Cervicogenic Headache Physiotherapy Management: Evidence-Based Insights

Cervicogenic Headache (CGH) is a secondary headache disorder, often triggered by issues in the cervical spine, including its bony, disc or soft tissue structures. These structures are innervated by the cervical nerves, which, when affected, can lead to headache symptoms.

 

Pathogenesis

The pathogenesis and etiology of cervicogenic headache remain complex and not fully understood.

Cervical Spine Origin:

Cervicogenic headache is thought to arise from dysfunction or irritation in the structures of the cervical spine. These include joints, intervertebral discs, ligaments, and muscles.

Trigemino-Cervical Convergence:

Pain from the cervical region is referred to the head due to the trigemino-cervical nucleus, a key pain processing center in the brainstem. This nucleus integrates sensory input from the trigeminal nerve (cranial nerve V, responsible for facial sensations) and the upper three cervical spinal nerves. Any irritation in cervical structures can result in referred pain to the head, mimicking headache disorders.

Stabilizing Structures:

Ligaments (e.g., transverse and alar ligaments) and other stabilizing structures like the tectorial membrane and joint capsules are implicated. However, they might not display overt pathological changes on imaging.

Muscle Tenderness:

Muscle tenderness, particularly on the side of the headache, indicates myofascial involvement or localized hyperalgesia. This is a distinguishing feature and supports a cervical origin of the pain.

Lower Cervical Disc Prolapse:

Cervical disc issues can cause radicular symptoms and pain, their direct role in cervicogenic headache remains unproven.

Despite the above findings, the exact mechanisms by which cervical structures contribute to cervicogenic headache remain speculative. Current hypotheses rely on clinical observations rather than definitive evidence.

 

Causes of Cervicogenic Headache 

Other Factors

• Post-surgical complications in the cervical region
• Referred pain from adjacent areas (e.g., temporomandibular joint dysfunction).

 

Signs and Symptoms

• Unilateral pain starting at the back of the head, radiating to the forehead or eyes.
• Non-throbbing, dull or deep pain.
• Aggravated by neck movement, sustained posture or pressure on neck/occipital region.
• Associated neck symptoms - stiffness, reduced range of motion, tenderness in cervical muscles or joints.
• Possible referred pain to shoulders or arms; occasional dizziness or light-headedness.
• Autonomic symptoms (less common) - nausea, light or sound sensitivity.

Muscle Impairments Include:

• Tightness/trigger points in upper trapezius, levator scapulae, scalenes, suboccipital extensors.
• Weakness of deep neck flexors, atrophy in suboccipital extensors affecting cervical segment support.
• Increased activity is seen in superficial flexors - muscles include upper trapezius, sternocleidomastoid, scalenes, levator scapulae, pectoralis major/minor, suboccipital extensors.

 

Diagnosing Cervicogenic Headache

Diagnosing CGH as a physiotherapist involves a thorough clinical examination, below is a questionnaire based on the IHS classification:

 

 

Differential Diagnosis

• Migraine
• Tension-type headache
• Cluster headache
• Occipital neuralgia
• Temporomandibular joint (TMJ) dysfunction
• Trigeminal neuralgia
• Sinus headache
• Post-concussion syndrome
• Vertebrobasilar insufficiency
• Rheumatoid arthritis-related headaches
• Meningitis or intracranial infections
• Brain tumor-related headaches
• Hypertension-related headaches
• Giant cell arteritis
• Primary stabbing headache

 

Physiotherapy Management of Cervicogenic Headache

Patient Education and Ergonomic Advice

• Educate patients about the relationship between cervical dysfunction and headache symptoms to reduce anxiety.
• Emphasize maintaining a neutral head and neck posture during daily activities.
• Avoid prolonged forward head positions, especially while using screens or reading.
• Use ergonomic setups for workstations, including adjustable chairs and monitor heights.
• Encourage regular breaks during sedentary activities and introduce exercises for postural correction.

 

Pain Management

Electrotherapy

• Transcutaneous Electrical Nerve Stimulation (TENS): Applied to the cervical region for pain modulation.
• Therapeutic Ultrasound: Promotes tissue healing and reduces inflammation.

Manual Therapy

Manual therapy targets joint dysfunction and myofascial pain associated with CGH. Techniques include:

• Cervical spine mobilization or manipulation: Improves joint mobility and reduces pain.
• Thoracic spine thrust manipulation: Focuses on seated mid-thoracic or cervicothoracic manipulations to enhance upper thoracic mobility.
• C1-C2 Sustained Natural Apophyseal Glide (SNAG): Demonstrated effectiveness in reducing CGH symptoms.

Trigger Point Therapy:

• Apply pressure release techniques over trigger points, gradually increasing pressure until tissue resistance is relieved.
• Use transverse friction massage and stretching to release myofascial tension.
• Stretch the lengthen taut bands in affected muscles without inducing pain.

Myofascial Mobilization

 It helps relax tense muscles and improve tissue mobility.

Dry Needling or Acupuncture

Targets hypertonic musculature to relieve pain and reduce tension.

 

Improving Range of Motion (ROM)

Active and Passive ROM Exercises:

Gentle neck rotations, lateral flexion, and extensions to restore mobility.

Self-Mobilization Techniques:

Use of foam rollers or small therapy balls to mobilize the upper thoracic and cervical spine.

 

Correcting Cervical Spine Dysfunction

Customized exercise programs target strength, endurance, and control in key muscle groups.

Deep Neck Flexor Exercises

Cranio-Cervical Flexion Test Training:

• Use pressure biofeedback to train deep neck flexors, focusing on holding a cranio-cervical flexion position for 10 seconds, repeated 10 times.
• Progress gradually to achieve a target pressure of 30 mmHg.

Antigravity Flexor Training:

Antigravity Flexor Training strengthens the deep neck flexors by controlling movements against gravity. Emphasize initiation of movement with deep neck flexors rather than sternocleidomastoid.

• Eccentric Phase (Cervical Extension): Slowly lower the head backward into extension, engaging the deep neck flexors to control the descent.
• Concentric Phase (Return to Neutral): Lift the head back to neutral, using the deep flexors without engaging superficial muscles.

Neck Extensor Training

Neck Extensor Training strengthens cervical extensors in a 4-point kneeling position (hands under shoulders, knees under hips).

• Eccentric Phase: Slowly lower the head into slight flexion, controlling with cervical extensors.
• Concentric Phase: Return the head to neutral by activating cervical extensors.
• Progression is made by performing small alternating movements of craniocervical flexion and extension with control.

Co-Contraction Training

Co-Contraction Training builds neck stability through controlled muscle engagement.

Self-Resisted Isometric Rotation:

• Push gently against your head with your hand, resisting rotation without moving.
• Use 10–20% effort, holding for 5–10 seconds per side.

Rhythmic Stabilization:

• Resist light, unpredictable taps to the head, keeping it steady.
• Focus on slow, controlled muscle activation and release.

 

Scapular Muscle Retraining

• Orientation Training: Correct scapular posture through slight retraction and external rotation.
• Endurance Training: Perform prone exercises to strengthen middle and lower trapezius muscles.
• Functional Training: Maintain scapular control during small arm movements or activities like deskwork.

Upper Quarter Strengthening

Focus on strengthening the middle and lower trapezius and other muscles connecting the axial and appendicular skeletons.

 

Posture Re-Education

• Train the correct sitting posture, starting with pelvic alignment.
• Re-educate scapular position to reduce muscular strain in levator scapulae.
• Use visual feedback (e.g., mirrors) for self-correction and habitual maintenance.

 

Sensorimotor Training

• Cervicogenic headache often involves sensorimotor dysfunction. Progress exercises to unstable surfaces:
• Use foam pads or exercise balls for balance and postural stability.
• Include functional activities like reaching or lifting to simulate daily tasks.

 

Ergonomic Training

• Evaluate workspaces and recommend ergonomic adjustments to reduce strain on the cervical and upper thoracic spine.
• Encourage regular breaks and posture correction during prolonged sitting or desk work.

 

Mobility, Strength and Stability Exercises

• Combine post-isometric relaxation techniques, McKenzie therapy and myofascial mobilization.
• Supervise gradual strengthening of previously tense muscles using therabands and dynamic exercises.
• Ensure exercises do not exacerbate pain or evoke headache symptoms.

 

Progression and Functional Training

• Transition patients to functional exercises that simulate real-life activities.
• Focus on improving overall neuromuscular coordination and endurance.

Evidence-Based Outcomes

A six-week physiotherapy program combining manual therapy and exercises has shown to effectively reduce CGH symptoms and decrease medication dependency, with sustained benefits at one-year follow-up.

Ergonomic and posture training further supports long-term management and prevention of CGH recurrence. This structured approach ensures comprehensive management, addressing both the symptoms and underlying causes of CGH.