Intervention For Cervicogenic Headache: Case Report with 15-Month Follow-Up

Eric Wilson, PT, DSc, OCS, SCS, CSCS1,2

1
Dyess AFB, TX., 2Regis University Manual Therapy Fellowship Program, Denver, CO.
Manual Therapy Fellowship

ABSTRACT Table 1: Cervical Spine AROM Figure 1: Neck Disability Index Scores Over Time
Purpose: Physical therapists are often faced with small windows of Eval Eval Eval+ Eval + Eval + 70

opportunity to treat patients prior to their prolonged absence from

the local area. This case describes the three treatment sessions of Pre-Treat Post-Treat 2 d 13 d 15 mo
a patient with chronic cervicogenic headaches over an eleven day Ext 29° 87° 63° WNL WNL
period. Case Description: The patient was a 17 year old female 50

Rt Rot 45° 75° 74° WNL WNL

with a 15-month history of right-sided suboccipital, occipital and
frontalis headaches not present prior to a MVA in October 2005. Lt Rot 30° 73° 73° WNL WNL
She presented as a direct access patient on January 2007,
reporting a frequency of three to five headaches per week causing
30
NDI Score

significant interruption in her sleep and ADL’s. She reported no Table 2: Craniocervical Flexion Text: Performance Index
relief with treatments from her pediatrician, neurologist and Eval Eval Eval+ Eval + Eval +
cardiologist. A family vacation was planned in two weeks. Neck Pre-Treat Post-Treat 2 d 13 d 15 mo 10

Disability Index (NDI) score was 69% and Numeric Pain Rating
Scale (NPRS) average score was 6.6. The physical exam
demonstrated:
• Limited cervical AROM extension & rotation (Table 1) caused pain
• Tightness of suboccipitals, right levator scapula & scalenes, and
bilateral upper trapezius
• Hypomobility at C0-C1 bilaterally & C1-C2 into left rotation
• Cranio-Cervical Flexion Test Performance Index (CCFTPI) score
of 10 (Table 2)
Treatment/Results: The patient was treated with muscle energy
technique (MET) at CO-C1 and C1-C2. Reassessment showed
• Reduction of headache (VAS 1/10)
• Increased cervical AROM (Table 1) and
• Improved CCFTPI of 60
• HEP prone chin-tuck on a towel roll
She returned two days later and reported no headaches since her
treatment.
• NDI was 9% and NPRS was 0.66.
• Cervical AROM (Table 1) all without pain.
• Left CO-C1 showed mild hypomobility, treated with MET.
• No other dysfunctions noted
Patient was re-evaluated 11 days post-evaluation.
• NDI was 2% and NPRS average was 0.
• Cervical AROM was WNL and CCFTPI increased to 80.
A follow-up was performed 15 months later at which the patient
reported no headaches since last being seen. Assessment
revealed cervical AROM WNL, no muscle tightness or dysfunctions
in the cervical area, NDI score of 0% and CCFTPI of 100.
Clinical Relevance: While a similar case study involving manual
therapy for cervicogenic headaches has been reported, this case is
different in that the window for intervention was considerably
shorter and the interventions were isolated to the suboccipital
region. The patient’s increase in the CCFTPI in the short-term may
indicate that MET applied at CO-C2 has a facilatory effect on the
deep cervical flexors similar to that of how HVLA at the SIJ has
been shown to facilitate Transverse Abdominis activation. The
efficacy of MET in the treatment of cervicogenic headaches and its
possible influence on the activation of the deep cervical flexors
CCFT *10 mmHg **60 mmHg N/A 80 mmHg 100 mmHg
PI
*10mmHg increased from 20mmHg x 1 rep -10
Eval Eval +2D Eval +13D Eval +15mo
**10mmHg increased from 20mmHg x 6
reps
BACKGROUND
• Headache lifetime prevalence – 96%
• 70% headache sufferers c/o neck pain associated w/ their headache
• Estimated Cervicogenic Headache (CGH)
• 14-18% of chronic headaches5
• 15-20% of recurrent headaches1,4
TEST ITEM CLUSTER TO DIAGNOSE CERVICOGENIC HEADACHES
• 1-Limited extension, 2-Deep cervical flexor impairments, 3-Painfully palpable upper cervical2
• 3 of 3: Sn 100%, Sp 94% (published after initial patient encounter)
• All 3 positive for this patient
DISCUSSION
• Patient’s deficits supported by literature (limited cervical AROM2,5, deep cervical flexor
impairments ,upper cervical dysfunctions and muscles identified as tight )
2,5 2 5
• Results of increased Cranio-Cervical Flexion Test Performance Index scores do not agree
with previous study by Jull3 in that the patient had increased scores with manual therapy
without exercise
• Jull3 used Maitland mobilizations and manipulations vs. the muscle energy techniques
(MET) used in this case
• The role MET may play on deep neck flexor activation merits investigation
REFERENCES:
• Hall et al. J Ortho Sports Phys Ther. 2007; 37:100-107.
• Jull et al. Cephalgia. 2007; 27:793-802
• Jull et al. Spine. 2002; 17:1835-1843
• Nilsson et al. J Manip Physiol Ther. 1997; 20:326-330.
• Zito et al. Man Ther. 2006; 11:118-129.
The opinions and assertions contained herein are the private views of the
author and are not to be construed as official or as reflecting the views of
the Departments of the Air Force or Defense.