1. Cervicogenic Headaches

2. Normal Anatomy Vast amount of soft tissue and joints within the upper cervical spine

3. Normal Anatomy Suboccipital nerve branches from C1 nerve root and supplies muscles of suboccipital region and atlano-occipital joint. Purely Motor. No sensory aspect Greater occipital and lesser occipital nerves branch from C2 nerve root and supplies C1/2 and C2/3, vertex and posterior scalp Third Occipital nerve branches from C3 nerve root supplying lower scalp and C2/3 Relationship between the trigeminal nerve and upper cervical spinal nerves in the brain “Trigeminocervical nucleus”

4. Normal Anatomy Structures innervated by C1,2,3 spinal nerves – Atlanto occipital joint – Ligaments of the atlanto-occipital joint – C2,3 facet joints – Sub-occipital and upper posterior neck muscles – Upper cervical spinal dura mater – Verterbral arteries – C2-3 intervertebral discs – Trapezius and SCM muscles

5. Pathophysiology Dysfunction to the any structure supplied by the upper cervical nerves can cause pain anywhere within the distribution of these nerves This often results in “Cervicogenic Headaches” i.e a headache due to a cervical origin

6. Mechanism Of Injury Traumatic – Whiplash – Sporting tackle – Fall Insidious Onset – Poor Posture – Muscular Imbalance – Degenerative Disc Disease/Spondylosis – Arthritis – Disc Herniation

7. Associated Pathologies/Differential Diagnosis

8. Classification Cervicogenic Headache International Study Group diagnostic Criteria Major Criteria1.Symptoms and signs of neck involvement a.Precipitation of comparable symptoms by: 1)Neck movement and/or sustained, awkward head positioning, and/or 2)External pressure over the upper cervical or occipital region b.Restriction of range of motion in the neck c.Ipsilateral neck, shoulder or arm pain 2.Confirmation evidence by diagnostic anaesthetic block 3.Unilaterality of the head pain, without sideshift Head Pain Characteristics4.Moderate-severe, non-throbbing pain, usually starting in the neck. Episodes of varying duration, or fluctuating, continuous pain

9. Classification Cervicogenic Headache International Study Group diagnostic Criteria Other Characteristic of some Importance5.Only marginal or lack of effect of indomethacin. Only marginal of lack of effect of ergotamine and sumatriptan. Female gender. Not infrequent history of head of indirect neck trauma, usually of more than medium severity Other Features of Lesser Importance6.Various attack-related phenomena, only occasionally present, and/or moderately expressed when present: a)Nausea b)Phono- and photophobia c)Dizziness d)Ipsilateral “blurred vision” e)Difficulties swallowing f)Ipsilateral oedema, mostly in the periocular area

10. Subjective A Headache in Occipital or trigeminal nerve distribution Aggravated by neck movements or positions Neck, shoulder or arm pain Non throbbing Traumatic or insidious onset

11. Objective Abnormal cervical posture Altered and painful cervical movements- usually extension and ipsilateral rotation Restricted upper cervical movements, usually ipsilateral rotation Pain on sustained postures, usually protraction Pain on palpation sub occipital soft tissue

12. Special Tests Cervical Flexion-Rotation Test – Patient supine, Full passive cervical flexion. Passive rotation. Abnormal finding if restricted/ painful/ reproduction of headache with rotation towards the side of headache – Full flexion initially allows rotation to purely assess the upper cervical spine

13. Further Investigation Diagnosis usually made clinically Imaging used to investigate/exclude more serious pathology Blood work used to exclude other pathology Zygapophyseal joint, cervical nerve or medial branch blockage

14. Conservative - Management Ergonomic advise 1.Restore normal mobility – Decrease inflammation if present with massage, ice, NSAID’s – Reduce tone of hypertonic muscles with soft tissue therapy and diaphragmatic breathing – Increase mobility of upper cervical spine, particularly flexion and rotation 2.Restore Normal Motor Control and Strength – Deep Neck Flexors – Deep Cervical Extensors – Scapular stabilisers 3.Restore Dynamic Stability Full comprehensive rehabilitation protocol see Page (2011) Cervicogenic Headaches: An Evidence Led Approach to Clinical Management Full comprehensive manual therapy approach see Fernandez-de-las-Penas & Coutney (2014) Clinical Reasoning for Manual Therapy Management of Tension Type and Cervicogenic Headache

15. Surgical - Management Anaesthetic injections – Spinal nerve, medial branch or facet joint blockade Radiofrequency thermal neurolysis Surgical Liberation of occipital nerve Surgery to underlying pathology (e.g disc pathology)

16. References Jull et al (2002) A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache. Spine Bondi (2005) Cervicogenic Headache: A Review of Diagnostic and Treatment Strategies. JAOA Zito et al (2006) Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache. Manual Therapy Piekartz et al (2007) Neurodynamic responses in children with migraine or cervicogenic headache versus a control group. A comparative study. Manual Therapy Hall et al (2008) Cinical Evaluation of Cervicogenic Headache: A Clinical Perspective. The Journal of Manual and Manipulative Therapy Page (2011) Cervicgenic Headaches: An Evidence leg approach to clinical management. IJSPT Fernandez-de-las-Penas (2014) Clinical Reasoning for manual therapy management of tension type and cervicogenic headache. The Journal of Manual and Manipulative Therapy