Headache Tree
No
Red Flags:
Worst HA of life, wake up at night, altered/LOC
Dizziness
Laterality of Sx?
Unilateral
(or U on both sides)
Bilateral
(sx reproduced B at the same time)
Tension HA
Tx: Pharmacological
Neck Motion,
Valsalva, Pressure
over C1-C3
Refer to MD/ER
Refer to Vestibular Sheet
Palpation: Sx may occur
ipsilaterally or shift to
contralateral side
Palpation: sx occur ipsilaterally
Multiple, but not
neck motion
Triggers?
Multiple, but not
neck motion
Alcohol, Occurs at
predictable times/day
Cervicogenic HA
Tx: PT (jt mobs/manips, stretching, STM,
strengthening, postural/NM re-education,
TENS, biofeedback) and/or
Pharmacological
Cluster HA
Tx: Pharmacological
Migraine HA
Tx: Pharmacological
None
Hemicrania Continua HA
Tx: Pharmacological
Adapted from Biondi (2005)
Differential Dx for Headaches
Biondi (2005)
Female : Male
Ratio
Laterality
Location
Duration
Triggers
Associated
Symptoms
Pharmocological
Treatment
Cervicogenic
Migraine
Cluster
Hemicrania
continua
F>M
Tension
F>M
F>M
M>F
Unilateral (no
sideshift)
Occipital to
frontoparietal and
orbital
Intermittent or
constant
Neck motion,
valsalva, pressure
over C1-3
Absent/similar to
migraine, but
milder
Decreased neck
motion
Anesthetic block,
migraine tx,
antiepiletic drugs,
antidepressant
(serotonin and
norepinephrine
reuptake inhibitors,
NSAIDs
Unilateral with
sideshift
Frontal, orbital,
temporal,
hemicranial
4-72 hrs
Unilateral without
sideshift
Orbital, temporal
Unilateral without
sideshift
Frontal, temporal,
orbital, hemicranial
Bilateral
15-180’ several
times a day
Multiple but neck
Alcohol, HA occur
motion not typical
at predicitable
times of day
Nausea,
Autonomic sx:
vommitting,
tearing, rhinorreha,
phono/photophobia, ptosis, miosis, all
visual scotoma
ipsilateral to pain
Constant with
attacks
None typically
Days to weeks
Typical migraine
(ergots, triptans)
Excellent response
to indomethacin
Oxygen, ergots,
triptans
Autonomic sx may
occur
F>M
Frontal, occipital,
circumferential
Multiple but neck
movement not
typical
Occasional
decreased appetite,
photo or
phonophobia
Simple analgesics,
muscle relaxants,
mediations used in
migraine tx
Cervicogenic Treatment Tree
Limited ROM:
Tx: Self stretches, PROM
Joint Mobility Assessment:
Central/U PAs cervical and thoracic,
downglides, OA, AA*
Tx: manips (per thoracic CPR or
qualified cervical therapist), mobs
*Test with Cervical Flexion Rotation Test (Hall 2010)
and HEP of self rotation SNAGS (Hall 2007)
Soft Tissue Assessment:
 Muscle Tension or TrP (UT, levator scap,
suboccipitals, SCM, scalenes, paraspinals)
Tx: STM, ischemic compression/suboccipital
release, stretching, e-stim
Strength/Endurance
Assessment:
Deep cervical flexors, scapular
stabilizers
Tx: strengthening/endurance
TEs, NM re-ed**
** Test with Craniocervical Flexion Test
(Harris et al 2005) and possible tx of low
load cervical motor control TEs (Jull 2002)
If Any Radicular Like Symptoms:
Assess for Radiculopathy CPR,
nerve tension tests, and/or TrP (ie:
SCM, scalenes)
Postural Assessment:
Forward head, rounded
shoulders, or  of thoracic
kyphosis or cervical lordosis
Tx: postural/NM re-ed,
biofeedback, pt education/
-ergonomics
Further Pain Management:
- Pt education for fear avoidance
- Refer out for
pharmacological/injection/behavior tx
- Possible surgical intervention
Cervicogenic Headache Diagnosis
Hadelman et al (2001)
Subjective
Location of Pain
Pain Characteristics
Pain Increases With
Objective
Cervical ROM
Palpable Findings
Response to Blockade
Radiologic Findings (possible)
Neck Trauma
Other
Starts neck, occipital
Ipsilateral, vague, nonradicular neck/shoulder/arm
Occasional radicular symptoms
Forehead, temporal, whole, frontal, orbital
Unilateral without sideshift or Bilateral
Moderate-severe
Non-throbbing/ dull, aching
Non-lancinating
Becomes more continuous
Varying duration
Neck movement
Posture
Awkward head positioning
Pressure over ipsilateral cervical/occipital area
Decreased PROM
Tender neck muscles
Change in neck muscle properties
Pain on C2/3 facet palpation and dermatome
Occipital nerves, facets, or nerve roots abolish or relieve pain
Flexion/extension abnormalities
Fracture
Congenital anomaly
Tumor/rheumatoid arthritis, not spondylosis
Possible
Nausea, vomiting
Edema, flushing
Dizziness
Phono/photophobia
Blurred vision
Dysphagia
No effect with indomethacin, ergotamine, or sumatripan
References
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Headache Reports 5. (2001): 387-392. 11 Nov 2010.
Biondi, David M. "Cervicogenic Headache: Diagnostic Evaluation and Treatment Strategies." Current Pain and Headache Reports 5. (2001): 361-368. 11 Nov 2010.
Biondi, David M. "Cervicogenic Headache: A Review of Diagnostic and Treatment Strategies." Journal of the American Osteopathic Association 105.4 (2005): S16-S22. 11 Nov
2010.
Biondi, David M. "Cervicogenic Headache: Mechanisms, Evaluation, and Treatment Strategies." Journal of the American Osteopathic Association 100.9 (2000): S7-S14. 11
Nov 2010.
Child’s, Cleland, Elliot, Teyhen, Wainner, Whitman, Sopky, Godges, Flynn. “Neck Pain: Clinical Practice Guidelines linked to the International Classification of Functioning,
Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association.” J Orthop Sports Phys Ther 2008; 38(9):A1-A34.
Falla, D. "Unraveling the Complexity of Muscle Impairment in Chronic Neck Pain." Manual Therapy 9. (2004): 125-133. 28 Nov 2010.
Fernandez-De-Las-Penas, Cesar, Marta Perez-De-Heredia, Alberto Molero-Sanchez, and Juan Carlos Miangolarra-Page. "Performance of the Craniocervical Flexion Test,
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Fernandez-De-Las-Penas, Cesar, Cristina Alonso-Blanco, Jesus
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Haldeman, Scott, and Simon Dagenais. "Cervicogenic Headaches: a critical review." Spine Journal 1. (2001): 31-46. 11 Nov 2010.
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Hall, Toby, Kathy Briffa, Diana Hopper, and Kim Robinson. "Long-Term Stability and Minimal Detectable Change of the Cervical Flexion-Rotation Test." Journal of Orthopedic
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Hall, Toby et al. "Efficacy of a C1-C2 Self-sustained Natural Apophyseal GLide (SNAG) in the Management of Cervicogenic Headache." Journal of Orthopedic and Sports
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