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Barkatullah University Bhopal

Career Institute of Medical Sciences Bhopal A Project on PHYSICAL THERAPY APPROACH IN CERVICOGENIC HEADACHE Session 2011-2012
Submitted by: Sarita Aarse B.P.T. IV Year Guided By: Dr.Vashuda Pingle (M.P.T. in Neuro)

Career Institute of Medical Sciences Bhopal

Certificate

This is to certify that a project on Physiotherapy approach in management of Cervicogenic Headache is submitted by Miss Sarita Aarse , a student of final year in partial fulfillment of the requirements for Bachelor of Physiotherapy, submitted to Physiotherapy Department of Career College of Batch 2011-12.

Dr.Vashudha Pingle (P.T.)

Dr.Rakhi Wadhwa (P.T.) HOD

Career Institute of Medical Sciences Bhopal

Certificate

This is to certify that a project on Physiotherapy approach in management of Cervicogenic Headache is submitted by Miss Sarita Aarse, a student of final year in partial fulfillment of the requirements for Bachelor of Physiotherapy, submitted to Physiotherapy Department of Career College of Batch 2011-12.

Internal Examiner

External Examiner

Acknowledgement

The moment of acknowledgement gives pride that gives me a feeling to cherish about; I take this opportunity to express my sincere gratitude to all who contributed in making this work possible within a very limited time.

I express my deep sense of gratitude to Mr. P.N. Tiwari, Principal, Career College of physiotherapy, who has given permission to carry out this project.

My sincere thanks to Mr. Vishnu Rajoriya, Chairman, Career College of Physiotherapy, who stood as a pillar of strength and gave his valuable help and cooperation in completion of this project.

My heartiest indebtedness to the head of Department, Dr. Rakhi Wadhwa who Patronized me at all times. I also wish to express my deep sense of gratitude to Dr. Vasudha Pingle , guide and lecturer for her continuous and tireless support and advice, not only during the course of my project making, but also during other times.

I am indebted to Dr. Swapnil, Dr. Namrata, Dr. Sneha, Dr. Saurav who imbibed in me the inspiration and zeal to complete the task.

Last but not the least; I would like to thank my parents, brother, colleagues as well as my well wishers for their sincere wishes and kind cooperation.

SARITA AARSE
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Cervicogenic Headache CONTENT

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1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

INTRODUCTION 6 DEFINITION.7 CAUSES ........7 SIGN & SYMPTOMS...........................................8 NECK PAIN AS A MENIFESTATION OF MIGRAIN..9 HEADACHE AS A MENIFESTATION OF MIGRAIN..10 DIAGNOSTIC TESTING 11 DIFFERENTIAL DIAOGNOSIS12 POSTURAL ASSESMENT .11 PHARMACOLOGICAL TREATMENT..14 PSYCHOLOGICAL &BEHAVIORAL TREATMENT..15 SURGICAL TREATMENT17 PHYSICAL THERAPY MANAGEMENT...........................18 CONCLUSION.42 REFRENCE..42

Introduction
Cervicogenic headache is a syndrome characterized by chronic hemicranial pain that is referred to the head from either bony structures or soft tissues of the neck. The trigeminocervical nucleus is a region of the upper cervical spinal cord where sensory nerve fibers in the descending tract of the trigeminal nerve (trigeminal nucleus caudalis) are believed to interact with sensory fibers from the upper cervical roots. This functional convergence of upper cervical and trigeminal sensory pathways allows the bidirectional referral of painful sensations between the neck and trigeminal sensory receptive fields of the face and head. A functional convergence of sensorimotor fibers in the spinal accessory nerve (CN XI) and upper cervical nerve roots ultimately converge with the descending tract of the trigeminal nerve and might also be responsible for the referral of cervical pain to the head. Diagnostic criteria have been established for cervicogenic headache, but its presenting characteristics occasionally may be difficult to distinguish from primary headache disorders such as migraine, tension-type headache, or hemicranias continua. This article reviews the clinical presentation of cervicogenic headache, proposed diagnostic criteria, pathophysiologic mechanisms, and methods of diagnostic evaluation. Guidelines for developing a successful multidisciplinary pain management program using medication, physical therapy, osteopathic manipulative treatment, other

nonpharmacologic modes of treatment, and anesthetic interventions are presented. Neck pain and cervical muscle tenderness are common and prominent symptoms of primary headache disorders. Less commonly, head pain may actually arise from bony structures or soft tissues of the neck, a condition known as cervicogenic headache . Cervicogenic headache can be a perplexing pain disorder that is refractory to treatment if it is not recognized. The condition's pathophysiology and source of pain have been debated but the pain is likely referred from one or more muscular, neurogenic, osseous, articular, or vascular structures in the neck.

Definition of Cervicogenic Headache (Also known as Headache, Cervical Headache, Neck Related Headache, Referred Pain from the Neck)

Cervicogenic headache is simply another name for a headache which originates from the neck and is one of the most common types of headache. It is important to note, however, that there are many types of headache of which cervicogenic is just one. Another common type is vascular (this includes migraines). The spine (neck) comprises of many bones known as vertebrae. Each vertebra connects with the vertebra above and below via two types of joints: the facet joints on either side of the spine and the disc centrally .During certain neck movements or sustained postures, stretching or compression force is placed on the joints, muscles, ligaments and nerves of the neck. This may cause damage to these structures if the forces are beyond what the tissues can withstand and can occur traumatically due to a specific incident or gradually over time. When this occurs pain may be referred to the head causing a headache. This condition is known as cervicogenic headache. Cervicogenic headache typically occurs due to damage to one or more joints, muscles, ligaments or nerves of the top 3 vertebra of the neck. The pain associated with this condition is an example of referred pain (i.e. pain arising from a distant source in this case the neck). This occurs because the nerves that supply the upper neck also supply the skin overlying the head, forehead, jaw line, back of the eyes and ears. As a result, pain arising from structures of the upper neck may refer pain to any of these regions causing a cervicogenic headache. Although cervicogenic headache can occur at any age, it is commonly seen in patients between the ages of 20 and 60.

Causes of cervicogenic headache

Cervicogenic headache typically occurs due to activities placing excessive stress on the upper joints of the neck. This may occur traumatically due to a specific incident (e.g. whiplash or heavy lifting) or more commonly, due to repetitive or prolonged activities such as prolonged slouching, poor posture, excessive bending or twisting of the neck or working at a computer. Contributing factors to the development of cervicogenic headache. There are several factors which can predispose patients to developing cervicogenic headache. These need to be assessed and corrected where possible with direction from a physiotherapist. Some of these factors include:

Poor posture Neck and upper back stiffness Muscle imbalances Muscle weakness Muscle tightness Previous neck trauma (e.g. whiplash) Inappropriate desk setup Inappropriate pillow or sleeping postures A sedentary lifestyle A lifestyle comprising excessive slouching, bending forwards or shoulders forwards activities.

Stress.

Signs and symptoms of cervicogenic headache

Patients with this condition usually experience a gradual onset of neck pain and headache during the causative activity. However, it is also common for patients to experience pain and stiffness after the provocative activity, particularly upon waking the next morning. The pain associated with cervicogenic headache can sometimes last days, weeks or even months.

Cervicogenic headache usually presents as a constant dull ache, normally situated at the back of the head Although sometimes behind the eyes or temple region, and less commonly, on top of the head, forehead or ear region. Pain is usually felt on one side, but occasionally, both sides of the head and face may be affected. Patients with this condition often experience neck pain. Stiffness and difficulty turning their neck, in association with their head symptoms. Pain, pins and needles or numbness may also be felt in the upper back, shoulders, arms or hands, although this is less common. Occasionally patients may experience other symptoms, including: lightheadedness, dizziness, nausea, tinnitus, decreased concentration, an inability to function normally, and depression

Patients with cervicogenic headache typically experience an increase in symptoms during certain movements of the neck or sustained positions (e.g. driving or sitting at a computer in poor posture).

Patients may also experience tenderness on firm palpation of the upper part of the neck just below the base of the skull along with muscle tightness in this region.

Cervical and trigeminal sensory pathways allow the bidirectional referral of painful sensations between the neck and trigeminal sensory receptive fields of the face and head.

Neck Pain as a Manifestation of Migraine

Neck pain and muscle tension are common symptoms of a migraine attack. In a study of 50 patients with migraine, 64% reported neck pain or stiffness associated with their migraine attack, with 31% experiencing neck symptoms during the program; 93%, during the headache phase; and 31%, during the recovery phase patients reported that pain was referred into the ipsilateral shoulder and 1 patient reported that pain extended from the neck into the low back region.
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In another study of 144 migraine patients from a university-based headache clinic, 75% of patients reported neck pain associated with migraine attacks Of these patients, 69% described their pain as tightness, 17% reported stiffness and 5% reported throbbing. The neck pain was unilateral in 57% of respondents, 98% of whom reported that it occurred ipsilateral to the side of headache. The neck pain occurred during the prodrome in 61%; the acute headache phase, in 92%; and the recovery phase, in 41%. Recurrent, unilateral neck pain without headache is reported as a variant of migraine Careful history gathering in cases of recurrent neck pain discovered that previously overlooked symptoms were either similar or identical to those associated with migraine. Differences in neck posture, pronounced levels of muscle tenderness, and the presence of myofascial trigger points were observed in subjects with migraine, tension-type headache, or a combination of both, but not in a nonheadache control group. A comparison of the headache groups demonstrated no significant differences in myofascial symptoms or signs, dispelling the common belief that tension-type headache is associated with a greater degree of musculoskeletal involvement than migraine.

Headache as a Manifestation of Neck Disorders

Head pain that is referred from the bony structures or soft tissues of the neck is commonly called cervicogenic headache. It is often a sequela of head or neck injury but may also occur in the absence of trauma. The clinical features of cervicogenic headache may mimic those commonly associated with primary headache disorders such as tension-type headache, migraine, or hemicranial continua, and as a result, distinguishing among these headache types can be difficult. The prevalence of cervicogenic headache in the general population is estimated to be between 0.4% and 2.5%, but in pain management clinics, the prevalence is as high as 20% of patients with chronic headache. The mean age of patients with this condition is 42.9 years, and cervicogenic headache is four times more prevalent in women. Patients with cervicogenic headache have demonstrated substantial declines in quality of life measurements that are similar to those in patients with migraine and tension-type
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headache when compared with control subjects, but they demonstrate the greatest loss in domains of physical functioning when compared with the groups with other headache disorders. The Cervicogenic Headache International Study Group developed diagnostic criteria that have provided a detailed, clinically useful description of the condition the diagnosis of cervicogenic headache can often be made without resorting to diagnostic neural blockade by completion of a careful history and physical examination.

Diagnostic Testing for Suspected Cervicogenic Headache

Patients with cervicogenic headache will often have altered neck posture or restricted cervical range of motion. The head pain can be triggered or reproduced by active neck movement, passive neck positioning especially in extension or extension with rotation toward the side of pain, or on applying digital pressure to the involved facet regions or over the ipsilateral greater occipital nerve. Muscular trigger points are usually found in the suboccipital, cervical, and shoulder musculature, and these trigger points can also refer pain to the head when manually or physically stimulated. There are no neurologic findings of cervical radiculopathy, though the patient might report scalp paresthesia or dysesthesia. Diagnostic imaging such as radiography, magnetic resonance imaging (MRI), and computed tomography (CT) myelography cannot confirm the diagnosis of cervicogenic headache but can lend support to its diagnosis One study reported no demonstrable differences in the appearance of cervical spine structures on MRI scans when 24 patients with clinical features of cervicogenic headache were compared with 20 control subjects Cervical disc bulging was reported equally in both groups (45.5% vs 45.0%, respectively). A comprehensive history, review of systems, and physical examination including a complete neurologic assessment will often identify the potential for an underlying structural disorder or systemic disease Imaging is then primarily used to search for

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suspected secondary causes of pain that may require surgery or other more aggressive forms of treatment.

Differential diagnosis
The differential diagnosis in cases of suspected cervicogenic headache include Posterior fossa tumor, Arnold-Chiari malformation, Cervical spondylosis or arthropathy, Herniated intervertebral disc, Spinal nerve compression or tumor, Arteriovenous malformation, Vertebral artery dissection, Intramedullary or extramedullary spinal tumors.

A laboratory evaluation may be necessary to search for systemic diseases that may adversely affect muscles, bones, or joints (i.e, rheumatoid arthritis, systemic lupus erythematosus, thyroid or parathyroid disorders, primary muscle disease, etc). Zygapophyseal joint, cervical nerve or medial branch blockade is used to confirm the diagnosis of cervicogenic headache and predict the treatment modalities that will most likely provide the greatest efficacy. The first three cervical spinal nerves and their rami are the primary peripheral nerve structures that can refer pain to the head. The suboccipital nerve (dorsal ramus of C1) innervates the atlanto-occipital joint; therefore, a pathologic condition or injury affecting this joint is a potential source for head pain that is referred to the occipital region. The C2 spinal nerve and its dorsal root ganglion have a close proximity to the lateral capsule of the atlantoaxial (C12) zygapophyseal joint and innervate the atlantoaxial and C23 zygapophyseal joints; therefore, trauma to or pathologic changes around these joints can be a source of referred head pain. Neuralgia of C2 is typically described as a deep or dull pain that usually radiates from the occipital to parietal, temporal, frontal, and
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periorbital regions. A paroxysmal sharp or shocklike pain is often superimposed over the constant pain. Ipsilateral eye lacrimation and conjunctival injection are common associated signs. Arterial or venous compression of the C2 spinal nerve or its dorsal root ganglion has been suggested as a cause for C2 neuralgia in some cases. The third occipital nerve (dorsal ramus C3) has a close anatomic proximity to and innervates the C23 zygapophyseal joint. This joint and the third occipital nerve appear most vulnerable to trauma from acceleration-deceleration (whiplash) injuries of the neck.Pain from the C23 zygapophyseal joint is referred to the occipital region but is also referred to the frontotemporal and periorbital regions. Injury to this region is a common cause of cervicogenic headache. The majority of cervicogenic headaches occurring after whiplash resolve within a year of the trauma. Of interest are reports that patients with chronic headache had experienced substantial pain relief after diskectomy at spinal levels as low as C56. Diagnostic anesthetic blockade for the evaluation of cervicogenic headache can be directed to several anatomic structures such as the greater occipital nerve (dorsal ramus C2), lesser occipital nerve, atlanto-occipital joint, atlantoaxial joint, C2 or C3 spinal nerve, third occipital nerve (dorsal ramus C3), zygapophyseal joint(s) or intervertebral discs based on the clinical characteristics of the pain and findings of the physical examination. Fluoroscopic or interventional MRI-guided blockade may be necessary to assure accurate and specific localization of the pain source. Occipital neuralgia is a specific pain disorder characterized by pain that is isolated to sensory fields of the greater or lesser occipital nerves. The classic description of occipital neuralgia includes the presence of constant deep or burning pain with superimposed paroxysms of shooting or shocklike pain. Paresthesia and numbness over the occipital scalp are usually present. It is often difficult to determine the true source of pain in this condition. In its classic description, the pain of occipital neuralgia is believed to arise from trauma to or entrapment of the occipital nerve within the neck or scalp, but the pain may also arise from the C2 spinal root, C12, or C23 zygapophyseal joints or pathologic change within the posterior cranial fossa.
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Occipital nerve blockade, as it is typically done in the clinic setting, often results in a nonspecific regional blockade rather than a specific nerve blockade and might result in a misidentification of the occipital nerve as the source of pain. This false localization might lead to unnecessary interventions aimed at the occipital nerve, such as surgical transection or other neurolytic procedures. A regional myofascial pain syndrome (MPS) affecting cervical, pericranial, or masticatory muscles can be associated with referred head pain. Sensory afferent nerve fibers from upper cervical regions have been observed to enter the spinal column by way of the spinal accessory nerve before entering the dorsal spinal cord. The close association of sensorimotor fibers of the spinal accessory nerve with the spinal sensory nerves is believed to allow for a functional exchange of somatosensory, proprioceptive, and nociceptive information from the trapezius, sternocleidomastoid, and other cervical muscles to converge in the trigeminocervical nucleus and ultimately resulting in the referral of pain to trigeminal sensory fields of the head and face. Muscular trigger points, a hallmark of MPS, are discreet hyperirritable regions of contracted muscle that have a lowered pain threshold and refer pain to distant sites in predictable and reproducible patterns. Anesthetic injections into trigger point regions can assist in the diagnostic evaluation and therapeutic management of referred head or face pain from cervical muscular sources.

Postural assessment:
Poked neck posture. This posture typically results in upper cervical spine joint stiffness, Adopted poor positions and sustaining them for long periods of time can result in a contributing directly to neck dysfunction and as a result cervicogenic headache. A physiotherapist is able to assess posture and give the most effective advice on correction.

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Pharmacologic Treatment
Pharmacologic treatment modalities for cervicogenic headache include many medications that are used for the preventive or palliative management of tension-type headache, migraine, and neuropathic pain syndromes. The listed medications have neither been approved by the US Food and Drug Administration (FDA) nor rigorously studied in controlled clinical trials for the treatment of cervicogenic headache and are only suggested as potential treatments based on the anecdotal experiences of clinicians who treat this condition or similar pain disorders. The side effects and laboratory monitoring guidelines provided are not intended to be comprehensive, and consultation of standard references or product package inserts are recommended before prescribing any of these medications. Many patients with cervicogenic headache overuse or become dependent on analgesics. Medication when used as the only mode of treatment for cervicogenic headache does not generally provide substantial pain relief in most cases. Despite this observation, the judicious use of medications can provide enough pain relief to allow greater patient participation in a physical therapy and rehabilitation program. To improve compliance, medications are initially prescribed at a low dose and increased over 4 to 8 weeks as necessary and tolerated. The cautious combining of medications from different drug classes or with complementary pharmacologic mechanisms may provide greater efficacy than using individual drugs alone (eg, an antiepileptic drug combined with a tricyclic antidepressant [TCA]). Frequent follow-up visits for medication dosage adjustments, monitoring of serum drug levels, and evidence of medication toxicity are recommended. AntidepressantsThe TCAs have long been used for management of various neuropathic, musculoskeletal, head, and face pain syndromes. Analgesic dosages are typically lower than those required for the treatment of patients with depression. The serotonin and nor epinephrine reuptake inhibitors (SNRIs) such as venlafaxine hydrochloride and duloxetine hydrochloride have been anecdotally observed helpful in
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the prophylactic management of migraine. Similar observations have been reported for venlafaxine in the treatment of painful diabetic neuropathy, fibromyalgia, and regional myofascial pain syndromes, while duloxetine is indicated for the management of painful diabetic neuropathy. The selective serotonin reuptake inhibitors (SSRIs) are generally ineffective for pain control. Antiepileptic Drugsthe antiepileptic drugs (AEDs) are believed to be modulators or stabilizers of peripheral and central pain transmission and are commonly used for the management of neuropathic, head, and face pain syndromes. Divalproex sodium is indicated for the preventive management of migraine headache and may be effective for cluster headaches as well as other neurogenic pain syndromes. Serum drug levels can be used as a therapeutic dosing guide. Monthly monitoring of liver transaminase levels and of complete blood cell (CBC) counts for evidence of toxicity is recommended, especially during the first 3 to 4 months of treatment or whenever dosages are escalated. Gabapentin is indicated for the management of postherpetic neuralgia and has been used for management of other neuropathic pain syndromes and migraine. No specific laboratory monitoring is usually necessary. Topiramate is indicated for migraine prophylaxis and has been anecdotally reported effective in the management of painful diabetic neuropathy and cluster headache. Intermittent monitoring of serum electrolyte levels might be needed because of this medication's diuretic effect through carbonic anhydrase inhibition. Carbamazepine is an effective medication in the treatment of patients with trigeminal neuralgia and central neuropathic pain. Serum drug levels can be used as a therapeutic dosing guide. Monthly monitoring of liver transaminase levels and of CBC counts is recommended, especially during the first 3 to 4 months of treatment or whenever dosages are increased. Several of the other newer AEDs might be used when other treatments are ineffective.

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AnalgesicsSimple analgesics such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) may be used as regularly scheduled medications for round-the-clock management of chronic pain or as needed for the management of acute pain. The selective cyclooxyenase-2 (COX-2) antagonist celecoxib might have less gastrointestinal toxicity than nonselective NSAIDs, but renal toxicity after long-term use remains as a concern. Recent reports have linked the long-term use of selective COX-2 antagonists with an increased risk of cardiovascular and cerebrovascular events; therefore, the risk-benefit ratio of their use requires strong consideration. It is recommended that prescribers review the safety information and warnings found in the product package inserts. Narcotic analgesics are not generally recommended for the long-term management of cervicogenic headache but may be cautiously prescribed for temporary pain relief to expedite the advancement of manual modes of therapy or improve tolerance for anesthetic interventions. Migraine-specific abortive medications such as ergot derivatives or triptans are not effective for the chronic head pain of cervicogenic headache but may relieve the pain of episodic migraine attacks that can occur in some patients with cervicogenic headache. Other MedicationsMuscle relaxants, especially those with central activity such as tizanidine hydrochloride and baclofen, may provide some analgesic efficacy. Botulinum toxin, type A injected into pericranial and cervical muscles is a promising treatment for patients with migraine and cervicogenic headache, but further clinical and scientific study is needed.

Psychological and Behavioral Treatment

Psychological and nonpharmacologic interventions such as biofeedback, relaxation, and cognitive-behavioral therapy are important adjunctive treatments in the comprehensive management of pain. Ongoing intensive, individual psychotherapy is often required if the

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patient with chronic pain has a prominent affective or behavioral component and the pain persists despite aggressive treatment.

Anesthetic Blockade and Neurolysis

Cervical epidural steroid injections may be indicated in patients with multilevel disc or spine degeneration. Greater and lesser occipital nerve blockade may provide temporary, but substantial, pain relief in some cases. A published report suggested that repeated greater occipital nerve blockade provided efficacy similar to repeated blockade of the C2 and C3 nerves. This finding suggests that repeated greater occipital nerve blockade in the office setting is a reasonable treatment option before considering referral for more invasive or more expensive interventions. Trigger point injections with a local anesthetic may also provide temporary pain relief and relaxation of local muscle spasm. If diagnostic blockade of cervical nerve, medial branch, or zygapophyseal joint blockade is successful in providing substantial, but temporary, pain relief, the treatment algorithm can then proceed to consideration for a longer-acting neurolytic procedure such as radiofrequency thermal neurolysis A course of physical therapy and rehabilitation is recommended after anesthetic blockade and neurolytic procedures to enhance functional restoration and effect a longer-lasting analgesic benefit.

Surgical Treatment
A variety of surgical interventions have been done for presumed cases of cervicogenic headache .Surgical liberation of the occipital nerve from entrapment in the trapezius muscle or surrounding connective tissues can provide substantial, but temporary, pain relief in some patients Similarly, only temporary pain relief is observed after surgical transection of the greater occipital nerve. Intensification of pain or anesthesia dolorosa is a potential adverse outcome that must be seriously considered when contemplating the use of surgical interventions. There have been preliminary reports of efficacy in reducing headache frequency, intensity, and associated disability in cases of chronic migraine after surgical
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implantation of occipital or spinal nerve stimulators Based on pathogenic models of cervicogenic headache, neurostimulation would appear to be a reasonable option for the management of cervicogenic headache, but its safety and efficacy have not yet been determined. Overall, surgical procedures such as neurectomy, dorsal rhizotomy, and microvascular decompression of nerve roots or peripheral nerves are not generally recommended without compelling radiologic evidence for a surgically correctable pathologic condition or a history of refractoriness to all reasonable nonsurgical treatment modalities.

Physical therapy Treatment for cervicogenic headache

The successful treatment of cervicogenic headache usually requires a multifaceted approach using pharmacologic, nonpharmacologic, manipulative, anesthetic, physical therapy and occasionally surgical intervention. Medications alone are often ineffective or provide only modest benefit for this condition. Anesthetic injections can temporarily reduce pain intensity but have their greatest benefit by allowing greater participation in physical treatment modalities. The success of diagnostic cervical spinal nerve, medial branch, or zygapophyseal joint blockade can predict response to radiofrequency thermal neurolysis developing an individualized treatment plan enhances successful outcomes. Most cases of cervicogenic headache heal
well with appropriate physiotherapy. The success rate of treatment is largely dictated by patient compliance. One of the key components of treatment is that the patient rests sufficiently from any activity that increases their pain or ache until they are symptom free (a postural support or postural taping may be required). Activities which place large amounts of stress through the upper neck should also be minimized, these include: sitting, standing or lying in poor posture (slouching), head looking down activities, shoulders forward activities and lifting. Resting from aggravating activities allows the body to begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.

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Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to lead to the condition becoming chronic. Immediate treatment for patients with cervicogenic headache is essential to ensure a speedy recovery. Once the condition is chronic, healing slows significantly resulting in markedly increased recovery times. Patients with cervicogenic headache should perform early movement and postural exercises (often "chin tucks" ) to prevent stiffness from developing and to ensure the neck is functioning correctly. The treating physiotherapist can advise which exercises are appropriate and when they should be commenced. Patients with this condition should also pay particular attention to maintaining good posture as much as possible to minimize stress on the neck. This is particularly important when sitting or driving. Optimal sitting posture can be obtained by sitting tall on an appropriate chair, with bottom in the back of the chair and a lumber support (or a pillow or rolled up towel) in the small of back. Shoulders should be back and chin should be tucked in slightly.

Physiotherapy treatment for patients with this condition is vital to hasten the healing process, ensure an optimal outcome and decrease the likelihood of injury recurrence. Treatment comprises:

Joint mobilization Soft tissue massage Myofascial release Muscle strength and stabilization Generalized strength conditioning and stretching programs Posture and body mechanic education Cervical traction Electrotherapy . Postural taping.

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Postural bracing. Clinical Pilates. The use of an appropriate pillow for sleeping. Exercises to improve flexibility, strength (particularly the deep cervical flexors) and posture.

Neck flexibility exercise. Ergonomic advice.

Description of physical therapy intervention for cervicogenic headache Joint Mobilization:

Decreased joint mobility or altered joint mechanics in the upper part of neck may result in cervicogenic headaches. Treatment for this is achieved through gentle joint mobilization techniques, strain counter strain techniques, and muscle energy techniques. Joint mobilizations are pain free techniques that improve the joint mechanics. This is not aggressive and is not manipulation. Joint mobility is also promoted throughout the lower cervical and thoracic spine, as restrictions in these areas may contribute to cervical condition.

Soft Tissue Mobilization:

Increased muscle tone (tightness) or muscle spasm may contribute to headaches. When the muscles that attach to the base of the skull are tight, they may compress the neurovascular bundle resulting in tension type or cervicogenic headaches. These
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headaches can start at the base of skull and radiate toward forehead in the shape of a banana. Jaw muscles may also get tight resulting in pain & headaches felt in the temples and forehead. Individuals with primary headache disorders (migraine, cluster, and tension type headaches) often develop muscle pain and stiffness which can increase the frequency and intensity of these headaches. There are multiple soft tissue mobilization techniques utilized to decrease muscle tone and improve flexibility in these muscles. Decreasing muscle tone and improving muscle flexibility may decrease the frequency and intensity of primary headaches, and help to resolve cervicogenic headaches.

Muscle Strength & Stabilization:

Proper joint mechanics in the cervical spine depend on muscle strength and tension relationships. When neck muscles are too weak or too tight more stress is placed on the ligaments and joint capsules. Tightening or shortening of the neck muscles can result in increased compression of the spine which may cause pain in the neck and head and may result in wearing away of the joint surfaces.

Generalized Strength, Conditioning & Stretching Program

Exercise and physical conditioning programs are established in order to promote longterm prevention and control of neck pain and headaches. Gentle stretching programs are included to promote flexibility and proper muscle length tension relationships.

Posture & Body Mechanic Education:

Education is provided on posture correction, proper ergonomics, and proper body mechanics in order to decrease repetitive stress and muscle strain throughout the spine. Performing activities with proper posture and body mechanics helps to prevent re-injury
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and recurrence of condition. Proper neck posture means alignment of the head and neck to minimize the forces on the discs, facet joints and other structures. Bad posture, especially when sitting for prolonged periods, is one of the most common causes of neck related headaches and improving posture often improves pain. Poor posture places strain on the discs and joints and causes pain. Good neck posture is also related to good low back posture. It is necessary to sit straight and allow back to keep its normal curve to balance the rest of the spine. Forward bending should occur mostly at the base of the skull, not the lower back.

Postural correction

Electro therapy
Ultrasound is used at is affected area where the pain is maximum felt. For the referred type of pain TENS is very helpful.

Cervical Traction:
This treatment means that traction is applied to stretch out the affected muscles and tissues of the cervical spine. For many people, cervical traction provides great relief by promoting space between the vertebrae and elongating the impaired muscle groups. This is usually only required in patients with arthritis, producing Cervicogenic headache.

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Posture Taping
The following posture taping techniques are designed to support the upper back and neck, improve postural alignment and reduce stress on the spine during activity. They can be used for both the treatment and prevention of upper back and neck injuries, particularly those associated with poor posture.

Benefits of Posture Taping

When used correctly, posture taping techniques can:

Decrease pain during sport or activity (especially prolonged sitting or standing). Aid healing of certain injuries. Allow an earlier return to sport or activity following injury. Reduce the likelihood of injury aggravation. Prevent injuries during high risk activities (usually involving repetitive bending

forwards or prolonged slouching such as sitting at a computer for long periods).

Indications for Posture Taping

It is generally beneficial to use postural taping in the following instances: 1. With certain upper back, neck or shoulder injuries such as postural

syndrome where poor posture is contributing to the injury (this should be discussed with the treating physiotherapist as certain injuries should not be taped).

To prevent injury or injury aggravation Posture taping may be beneficial during activities or sports that place the upper back or neck at risk of injury or injury aggravation (such as office work, gardening, repetitive bending forwards, activities encouraging poor posture etc.).

When should avoid Posture Taping?

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Posture taping should be avoided in the following instances:

Patient has certain injuries (such as some fractures - this should be discussed with the treating physiotherapist).

Patient has a skin allergy to sports tape. The taping technique results in an increase in symptoms such as pain, ache, itchiness, discolouration, pins and needles, numbness, or excessive redness of the back, neck, shoulders, arms or hands.

Patient has sensory or circulatory problems.

Weaning off posture tape in general activity is usually recommended as posture, strength and range of movement improves and symptoms reduce. In these instances, taping during activities encouraging poor posture may still be recommended.

Posture Taping Techniques

The following postural taping techniques may be used to provide support for the upper back and neck and to improve posture. Generally it is recommended that the back is shaved 12 hours prior to taping (to prevent painful removal of hairs and skin irritation). The skin should be cleaned and dried, removing any grease or sweat. Low irritant fix mull tape should be applied as an under-wrap to reduce the likelihood of skin irritation with rigid sports tape over the top of this.

Posture Taping
Begin sitting or standing in good posture. spine should be straight with shoulders back and chin tucked in (eyes looking straight ahead figure 1).

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Figure 1 Good Posture

Anchors Place a strip of tape along the top of the shoulders and across the top of the lower back (figure 2). These are used as a fixation point for the other taping techniques.

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Figure 2 Anchors

Vertical Lines
Maintain the spine in optimal posture (figure 1). Begin this taping technique at the level of the top anchor by following the black arrows (figure 3). Conclude this taping technique at the level of the bottom anchor by following the white arrows (figure 3). Create 3 straight lines with the middle line in the centre of the spine.

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Figure 3 Vertical Lines

Diagonal Lines Removing the tape

Care should be taken when removing the tape to avoid injury aggravation or skin damage. The tape should be removed slowly, pulling the tape back on itself with pressure placed on the skin as close as possible to the line of attachment of the tape.Generally tape should be removed within 48 hours of application or sooner if there is any increase in pain or symptoms (including skin irritation or itchiness).

Body Assist Posture Support

The Body Assist Posture Support is one of the most commonly recommended posture supports by physiotherapists. This light-weight support is designed to improve posture and reduce stress on the upper back and neck. It is particularly useful for patients who have poor posture or 'rounded shoulders', or for patients who experience upper back or neck pain during positions of poor posture (e.g. sitting at a computer, driving, performing household duties such as cooking, ironing, vacuuming etc.). The support is easily applied by inserting each arm into the circular loop at the end of each of the 2 straps. Having anchored the straps around both shoulder joints, cross the straps at the mid back and close at the front of your body. This results in a gentle but firm support, pulling the shoulders back and a subsequent taller, straighter spine. The support is made of a unique elastic material that has been brushed on one side to create an almost 'cotton-wool' finish. Consequently, it can be applied directly over bare skin with comfort and is almost invisible under your clothes. This product improves posture, allows unrestricted movement, delivers all day comfort and is totally washable and hygienic.

Exercises for cervicogenic headache

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The following exercises are commonly prescribed to patients with this condition. .Generally, it should be performed 3 5 times daily and only provided they do not cause or increase symptoms.

Neck Stretches Basic Exercises Chin Tucks

Begin sitting or standing tall with back and neck straight, shoulders should be back slightly. Tuck your chin in until feel a mild to moderate stretch pain-free (figure 1). Keep your eyes and nose facing forwards. Hold for 2 seconds and repeat 10 times.

Figure 1 Chin Tucks

Shoulder Blade Squeezes

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Begin sitting or standing tall with your back straight. Squeeze your shoulder blades together as hard and far as possible pain-free (figure 2). Hold for 5 seconds and repeat 10 times.

Figure 2 Shoulder Blade Squeezes

Extension in Sitting
Begin sitting tall, with back and neck straight, shoulders back slightly. Gently take neck backwards, looking up towards the ceiling until you feel a mild to moderate stretch painfree (figure 3). Repeat 10 times.

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Figure 3 Extension in Sitting

Rotation in Sitting
Begin sitting with back and neck straight and shoulders back slightly. Turn head looking over one shoulder until feel a mild to moderate stretch pain-free (figure 4). Keep neck straight and don't allow head to poke forwards during the movement. Repeat 10 times to each side.

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Figure 4 Rotation in Sitting (right side)

Side Bend in Sitting

Begin sitting tall with back and neck straight, shoulders should be back slightly. Gently bend neck to one side until feel a mild to moderate stretch pain-free (figure 5). Make sure neck does not bend forwards during the movement. Repeat 10 times on each side.

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Figure 5 Side Bend in sitting (right side)

Flexion in Sitting
Begin sitting tall, with neck and back straight, your shoulders should be back slightly. Gently bend neck forwards, taking chin towards chest until you feel a mild to moderate stretch pain-free (figure 6) . Repeat 10 times.

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Figure 6 Flexion in Sitting

Beginner Pilates Exercises

The following beginner Pilates exercises should be performed approximately 1 - 3 times per week. As control improves, the exercises can be progressed by gradually increasing the repetitions or frequency of the exercises provided they do not cause or increase pain.

Heel Slides
Begin this Pilates exercise lying on back with hands by side in neutral spine as demonstrated (figure 1). Maintain activation of transversus abdominis and pelvic floor muscles throughout the exercise. Slowly straighten one knee and then return to the starting position. Keep spine and pelvis completely still and breathe normally. Perform 10 times alternating between legs.

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Figure 1 Heel Slides

Leg Openings
Begin this Pilates exercise lying on back with hands by side in neutral spine as demonstrated (figure 2). Maintain activation of transversus abdominis and pelvic floor muscles throughout the exercise. Slowly take one knee to the side and then return to the starting position. Keep spine and pelvis completely still and breathe normally. Perform 10 times alternating between legs.

Figure 2 Leg Openings

Leg Lifts
Begin this Pilates exercise lying on back with hands by side in neutral spine as demonstrated (figure 3). Maintain activation of transversus abdominis and pelvic floor muscles throughout the exercise. Slowly lift one leg and then return to the starting position. Keep spine and pelvis completely still and breathe normally. Perform 10 times alternating between legs.

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Figure 3 Leg Lifts

Heel Taps
Begin this Pilates exercise lying on back in neutral spine with hands by side and hips and knees bent to 90 degrees as demonstrated (figure 4). Maintain activation of transversus abdominis and pelvic floor muscles throughout the exercise. Slowly lower one leg until heel touches the ground and then return to the starting position. Keep spine and pelvis completely still and breathe normally. Perform 10 times alternating between legs.

Figure 4 Heel Taps

Bridging
Begin this Pilates exercise lying on back in neutral spine as demonstrated (figure 5). Maintain activation of transversus abdominis and pelvic floor muscles throughout the exercise. Slowly lift bottom pushing through feet, until knees, hips and shoulders are in a straight line and then return to the starting position. Breathe normally. Perform 10 times.

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Figure 5 Bridging

Physiotherapy products for cervicogenic headache

Some of the most commonly recommended products by physiotherapists to hasten healing and speed recovery in patients with this condition include: 1. Postural supports 2. Therapeutic pillows 3. Ice packs &hot packs 4. Lumber rolls for sitting 5. Sports tap for post

Neck: Exercises to increase flexibility & muscle control.

The neck consists of a series of interlocking blocks (vertebrae), each linked on either side by a facet point, and all but the top two separated by a disc. Problems can arise with any of these structures: it is possible to have a painful, stiff facet joint on one side only or on both sides, and pain at more than one facet joint on one or both sides, or at one or more facet joints and discs. Pain may be localized, or it
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NECK TURNS

Lie on back with a pillow under your head gently turn your head to the right and return. Repeat.

Gently turn head to the left and return. Repeat.

NECK TILTS

Lie on back with a pillow under your head. Gently tilt your head sideways to the right, bringing y ear to shoulder. Return and repeat.

Gently tilt head sideways to the left, bringing ear to shoulder. Return and repeat.

NECK STRETCHES

Lie on whichever side is more comfortable, with a pillow under head. Bend your head down toward chest. Return and repeat.

Tip head back gently, without letting chin point up- i.e. keep neck straight, don't twist it. Return and repeat.

Importance of ergonomic computer setup

Maintaining correct posture whilst sitting at a computer is extremely important to minimize stress on the spine and reduce the likelihood of injury. This is particularly important due to the high prevalence of injuries in society due to poor ergonomic

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computer setup, long hours of work in front of a computer and a sedentary lifestyle. Low back pain, neck pain, shoulder pain and headaches are all common injuries that can occur from having your office, desk or computer set up incorrectly.

Ergonomic sitting
When sitting at your desk the following ergonomic points should be considered:

It is important to have an ergonomically correct chair which offers firm support, thereby allowing your body to maintain correct posture.

The height of the chair should allow hips and knees to be at right angles (it is important not to have knees higher than the level of hips) and feet firmly supported on the floor (a foot stool may be required).

Bottom should be situated at the back of the chair and a lumbar support should be placed in the small of back.

Shoulders should be held back slightly and chin should be tucked in a little A 'Kneeling Chair' or 'Swiss Ball' can sometimes assist in reducing the stress on the lumbar spine and assist with maintaining good posture whilst working at a desk.

How to create an ergonomic computer setup

When sitting at a computer desk, the goal is to organize environment ergonomically so you can easily maintain correct posture. The following ergonomic points should be considered:

The height of the desk should allow you to have elbows bent at approximately 90 degrees.

Provided touch type, keyboard should be close to patient. Have to look at the keys, it should be as close as possible so patient can look down at the keys (using eyes only) without having to bend neck.

Mouse, telephone and other accessories should be as close as possible to prevent patient having to lean forwards or to the side to reach them.

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Computer monitor should be positioned directly in front, at, or slightly, below eye level (certainly not to the side or above the level of eyes).

Chair should be situated as close to the desk as possible. Actively practice holding yourself in good posture during sitting and check position regularly to ensure have not resumed slouching.

Regular breaks from sitting are recommended with standing, walking or lying and should occur regularly enough to prevent any onset of pain.

It is good practice to regularly switch the side of body use to perform various tasks to maintain balance and give one side of body a break from repetitive or prolonged stress (e.g. use the mouse in left and right hands equally)

Performing regular exercises can also assist in preventing a posture related injury by giving body a break from the continuous stress of sitting in one position.

Prognosis for cervicogenic headache

Most patients with this condition heal quickly and have a full recovery with appropriate physiotherapy treatment. Recovery time varies from patient to patient depending on compliance with treatment and severity of injury. With ideal treatment, patients with minor cases of cervicogenic headache may be pain free in as little as a couple of days, although sometimes it may take 2 3 weeks. In severe or chronic cases a full recovery may take weeks to months.

Conclusion
By the help of the physical therapy approaches like joint mobilization, soft tissue manipulation, postural correction techniques, specific neck stretching and strengthening programs, Pilates exercise, and postural taping help to reduced the symptoms of cervicogenic headache and provide stability for the neck muscles and reduced the pain.

References
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Wikipaedia Blau JN, MacGregor EA. Migraine and the neck. Headache. 1994;34:88-90. Sjaastad 0, Saunte C, Hovdahl H, Breivik H, Gronback E. Cervicogenic headache. A hypothesis. Cephalalgia. 1983;3:249-256. Edmeads J. The cervical spine and headache. Neurology. 1988;38:1874-1878. ollmann W, Keidel M, Pfaffenrath V. Headache and the cervical spine: a critical review. Cephalalgia. 1997;17:501-516. Leone M, D'Amico D, Grazzi L, et al. Cervicogenic headache: a critical review of the current diagnostic criteria. Pain. 1998;78:1-5. Bogduk N. The anatomical basis for cervicogenic headache. J Manipulative Physiol Ther. 1992;15:67-70 Tfeld-Hansen P, Lous I, Olesen J. Prevalence and significance of muscle tenderness during common migraine attacks. Headache. 1981;21:49-54.

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