Cervicogenic Headache & Cervical Instability

Cervicogenic Headache – Physiopedia

Due to our overly-stretchable tendons and ligaments, we with EDS often get these headaches that arise from misalignments of our upper cervical spine.

Cervicogenic headache is a chronic headache that arises from the atlanto-occipital and upper cervical joints and perceived in one or more regions of the head and/or face

The International Headache Society (IHS) has validated cervicogenic headache as a secondary headache type that is hypothesized to originate due to nociception in the cervical area. (See more about classification on the headache page).  

Epidemiology/Etiology

The term cervicogenic headache (CGH) was coined almost 3 decades ago, and the general condition of pain located in the head but originating in the cervical spine was described over 100 years ago.

There is some evidence that multiple structures in the upper cervical spine can be the source that is referring pain into the head. The implicated structures are generally centered around C1, C2, and C3 spinal levels.

Below is an article from the same source describing the cervical instability that often leads to cervicogenic headaches.

Cervical Instability – Physiopedia

Definition/Description

Clinical instability of the cervical spine is defined as the inability of the spine under physiological loads to maintain its normal pattern of displacement so that there is no neurological damage or irritation, no development of deformity, and no incapacitating pain.

Clinically Relevant Anatomy

The cervical spine consist of 7 separate vertebrae. The first two vertebrae (referred as upper cervical spine) are highly specialised and differ from the other 5 cervical vertebrae (lower cervical) regarding anatomical structure and function

The upper cervical spine is made of the atlas (C1) and the axis (C2). It comprises of two joint structures:

1. one in between os occipital and atlas (atlanto-occipital joint),
2. the other one between atlas and axis, which forms the atlanto-axial joint.

The atlantoaxial joint is responsible for 50% of all cervical rotation; the atlanto-occipital joint is responsible for 50% of flexion and extension.

The craniocervical junction (atlanto-occipital joint), the lower atlanto-axial joint and other cervical segments are reinforced by internal as well as external ligaments. They secure the spinal stability of the cervical spine as a whole, together with surrounding postural muscles and allow cervical motion.

The orientation of the cervical spine facet joints means the cervical spine is designed for a great deal of mobility, but it lacks stability.

The nonlinear displacement curve of the spine, the total range of motion of a spinal segment may be divided into the neutral zone and the elastic zone.

1. Neutral zone: motion occurring in this zone is produced against a minimal passive resistance.
2. Elastic zone: motion occurring in occurring near the end-range of spinal motion is produced against increased passive resistance.

Panjabi conceptualised the components into 3 functionally integrated subsystems of the spinal stabilising system:

The passive subsystem:

• Consists of vertebral bodies, facet joints and capsules, spinal ligaments (lig. longitudinale anterius and posterius, ligamentum interspinosum, lig. Interspinosus and lig. Flavum).
• Passive tension from spinal muscles and tendons.
• Provides significant stabilization of the elastic zone and limits the size of the neutral zone.
• Acts as a transducer and provides the neural control subsystem with information about vertebral position and motion

The active subsystem:

• Consists of spinal muscles and tendons, such as: multifidus cervicis, Longus capitis and the Longus Colli.
• Generates forces required to stabilize the spine in response to changing loads.
• Controls the motion occurring within the neutral zone and contributes to maintain the size the size of the neutral zone.
• Acts also as a transducer by providing the neural control subsystem with information about the forces generated by each muscle.

The neural control subsystem:

• Consists of peripheral nerves and the central nervous system.
• Receives information from the transducers of the passive and active subsystems about vertebral position, vertebral motion, and forces generated by spinal muscles.
• The subsystem determines the requirements for spinal stability and acts on the spinal muscles to produce the required forces.

Epidemiology /Etiology

It is generally accepted that cervical instability is caused by trauma (one major trauma or repetitive microtrauma).

With EDS we suffer from repeated microtrauma in many joints, which eventually becomes increasingly painful.

Because the cervical spine is not sturdy, we can easily develop problems in this area and suffer from the frequent headaches associated with it.

Cervical instability is often diagnosed in patients with rheumatoid arthritis, due to the progressive destruction of the cervical skeletal structures.

Congenital deviation (eg, down syndrome) also can cause upper cervical spine instability.

Usually, persons with congenital anomalies do not become symptomatic before midlife adulthood.

The spine is assumed to be able to accommodate differing regions of hypermobility and fusions.

With time, the degenerative changes occurring in the lower cervical spine increase rigidity and alter the balance. This gradual loss of motion places increasing loads on the atlantoaxial articulation

The following risk factors are associated with the potential for bony or ligamentous compromise of the upper cervical spine:

• History of trauma (e.g. whiplash, rugby neck injury)
• Throat infection
• Congenital collagenous compromise (e.g. syndromes: Down’s, Ehlers-Danlos, Grisel, Morquio)
• Inflammatory arthritides (e.g. rheumatoid arthritis, ankylosing spondylitis)
• Recent neck/head/dental surgery.

Characteristics/Clinical Presentation

There is a large agreement on following symptoms to make a clinical judgment on CCSI:

• “intolerance to prolonged static postures,”
• “fatigue and inability to hold head up,”
• “better with external support, including hands or collar,”
• “frequent need for self-manipulation,”
• “feeling of instability, shaking, or lack of control,”
• “frequent episodes of acute attacks,” and
• “sharp pain, possibly with sudden movements.”

Aberrant motions occurring in the mid-ranges of active cervical movement are cardinal signs of cervical clinical instability

Symptoms can be different but the most frequent clinical findings are:

• Tenderness in the cervical region
• Referred pain in the shoulder or paraspinal region
• Cervical radiculopathy
• Cervical myelopathy
• Headaches
• Paraspinal muscle spasm
• Decreased cervical lordosis
• Neck pain with sustained postures
• Hypermobility and soft end-feeling in passive motion testing
• Poor cervical muscle strength (multifidus, longus capitis, longus colli)

Diagnostic Procedures

Cervical instability is a diagnosis based primarily on a patient’s history and reported symptoms.

Imaging

There is often little correlation between the degree of instability or hypermobility shown on radiographic studies and clinical symptoms.

However, functional computerized tomography (fCT) and magnetic resonance imaging (fMRI) scans and digital motion x-ray (DMX) are able to adequately depict cervical instability pathology .

Functional imaging technology, as opposed to static standard films, is necessary for adequate radiologic depiction of instability in the cervical spine because they provide dynamic imaging (flexion and extension images of the spine) of the neck during movement and are helpful for evaluating the presence and degree of cervical instability

Examination

The related symptoms listed in descending rank of relationship are:

• Intolerance to prolonged static postures
• Fatigue and inability to hold head up
• Better with external support, including hands or collar
• Frequent need for self-manipulation
• Feeling of instability, shaking, or lack of control
• Frequent episodes of acute attacks
• Sharp pain, possibly with sudden movements
• Head feels heavy
• Neck gets stuck, or locks, with movement
• Better in unloaded position such as lying down
• Catching, clicking, clunking, and popping sensation
• Past history of neck dysfunction or trauma
• Trivial movements provoke symptoms
• Muscles feel tight or stiff
• Unwillingness, apprehension, or fear of movement
• Temporary improvement with clinical manipulation

The 12 physical examination findings included:

• Poor coordination/neuromuscular control, including poor recruitment and dissociation of cervical segments with movemen
• Abnormal joint play
• Motion that is not smooth throughout range (of motion), including segmental hinging, pivoting, or fulcruming
• Aberrant movement
• Hypomobility of upper thoracic spine
• Increased muscle guarding, tone, or spasms with test movements
• Palpable instability during test movements
• Jerkiness or juddering of motion during cervical movement
• Decreased cervical muscle strength
• Catching, clicking, clunking, popping sensation heard during movement assessment
• Fear, apprehension, or decreased willingness to move during examination
• Pain provocation with joint-play testing

Examination

Because a definitive diagnostic tool has not been developed, cervical clinical instability will continue to be diagnosed through clinical findings, including

• history,
• subjective complaints,
• visual analysis of active motion quality, and
• manual examination methods

Cook et al proposed different identifiers for cervical spine instability. They divided them into different categories: movements, descriptive components, and postures.

Patients also experienced neurological problems and headaches.

In general, these tests have sufficient specificity and can rule in upper cervical ligamentous instability, but degrees of sensitivity varied.

Magee et al reported poor cervical muscle endurance is one of the clinical findings we find with cervical instability. A good way to test these muscles (the deep cervical flexor muscles, the longus capitis and longus colli) is the craniocervical flexion test (CCFT) which is a test of neuromotor control.

The main goal of the test is to apply an isometric force on a pressure sensor placed behind the neck without using the superficial cervical flexors. The construct validity of the craniocervical flexiontest has ben verified in a laboratory setting

Physical Therapy Management

Conservative treatment is indicated when cervical clinical instability does not severely involve or threaten neurological structures.

The goal of nonsurgical treatment should be

• to enhance the function of the spinal stabilising subsystems and
• to decrease the stresses on the involved spinal segments.

Strengthening exercises

• Enhance the function of the active subsystem.
• The cervical multifidus may provide stability via segmental attachments to cervical vertebrae.
• The longus colli and capitus provide anterior stability.
• Strengthening the stabilizing muscles may enable those muscles to improve the quality and control of movement occurring within the neutral zone
• Exercise video: Neck strength and stability www.youtube.com/watch

Active exercise therapy

• Partial suboccipital nod with a head lift in supine to strengthen the longus capitus and longus colli muscles – The patient lies on his back with his head on the table/a pillow. He nods and holds this position as he lifts his head off the table/pillow. This position is held for 2-3 seconds and then the patient lowers his head back on the table/pillow. 3-4 sets of 10 repetitions were performed.
• Active suboccipital nodding – The patient lies on his back with a pillow under his head and nods. The physiotherapist applies a little resistance to prevent the patient from performing a neck flexion. The patient is then asked to bend his neck from a neutral position to the point of first resistance and then return to a neutral position. The patient is instructed to keep her head on the pillow throughout the performance of the exercise. 3-4 sets of 10 repetitions were performed.
• Craniovertebral side-bending isometric manipulation – With the patient is supine, head resting on a low pillow, passively position the craniovertebral region into right sidebending to the point of resistance to the motion. Manually resist further right side-bending by applying manual pressure above the right ear as the patient holds isometrically for 10 seconds. Passively reposition the patient into further right side-bending if the passive motion has improved, and then reapply the isometric force for 10 seconds. This sequence is repeated 3-4 times in 1 session.
• Quadruped position arm lift with spinal stabilisation.

All those exercises can be performed at home in 3-4 sets of 10 repetitions.

Anita R. Gross et al listed an evidence-based home neck care exercise program that can be included if the CCFT test was found positive.

It is in 3 progressive phases. These exercises should be judiciously tailored to individual circumstances and applied as indicated based on a clinical examination

You can find a description of these in the full article, but the descriptions are cryptic.