Cervicogenic Headaches


In the private Settings, headaches are a typical presenting ailment. We need to be able to distinguish between a variety of headache kinds, such as migraine without aura, migraine with aura, cluster headaches, tension-type headaches (TTH), persistent paroxysmal headaches, and cervicogenic headaches, which we choose to treat. It’s critical to understand how to identify the signs and symptoms unique to each form of headache, especially the CGH diagnostic criteria. This is not to argue that individuals with different forms of headache cannot benefit from physiotherapy therapies; nevertheless, the benefits are not predicated on the idea that we are treating the fundamental musculoskeletal problem in the cervical spine.

According to research, up to 70% of persons who have headaches also experience neck discomfort, but only 18% of these people also experience CGH, demonstrating the TCN’s bidirectional nature (Nilsson, 1995). Neck pain and hypersensitivity are not only associated with CGH because of the interactions between the TCN and cervical afferents in both directions; they may also occur in migraine and TTH (Jull, et al., 2007; Jull, et al., 2009).

Contrary to migraine and tension-type headaches (TTH), which are classified as primary headaches, cluster headache syndrome (CGH) is classified as a secondary headache and is thought to be caused by muscular dysfunction of the upper cervical spine (Sjaastad & Bakketeig, 2008; Sjaastad, Fredriksen, & Pfaffenrath, 1998; Sjaastad, Saunte, Hovdahl, Breivik, & Gronbaek, 1983). Today, three musculoskeletal deficits that are specific to CGH have been established as clinical characteristics (Jull, Amiri, Bullock-Saxton, Darnell, and Lander, 2007; King, Lau, Lees, and Bogduk, 2007; Zito et al., 2006); they include:

Loss of range of motion, a painful upper cervical joint, and damage to the cervical spine’s musculature.
Our knowledge of the mechanism and symptoms of CGH has evolved throughout time. The trigeminocervical nucleus (TCN), which allows the neck to transmit pain into areas of the head, is currently assumed to be the site of convergence of primary afferent neurones from the top three cervical nerves.


Paroxysmal Hemicrania, a form of unilateral headache triggered by neck motions, was first described by writers in the early 1980s, but therapists were baffled by the unusually mechanical aspect of these headaches (Sjaastad, et al., 1983). In 1988, Sjaastad and colleagues defined cervicogenic headache as a secondary headache, which is now recognised by The International Headache Society. As a result, a new category of headaches was created (Olesen & Steiner, 2004). There were two cardinal indications of CGH at this time, and they are still essential components of the differential diagnosis today. They are a unilateral headache’s existence and a headache that is triggered by neck motions. The most recent definition is offered in Jull, Sterling, Falla, Treleaven, and O’Leary (if you’d want to read more) (2009, p. 119).

The use of diagnostic blockade remained the gold standard for diagnosis during the time when considerable research on the diagnosis of CGH started (in the early 1980s) (Amiri, et al., 2007; Bogduk & Govind, 2009; King, et al., 2007; Sjaastad, et al., 1983). Unfortunately, not all headache patients with potential CGH presentations have access to this. We depend on our musculoskeletal examination instead.

Manual palpation of the upper cervical spine is a significant and often underexplained aspect of this examination. In a seminal publication from 1988, Jull, Bogduk, and Marsland claimed that a skilled musculoskeletal physiotherapist can identify a problematic joint with manual examination with equal accuracy as radiologically controlled diagnostic nerve block. Manual palpation, on the other hand, is a skilled technique that doctors use to describe or identify changes in sensation while pressing on a part of the body.

Since then, a lot of writers have argued about whether manual palpation is always 100% specific and sensitive. The foundation for this argument is the following set of questions (Bogduk & Govind, 2009; King et al., 2007):

  • Are there any spinal joints that manipulative therapists can truly feel moving?
    – Are the apparently palpable irregularities even indicative of anything more than general symptoms?
    – Can manipulative therapists correctly identify spinal problems by manual examination?

There is moderate agreement that there is significant overlap between the symptoms of CGH, migraine, and TTH, and that no individual symptom is unique to each form of headache (Antonaci & Sjaastad, 2011; Biondi, 2005; Jull, et al., 2009). In order to determine that the cervical spine is the major cause of the headache, we thus depend more on the physical examination.

In order to diagnose CGH, in particular, we must conduct an examination that reveals a loss of range of motion (in AROM testing or with the flexion/rotation test), deficits in muscular activation, endurance, and coordination (using the craniocervical flexion test and a pressure biofeedback unit), and a comparable joint sign that can be palpated manually (hopefully with reproduction of the headache).


Manual palpation is a method that Maitland and Hengeveld (2005) define as an objective means to assess the quantity and quality of movement at a spinal segment. The therapist’s capacity to explain the final sensation of a joint, the nature of movement resistance, and the replication of pain are all crucial to the accuracy and sensitivity of palpation.

The lack of a uniform evaluation process in Jull and colleagues’ (1997) study has drawn criticism. The manual palpation was carried out by the therapists in the same way as it would be in a clinical setting. While this study’s findings indicated that therapists had high agreement on their capacity to identify a degree of symptomatology, the study’s methodology and the validity of its conclusions were called into doubt.

First authors to successfully replicate Jull’s research design from 1988, King et al. (2007) evaluated the reliability of manual palpation in the diagnosis of zygopophysial joint dysfunction. Compared to the other research, this one was eight times bigger and had a far better methodology. The findings showed that the total likelihood ratio was 1.7, with sensitivity being 89% and specificity being 47%. The results are arguably more realistic since they were based on bigger sample sizes and do not suggest infallibility, as a value of 1.00 implies, which is one of the research’s main advantages (King, et al., 2007, p. 25).

Both of these cornerstone articles lack specificity in that the writers do not explain how to do manual palpation, leaving readers in the dark as to how to carry out passive accessory intervertebral motions in the most effective way (PAIVMS). Musculoskeletal physiotherapists with 20 years or more of expertise or more are used as the trial’s examiners across the literature. Maybe this is a real reflection of how physiotherapy is actually practised? Yet it raises the issue of whether the findings can even be extrapolated to physiotherapists with less training who may not have honed the same handling technique.


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