Cervicogenic headaches occur from referred pain to the head originating from the joints and/or soft tissues of the cervical spine or neck. Soft tissues of the neck include the muscles, fascia or connective tissue, ligaments, discs, or nerves. Cervicogenic headache (CGH) patients present with neck tenderness and stiffness. By definition, CGH is usually on one side without side shift, but in some cases, the condition may present on both sides. Moderate to severe pain may begin in the neck and progressively affect the areas around the base of the skull, temples, forehead, or the region above the eyes. In some instances, pain may refer to the arm on the same side as the headache. Symptomatic episodes may last hours to days. The characteristic continuous, fluctuating pain is described as “deep” but generally not throbbing. Some patients report it feels like they have a tight band wrapped around their head or it feels like someone is squeezing their head. Symptoms may be triggered or reproduced by sustained or awkward posture, especially in those who sit for multiple hours per day.
This past year, recent studies have found that people who suffer from cervicogenic headaches respond very favorably to spinal manipulative therapy (SMT), or chiropractic adjustments, especially in the short-term. One study highlighted that SMT was a superior treatment to others, including medication, in reducing pain intensity, frequency, and disability associated with this type of headache! The study continued to report that the long-term benefits of SMT on cervicogenic headaches were not as significant. So, what does this mean? Simply put, SMT is an extremely beneficial treatment in quickly reducing symptoms and pain intensity of cervicogenic headaches when used as a stand-alone treatment. Although patients reported a significant decrease in frequency and intensity of headaches, the headaches were not eradicated long-term by SMT alone.
So, why is chiropractic care so effective at treating CGH? The answer is that most chiropractors do not use SMT as a stand-alone treatment. Instead, we use it in combination with other effective treatments including myofascial release, therapeutic exercise, workstation/ergonomic/postural modification, and nutritional counseling. Almost every manual therapist agrees that manipulation is an essential component for managing CGH. However, as mentioned earlier, the successful long-term resolution of CGH patients often requires a multifaceted approach that includes more than isolated SMT.
In order to treat cervicogenic headaches and help reduce or eliminate symptoms long-term, treatments must not only target the symptom or pain-generating tissue but we must aim to understand the root cause or aggravating factor(s). Joint dysfunction, or lack of proper motion and control, of the joints of the upper neck, is a key finding in CGH patients. In many cases, this dysfunction is secondary to chronic muscular imbalance and sustained poor posture. Muscular imbalances occur when we overuse certain muscles of the neck and upper back that are not equipped to withstand the load of sustained poor posture that most of us adopt on a daily basis. Think for a moment about your posture when you are sitting at your computer working for 8 or more hours every day. How would you grade your posture? With poor posture, we create an environment for muscle imbalances to easily occur. Specifically, loss of strength in the deep neck flexors and over-activation of the sternocleidomastoid (SCM), suboccipital muscles, and upper trapezius is a common finding in CGH patients. The deep neck flexors are important muscles for keeping your head retracted over your shoulders and neck in neutral alignment. If these muscles become weak the SCM, suboccipital muscles, and upper trapezius become overactive, tight, and will most certainly refer pain to the head as they develop trigger points or muscle knots.
A prominent rehabilitation specialist in our field has developed specific tests to assess the strength of the deep neck flexors including the neck flexion test and the deep neck flexor endurance test. These tests can accurately identify if these muscles are weak and underdeveloped which can help solidify the diagnosis and the root cause of the CGH. With this information, we can formulate a specific treatment plan including SMT to address the joint dysfunction and a corrective exercise program to address the weakness of the muscles described above. It is typically also very important to perform myofascial release treatments to the overactive muscles to eliminate myofascial tension, trigger points, and scar tissue.
The greater occipital nerve is a spinal nerve that passes through the suboccipital muscles at the base of the skull. This nerve can become entrapped between the muscles and become irritated and inflamed. In this case, neural mobilization exercises, as well as myofascial release and SMT, may need to be performed in order to help guide the nerve more easily through the muscles where it is “trapped”.
All of the above treatments have proven effective in treating the pain-generating tissues that cause CGH. However, we previously stated that these treatments will be effective only short-term if the root cause of the insult to the pain-generating tissues is not addressed. Routine daily activities involving workstations and cell phones can be potent postural trainers to guarantee a flexor-dominated (forward/ head, forward/shoulder) posture. While manipulation is an effective tool for resolving the symptom of this postural fault, it’s no match for the cause. Even treatment three times per week rarely wins the long-term war against 8+ hours of ongoing postural stress. Lasting improvement necessitates a plan to minimize cumulative trauma.
In addition to equipping our patients with corrective exercises, we must seek to eliminate the habits, hobbies, activities, and postures that perpetuate postural imbalance; and workstations are at the top of that list. It is imperative that patients understand the essentials of an ergonomically-friendly workstation in order for treatment to be successful long-term:
Workstation ergonomics:
- Monitors should be visible without leaning or straining, and the top line of type should be 15 degrees below eye level.
- Use audio equipment that keeps you from bending your neck (i.e., Bluetooth, speakerphones, headsets).
- Keep your shoulders relaxed and elbows bent to 90 degrees.
- Wrists should not be bent while at the keyboard. Forearms and wrists should not be leaning on a hard edge.
- Keep frequently used objects, like your telephone, close to your body to prevent excessive reaching.
- Take a 10-second break every 20 minutes: Micro activities include: walking, stretching, or moving your head in a “plus sign” fashion.
- Periodically, perform the “Brugger relief position”: Position your body at a chair’s edge, feet pointed outward. Weight should be on your legs and your abdomen should be relaxed. Tilt your pelvis forward, lift your sternum, arch your back, drop your arms, and roll out your palms while squeezing your shoulders together. Take a few deep cleansing breaths.
In conclusion, chiropractic treatment is extremely effective in reducing symptoms and treating the pain-generating tissues that cause cervicogenic headaches. However, lifestyle modification prescribed by your chiropractic physician is imperative to achieve lasting results. In cases where headaches become chronic and debilitating, medical co-management including medications or injections can also be extremely useful in reducing inflammation and pain. Other adjunctive treatments such as acupuncture can also be useful. At Physio Logic, we deploy the needed treatments led by a group of practitioners trying to achieve the goal of long-term pain reduction guided by the most up-to-date evidence-based care. Give us a call to schedule an appointment or reach out to us by filling out the form below.