T he World Health Organization (WHO) declared that headache disorders generate a substantial disability burden and suggested health classification of headaches amongst major public health disorders. WHO also points out that there is a specific lack of public and professional awareness of the epidemiology of headache disorders and their impact on individual sufferers, their careers, family and colleagues, and on society.1
While health care professionals continue the controversial debate over the classification of cervicogenic headaches, a comprehensive multidisciplinary pain treatment program provides the greatest opportunity for overall clinical improvement.2 Recent evidence suggests that chiropractic care, including spinal manipulation, improves migraine and cervicogenic headaches.3
The cervicogenic headache (CGH), first introduced by Sjaastad in 1983,4 had been discussed between 1860 and 1862 and described as a pain in the scalp mediated through the trigeminal nerve or the occipital nerves due to disease of the spine as documented in John Hilton’s classical text, Rest and Pain5. A more recent review defines CGH and describes the nociceptive pathways: A chronic, hemicranial pain syndrome in which the sensation of pain originates in the cervical spine or soft tissues of the neck and is referred to the head.
The trigeminocervical nucleus is a region of the upper cervical spinal cord where sensory nerve fibers in the descending tract of the trigeminal nerve converge with sensory fibers from the upper cervical roots. This convergence of nociceptive pathways allows for the referral of pain signals from the neck to the trigeminal sensory receptive fields of the face and head.6
While science attempts to define CGH, the public suffers with headaches. In fact, twenty-five percent of all headaches are actually “rebound” episodes triggered by the overuse of common pain medications, which include both prescription and over-the-counter drugs.7 This putative case report provides the reader with a clinical learning opportunity. The discussion addresses certain aspects of the evaluation and management process and proper documentation of the intervention. I will demonstrate a reasonable approach to the examination and differential diagnosis of a patient with cervicogenic headaches, back and neck pain and offer a prudent treatment plan.
Chief Concern: “I have headaches, back and neck pain”
A woman claims that headaches have occurred 1-2 times per week for the past two months and that sitting at the computer for extended periods usually produces the headaches. She confirms that she leans forward while typing on the laptop and experiences the headaches after 2-3 hours of work. She demonstrated her slouching work posture while using the computer, which displayed a rounding of the shoulders and significant forward head posture. Then she pointed to the right occipital and temporal areas as the areas of her pain. She denied any morning headaches, loss of vision, weakness or loss of consciousness with the headaches.
A dull ache in the neck has been bothering her for the past six months. The daily neck ache occurs with prolonged work at the computer. The neck pain becomes a sharp, localized pain in the lower neck on the right side when she turns her head to the right. She also experiences stiffness in the neck upon waking in the morning. A hot shower reduces the discomfort. Throbbing and aching in neck and shoulder blades occurs during the afternoons.
For the past three months, she has experienced lower back pain with prolonged sitting. She described the low back pain as a burning pain across her lower back. She experiences lower back pain and difficulty rising to stand due to stiffness in the back and hips after sitting for a prolonged time (3-5 hours). Severe tightness in the back of her thighs and legs bother her while gardening. She experienced 50 percent relief of lower back pain after receiving one chiropractic adjustment last year. She denied weakness or radiating pains in the extremities. She rated her head pain on an 11-point numerical pain scale at between 3-6/10 and the neck and lower back pain rated at 0-4/10.
NSAIDS, relaxation, hot bath or shower and massage usually provide relief of her pains. Her past medical history included numerous spinal strains and sprains as a young gymnast. She consumes two sodas and eleven glasses of water per day. She has gained 40 pounds over the past 4 months following treatment of an infection with steroids. She would like to have her neck and back adjusted to gain relief of the headaches and spinal pain. This young woman insisted that adjustments “help a lot” and provide a “quick fix.”
This pleasant but distressed 35-year-old Hispanic female appears to be her stated age. She is well-developed, obese, alert, cooperative and a good historian.
Vital signs: Height: 65” Weight: 183#, B/P: 169/123, Pulse: 78, Temperature: 97.35 degrees Fahrenheit aural. Allergies: milk, sulpha, codeine. Tobacco: She smokes three cigarettes during the day. If she is “stressed out”, she smokes another three at night. Alcohol: denies. Recreational drugs: denies.
Posture: She exhibited a forward head posture and rounded shoulders while seated. An inferior left iliac crest and right shoulder inferiority was observed while she was standing.
Leg length mensuration: She demonstrated a left functional leg length deficiency in the supine position and a right functional leg length deficiency while seated. Anatomical measurement of the leg lengths demonstrated the lengths to be symmetrical at 33 inches.
Palpation: Pain produced at the occipital nerves on the right. Pinching of the right upper trapezius muscles demonstrated a positive jump sign, taut bands, painful nodules and hypertonicity. Myofascial trigger points revealed in the sternocleidomastoideus and posterior scalene muscles on the right. Lumbar multifidi muscles were hypertonic with painful nodules at the levels of L4-5 bilaterally. Palpation produced pain over the ligamentum nuchae at C2-3, C4-5--6 and the supraspinous ligaments of L5-S1.
Cervical range of motion: Active range of motion was full, symmetrical and without pain with flexion, extension, lateral flexion and rotation except for reduced right rotation and lateral flexion with pain at C2-3 and C5-6 on the right. Passive range of motion produced pain at C2-3 and C5-6 right with right rotation and lateral flexion.
Dorso-lumbar range of motion: Active range of motion was symmetrical without pain with flexion and lateral flexion but hyperextension demonstrated hypermobility and pain at the lumbosacral joints bilaterally.
Posterior joint dysfunction revealed at L5-S1, C2-3 and C 5-6. There was a reduced range of motion with right lateral flexion and rotation with pain on right at C2-3 and C5-6. Palpation revealed cervical paravertebral hypertonicity on the right and pain at C2-3 and C5-6 over the ligamentum nuchae and the right posterior cervical muscles. Hypermobility and localized pain demonstrated at L5-S1 bilaterally with extension.
Cervical compression: Active and passive maximal foraminal compression produced pain at C 5-6 on right.
Cervical distraction: Positive with relief of pain in neck.
Kemp maneuver: Negative without sciatica but produced pain at L5-S1 bilaterally.
Modified Gillet: Demonstrated SIJ fixation left with a left thumb up going while the right thumb was down going.
One-leg hyperextension: Test produced pain at L5-S1 on right with flexion of left lower extremity.
Lumbar stabilization test: Negative and without pain upon extension of legs while prone.
Neurological examination: Deep tendon reflexes were 2+ bilaterally and brisk for the upper and lower extremities. Motor testing revealed the upper and lower extremities to be 5/5 without signs of atrophy. Sensory testing revealed the trigeminal nerve and extremity dermatomes to be intact for sharp and light touch. There were no signs of upper or lower motor neuron lesions.
- Decreased disc spacing at C5-6 and L5-S1
- Osteophytic formations at the anterior margins of the vertebral bodies at C5-6
- Imbrication of L5 and S1 zygapophyseal joints
- No signs of fracture, dislocation, or bone destruction
- Cervicogenic headaches due to postural strain with resultant active myofascial trigger points and posterior joint dysfunction
- Lumbar facet syndrome
- Postural imbalance due to pelvic obliquity
- Suspected cervical and lumbar degenerative joint and disc disease
- Consult with the primary care provider prior to commencing conservative chiropractic management of her condition. Suggest follow-up with her primary care physician due to the hypertension and sudden weight gain. Discuss co-management of patient due to her hypertension, obesity and chronic musculoskeletal pain conditions.
- Upon approval by her primary care provider, I would like her to begin chiropractic care, a regular walking program and yoga in order to reduce weight and improve flexibility.
- Ordered radiographic study of the cervical and lumbar spine to determine status of discs and joints and determine indications of spinal manipulation.
- Will recommend chiropractic manipulation treatments and soft-tissue treatments three times per week for a period of two weeks to reduce pain and improve spinal function. Follow-up exam after she receives the initial six treatments. Advised 6-12 chiropractic treatments might be necessary to provide relief of her pain.
- Will recommend massage therapy once per week for 6 weeks to relieve stress and provide muscle relaxation.
- Recommended postural exercises to reduce forward head posture and rounded shoulders.
- We discussed the advantages and complications of chiropractic care. She understands the diagnosis and treatment plan. She consents to this treatment plan. She has been a patient in this office in the past and is very familiar with the recommended treatments. She will follow-up with her primary care provider this week prior to commencing chiropractic care.
Her current reading of 169/123 classifies her condition as stage 2 hypertension.8 Hypertension,9 which causes arteriosclerosis10 and predisposes patients to heart disease,11 peripheral vascular disease, and cerebrovascular attacks,12 is the most common cause of death in the United States.13 As patient-centered clinicians, we must appreciate the need to evaluate this most serious condition and refer the patient to the primary care provider
Many family physicians consider headaches, which are common primary care conditions, to be enigmatic.14 Cervicogenic headaches arising from cervical vertebrae or myofascial tissues or other soft tissues of the neck and shoulders15 may be resistant to care if not properly diagnosed.16 Bogduk has described the anatomical basis for cervicogenic headaches, which might explain the rationale for chiropractic interventions with upper cervical spine manipulation: 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.17
Chiropractors who use spinal manipulation and prescribe cervical exercises for cervicogenic headaches are likely to render the most effective treatment.18 Yet, clinicians must perform a detailed neuromusculoskeletal evaluation in order to identify the involved tissues responsible for cervicogenic headaches. Haldeman confirms my statement by saying that most pathologies affecting the cervical spine have been implicated in the genesis of cervicogenic headaches because of convergence of sensory input from the cervical structures within the spinal nucleus of the trigeminal nerve.19
As a Board Certified Chiropractic Orthopedist, I am confident with my assessment of this patient for neuromusculoskeletal disease. Many prescription and nonprescription drugs can cause or exacerbate hypertension, which includes corticosteroids and NSAIDS.20 Consequently, I am not comfortable evaluating and managing a patient presenting with hypertension and sudden weight gain following the use of corticosteroids. I will consult with the primary care provider, express my concerns and discuss my neuromusculoskeletal evaluation and management.
The Affordable Care Act and the National Prevention Strategy expect health care providers to enhance coordination and integration of clinical, behavioral, and complementary health strategies.21 Since integrated health care describes a coordinated system in which health care professionals are educated about each other’s work and collaborate with one another and with their patients to achieve optimal patient well-being,22 co-managing this patient’s conditions will benefit the patient and educate the involved health care providers.
Chiropractic physicians should develop treatment plans based upon patient needs, diagnoses, and response to care. A study by Haas et al. suggests that multiple treatments are necessary to manage patients with cervicogenic headaches:
A large clinical trial on the relationship between pain relief and the number of chiropractic treatments is feasible. Findings give preliminary support for the benefit of larger doses, 9 to 12 treatments, of chiropractic care for the treatment of cervicogenic headache.23
Chiropractic physicians are responsible for evaluation and management of patients presenting with headaches. The evaluation requires the use of orthopedic and neurological examination procedures that develop a differential diagnosis and a reasonable treatment plan.
James J. Lehman, D.C., M.B.A., D.A.B.C.O. is an Associate Professor of Clinical Sciences at the University of Bridgeport College of Chiropractic. Please remit any questions or comments to
- Headache Disorders and Public Health: Education and Management Implications. This document results from the Meeting on Headache and Related Disorders, held at WHO headquarters, Geneva, 13-14 March 2000. [Cited October 22, 2011] Available from: http://www.migraines.org/new/pdfs/who.pdf
- Yadka, S., Gehret, J., Campbell, P., Mandell, S., & Ratliff, J.K. A Pain in the Neck: Review of Cervicogenic Headaches and Associated Disorders. JHN Journal. [Cited October 22, 2011] Available from: http://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1043&context=jhnj
- Bryans, R., Descarreaux, M., Duranleau, M., Marcoux, H., Potter, B., Ruegg, R., Shaw, L., Watkin, R., & White, E. Evidence-based guidelines for the chiropractic treatment of adults with headache. J Manipulative Physiol Ther. 2011 Jun;34(5):274-89. [Cited October 22, 2011] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21640251
- Sjaastad, O., Saunte, C., Hovdohl, H., Gronbaek, E. ’Cervicogenic’ Headache, An Hypothesis. Cephalgia, 1983, 249-256.
- Hilton J. Rest and pain (1950:77). Walls, E.W. & Phillips E.E., eds. London: Bell.
- Biondi JM. Cervicogenic Headache. JAOA, September 2000; Vol 100, No. 9. Supplement to September 2000. S7-14. [Cited October 22, 2011] Available from: http://www.jaoa.org/content/100/9_suppl/7S.full.pdf
- Diener, H.C. & Limmroth, V. Medication-overuse headache: a world-wide problem. The Lancet Neurology, Volume 3, Issue 8, Pages 475 - 483, August 2004. [Cited October 22, 2011] Available from: http://www.thelancet.com/journals/laneur/article/PIIS1474-4422(04)00824-5/fulltext Chobanian, A.V., Bakris, G.L., Black, H.R. et al. (December 2003). Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension, 42(6), 1206–52.
- Chobanian, A.V., Bakris, G.L., Black, H.R. et al. (December 2003). Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension, 42(6), 1206–52.
- Novo, S., Lunetta, M., Evola, S., & Novo, G. (January 2009). Role of ARBs in the blood hypertension therapy and prevention of cardiovascular events. Current Drug Targets, 10(1), 20–5.
- Riccioni, G. (2009). The effect of antihypertensive drugs on carotid intima media thickness: an up-to-date review. Current Medicinal Chemistry, 16(8), 988–96.
- Agabiti-Rosei, E. (September 2008). From macro- to microcirculation: benefits in hypertension and diabetes. Journal of Hypertension, 26 Suppl 3, S15–21.
- Singer, D.R., Kite, A. (June 2008). Management of hypertension in peripheral arterial disease: does the choice of drugs matter?. European Journal of Vascular and Endovascular Surgery, 35(6), 701–8.
- Novo, S., Lunetta, M., Evola, S, & Novo, G. (January 2009). Role of ARBs in the blood hypertension therapy and prevention of cardiovascular events. Current Drug Targets, 10(1), 20–5.
- Sierpina, V., Astin, J., Giordano, J. Mind-body Therapies for Headache. Am Fam Physician. 2007 Nov 15; 76(10):1518-1522. [Cited October 23, 2011] Available from: http://www.aafp.org/afp/2007/1115/p1518.html
- Biondi, D.M. Cervicogenic Headache: A Review of Diagnostic and Treatment Strategies. J Am Osteopath Assoc April 1, 2005 vol. 105 no. 4 Suppl 16S-22S. [Cited October 23, 2011] Available from: http://www.jaoa.org/cgi/content/full/105/4_suppl/16S
- Edmeads, J. The cervical spine and headache. Neurology, 1988;38:1874-1878.
- Bogduk, N. The anatomical basis for cervicogenic headache. J Manipulative Physiol Ther. 1992;15:67-70.
- Jull, G., Trott, P., Potter, H., Zito, G., Niere, K., Shirley, D. et al. (2002). A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine, 27(17), 1835-1843.
- Haldeman, S., Dagenais, S. Cervicogenic headaches: a critical review. Spine J. 2001 Jan-Feb;1(1), 31-46.
- Onusko E. Diagnosing Secondary Hypertension. Am Fam Physician. 2003 Jan 1;67(1):67-74. [Cited October 22, 2011] Available from: http://www.aafp.org/afp/2003/0101/p67.html
- Onusko E. Diagnosing Secondary Hypertension. Am Fam Physician. 2003 Jan 1;67(1):67-74. [Cited October 22, 2011] Available from: http://www.aafp.org/afp/2003/0101/p67.html
- U.S. Preventive Services Task Force. Integrating Evidence-Based Clinical and Community Strategies to Improve Health. Available at http://www.uspreventiveservicestaskforce.org/uspstf07/methods/tfmethods.htm. Accessed May 17, 2011.; Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academies Press; 2001. [Cited October 22, 2011] Available from:
- Haas, M., Groupp, E., Aickin, M., Fairweather, A., Ganger, B., Attwood, M., Cummins, C., & Baffes, L.J. Manipulative Physiol Ther. Dose response for chiropractic care of chronic cervicogenic headache and associated neck pain: a randomized pilot study.2004 Nov-Dec; 27(9):547-53. [Cited October 23, 2011] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15614241