
 Structural Causes3
 Gross cervical ROM vs. C0-1 & C1-2 ROM 4,5,6
Anatomy
Kinesiology & Biomechanics
C0-1-Convex-concave articulations
Atlas moves in direction of skull
motion7
C1-2: Convex-convex articulations
History
“Heather” is a 17 year old female about to begin her
senior year of high school. She started experiencing
intermittent neck pain and headaches about 2 years
ago. She reports no known MOI, but notes the pain
has steadily increased. She inconsistently tried
chiropractic treatments about 6-7 months ago, but
found no relief. She said her headaches are usually
right-sided and can be brought on with extended
periods of reading. She also notes that sometimes she
experiences “numbness” in her R arm with certain arm
movements. She reports taking 2 extra strength
Tylenol 4x/d.
Initial Examination
Posture
FHP, increased upper thoracic spine kyphosis, rounded
shoulders
UE:
Dermatomes
Myotomes
Reflexes
Normal: C4-T1
Normal: C4-T1
2+: biceps brachii, triceps & brachioradialis
Cervical AROM
RR/LR=60º; FB/BB=60º; RSB/LSB=45º
Supine OA Nodding6
Unable to achieve neutral
Sitting C1-2 Rotation6
RR=2º; LR=5º
Supine C2-3 PIVM8
R=1/6; L=2/6
Supine C3-6 PIVM8
R/L=4/6
Thoracic Spine Mobility
Limited bilateral C7-T4 extension
NDI: NPRS
27: 6/10
Spurlings
ULTT (Median Nerve bias)
Cervical distraction test
Negative = R/L
Negative = R/L
Negative
Muscle Palpation
Pain to the suboccipital mm. specifically superior oblique,
rectus capitis posterior major, semispinalis capitis; muscles
of mastication including bilateral superficial masseters,
anterior and middle temporalis and medial pterygoids. DNF
painful B with decreased strength/endurance (5 seconds)
Radiograph
Evaluation
PIP: “I am unable to complete all my homework on time,
because too much reading makes my headaches and neck
pain worse.”
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

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Pt presents with signs and symptoms consistent with
cervicogenic headache as is seen by:
movement abnormalities of the upper cervical spine (C0-3)
in flexion on radiographic imaging,
decreased cervical lordosis in neutral on radiographic
imaging,
limitation of passive neck movements at C0-3,
abnormal tenderness of neck musculature, and
unilateral headaches and neck pain is aggravated by
prolonged flexion.
Diagnosis/Prognosis
Preferred Practice Pattern B- Impaired Posture
ICD-9 Codes:
 723.1- Cervicalgia
 784.0- Headache
Prognosis:
Based on the following prognostic factors, this patient has a good
prognosis for restoration of upper cervical spine ROM and
decreased HA frequency with physical therapy interventions.
 Positive Factors: young age, active, unremarkable PMH, family
support, motivated.
 Negative Factors: chronic headache duration.
Goals
 Within 2 weeks patient will:
 Achieve at least 10º of R/L C1-2 rotation.
 Be able to read for 15 continuous minutes without
increasing neck pain and exacerbating headaches.
 Within 4-6 weeks patient will:
 Achieve 20º of R/L C1-2 rotation.
 Be able to read for 30 continuous minutes without
experiencing neck pain (0/10) or headaches.
 Decrease headache frequency to no more than 2x/wk.
Plan of Care
Physical therapy 2x/wk for 4-6 weeks including:



Manual therapy treatment utilizing the following:
joint mobilization/manipulation techniques to
limited joints and soft tissue techniques including
soft tissue mobilization to restore muscle motion and
normal tone.
Exercise program for neck specific ROM and nodding
of the upper cervical spine.
NO STRETCHES. This patient has increased midcervical spine joint motion.
Intervention and Evidence
Van Duijn J, Van Duijn AJ, Nitsch W. Orthopaedic manual physical therapy
including thrust manipulation and exercise in the management of a
patient with cervicogenic headache: A case report. J Manual
Manipulative Ther. 2007;15(1):10-24.9
Case Study: the use of manual therapy, including mobilization and
manipulation to the upper neck, and exercise to treat a patient with
cervicogenic headaches. Favorable response. ROM improved as well as
subjective findings (I.e. NDI, pain).
Hoving JA, Koes BW, de Vet HCW, et al. Manual therapy, physical therapy or
continued care by a general practitioner for patients with neck pain.
Ann Intern Med. 2002;136:713:722.10
“Manual therapy is a favorable treatment option for patients with neck
pain when compared with physical therapy or continued care by a
general practitioner”
Interventions
97140: Manual therapy
 Soft tissue mobilization (STM) to posterior neck and

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upper thoracic spine (lamina release)
Supine bilateral OA nodding
Supine unilateral R/L OA nodding
Supine unilateral R/L C1-2 rotation
Sitting C1-2 rotation stretch
Supine unilateral R/L C3-6 facet upglides/downglides
Standing thoracic manipulation
Prone thoracic PA mobilizations/manipulations.
97112: Neuro Re-Education
 Postural re-education
 Supine DNF exercises
Re-Evaluation at visit 10
Initial Evaluation
@ Visit 10
Posture
FHP, increased thoracic spine
kyphosis, rounded shoulders.
Decreased FHP, decreased upper
thoracic spine kyphosis, decreased
rounded shoulders.
Supine OA Nodding
Unable to achieve neutral
FB = 10º
Sitting C1-2 Rotation
RR = 2º; LR = 5º
RR = 15º; LR = 20º
C2-3 PIVM
R = 1/6; L = 2/6
R = 2/6; L = 3/6
C3-6 PIVM
R/L = 4/6
R/L = 3/6
Thoracic Spine
Mobility
Limited B C7-T4 extension
Limited R extension C7-T2
NDI: NPRS
27: 6/10
18: 2/10
Muscle Palpation
Pain to the suboccipital mm.
specifically superior oblique,
rectus capitis posterior major,
semispinalis capitis; muscles of
mastication including bilateral
superficial masseters, anterior
and middle temporalis and medial
pterygoids. DNF painful B with
decreased strength/endurance (5
seconds)
Minimal, intermittent pain to
suboccipital mm specifically superior
oblique, rectus capitis posterior major;
muscles of mastication including
superficial masseter and R medial
pterygoids. DNF strength/endurance
(25 seconds)
Review
Diagnostic Criteria for Cervicogenic Headache- IHS
Clinical Tests – Sitting C1-2 Rotation Test, Cervical
Radiographs Flexion/Extension views, upper cervical
joint mobility.
Treatment – Manual therapy to restore upper neck ROM,
STM to decrease increased muscle tension, DNF training
to increase muscle endurance.
Check for Understanding
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T/F: According to the International Headache Society an
individual must present with bilateral pain in the neck and
occiput to meet the diagnostic criteria for cervicogenic
headache.
Which test does the literature show is the most useful for the
measurement of C1-2 rotation?
1.
Sitting C1-2 rotation
2.
Cervical flexion rotation
3.
General cervical AROM
Which of the following is NOT an appropriate intervention
strategy for a person with cervicogenic headaches presenting
with mid-cervical spine hypermobility?
1.
2.
3.
Manual therapy to the cervical spine
Cervical spine stretching
DNF training
References
1.
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9.
10.
Headache classification subcommittee of the International Headache Society. The
international classification of headache disorders: 2nd edition. Cephaligia.
2004;24 Suppl 1:9-160.
Hall T, Robinson K. The flexion-rotation test and active cervical mobility: A
comparative measurement study in cervicogenic headache. Manual Ther.
2004;9:197-202.
Zito G, Jull G, Story I. Clinical tests of musculoskeletal dysfunction in the
diagnosis of cervicogenic headache. Manual Ther. 2006;11:118-129.
Smedmark V, Wallin M, Arvidsson I. Inter-examiner reliability in assessing
passive intervertebral motion of the cervical spine. Manual Ther. 2000;5(2):97-101.
Hoppenfeld S, Murthy VL. Treatment and rehabilitation of fractures. 1st ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 1999:515.
Aprill C, Axinn MJ, Bogduk N. Occipital headaches stemming from the lateral
atlanto-axial (C1-2) joint. Cephaligia. 2002;22:15-22.
University of St. Augustine for Health Sciences. S3: Advanced evaluation &
manipulation of cranio facial, cervical & upper thoracic spine. St. Augustine, FL.
Gonnella C, Paris SV, Kutner. Reliability in evaluating passive intervertebral
motion. Phys Ther. 1982;62(4):436-444.
Van Duijn J, Van Duijn AJ, Nitsch W. Orthopaedic manual physical therapy
including thrust manipulation and exercise in the management of a patient with
cervicogenic headache: A case report. J Manual Manipulative Ther. 2007;15(1):1024.
Hoving JA, Koes BW, de Vet HCW, et al. Manual therapy, physical therapy or
continued care by a general practitioner for patients with neck pain. Ann Intern
Med. 2002;136:713:722.