Modern chiropractic medicine focuses diagnostic efforts for the treatment of headache sufferers at the contents of the cranium. Ruling out the rare space-occupying lesion and confirming the more common vascular cause (migraine), is the normal protocol for allopathic neurologist. I do not recall receiving a single referral from a neurologist in my twenty-five years of chiropractic practice for the treatment of headaches caused by biomechanical joint dysfunctions.

The term “cervicogenic headache” was first introduced by Sjaastad in 1983. [i] It is defined as pain to arise from or be localized within the head, but actually originated in the cervical spine. [ii] Many different conditions of the cervical spine, including mechanical pain, join, and soft tissue pathology have been reported to cause cervicogenic headache. [iii]

Hubka and Hall believe that cervicogenic headache is more common than migraine. [iv] Bogduk claims that congenital, traumatic, mechanical, degenerative, inflammatory, and neoplastic disorders affecting these tissues can potentially cause cervicogenic headache.

The International Headache Society provides a classification and diagnostic criteria for headache disorders, cranioneuralgia and facial pain. This was published in “Cephalgia” in 1988. The diagnostic criteria for cervicogenic headache are:

1. Pain localized to neck and sub occipital region, may project to forehead, orbital region, temples, vertex, or ears.
2. Pain is precipitated or aggravated by special neck movements or sustained neck posture.
3. At least one of the following is present:
   • Resistance or limitation of passive neck movements.
   • Changes in neck muscle contour, texture, tone, or response passive stretching or contraction.
   • Abnormal tenderness of neck muscles.
4. Radiologic examination reveals at least one of the following:
   • Movement abnormalities in flexion/extension.
   • Abnormal posture.
   • Fractures, congenital anomalies, bone tumors, rheumatoid arthritis, or other distinct pathology (not spondylosis or osteochondrosis).

In order to reduce the frequency of misdiagnosis with headache patients, Sjaastad proposed diagnostic criteria. The differential diagnoses of cervicogenic headache and migraine are summarized in Table 1.

Appropriate differential diagnoses of migraine and cervicogenic headaches by the chiropractic physician is an essential step prior to implementation of a treatment plan. Managed care organizations would save valuable resources and eliminate adverse drug reactions by utilizing chiropractic medicine services for the management of cervicogenic headache.

In order to substantiate my statement, I offer the following case study. May I add that in the past twenty-five years of clinical practice, I have successfully managed hundreds of headache sufferers who were misdiagnosed by the allopathic medicine providers. Appropriate initial management of cervicogenic headache with chiropractic medicine services would save managed care organizations millions of dollars per year and improve the quality of care with resultant improved patients satisfaction levels.

On May 11, 1997, I examined a 31 year old Hispanic female with a chief complaint of migraine headaches. She was unable to work for the past four weeks due to the severe migraine headaches. She complained of visual changes and a prodromal sensation of pressure in the back of the neck. Sometimes she experienced sharp pain on the top of the head and/or throbbing on both sides of the temples.

In addition, she complained of sharp ear pain on the right side and pain in the neck, which she described as a pressure sensation. She commented that by turning her head far enough that it would pop, she reduced the pain. In addition, she related to this examiner that bright light and cloudiness sometimes brought on the headache. She utilized Imitrex injections two to three times per month in order to reduce the pain from the headache. Her teeth had been treated for the past two and a half years with two-post braces. According to this patient, her jaw moves inappropriately and pops frequently. She has been under orthodontic care for the past four years. In addition, she complained of facial pain, and tinnitis with the headaches. She claimed that the headaches had been intermittent since November 1996. Unfortunately, for the past six weeks she had experience daily and more severe headaches.

Past History:
She claims to be allergic to erythromycin. She denied the use of tobacco, alcohol, or recreational drugs. She reported a whiplash injury in 1992, which was successfully treated with chiropractic management. Two family practitioners have been treating her for her migraine headaches.

Examination:
Revealed a 31-year old Hispanic female, standing 63 inches in height, weighing 137 lbs., with a blood pressure of 120 millimeters of mercury systolic, and seventy millimeters of mercury diastolic. Her pulse rate was 80 beats per minute. Her aural temperature registered 97.7 degrees Fahrenheit.

Palpation produced pain at C1 bilaterally. In addition, Palpation revealed pain over the greater occipital nerves bilaterally and over the C3, C4, C5, C6, and C7 spinous processes and nuchal ligamentous tissue. Palpation also elicited pain over the C3-C4-C5 zygapophyseal joins bilaterally. Myofascial trigger points with hypertonicity were revealed at the posterior cervical, upper trapezi, sternocleidomastoideus, scalenes, and levator scapulae bilaterally. Cervical active range of motion was within normal limits, except left lateral flexion and right lateral flexion, which were decreased with contralateral scalene pain. Stimulation of the right sternocleidomastoideus trigger point referred pain to the right ear and the top of the head. The patient complained that the sharp pain was the same as the headache pain she had been experiencing. Temporomandibular joint examination revealed crepitation with deviation on the left and capsulitis bilaterally. Trigger points were present in the masseter muscles. Neurological evaluation revealed the deep tendon reflexes to be 2+ bilaterally and brisk. Sensory evaluation revealed the upper and lower extremities to be intact and functioning within normal limits. Motor evaluation revealed the upper and lower extremities to be 5/5 and considered normal. Babinski’s was absent, consequently there was no concern with central nervous system pathology.

My Initial Impressions Were:

1. Cervicogenic headache syndrome.
2. Temporomandibular joint dysfunction.
3. Migraine with aura by patient history.
4. Myofascial pain syndrome.
5. Status post spinal sprain 1992.

The immediate goal of the treatment was to return this patient to work as soon as possible. Six treatments were administered with excellent response to care.

Reexamination:
On June 12, 1997. Subjectively, she stated, “overall I am doing really well and I can’t believe the difference!” She rated her improvement at 97% due to the reduction of frequency of daily headaches, which had lasted all day long. Currently, she has experienced only one mild headache in the past thirteen days while under care. She stated that she did have a little headache one day with increased shoulder tension due to a rough day at work. Evening walks seem to relax her. She reports just a little jaw pain, which she states is being managed by the dentist. Since receiving chiropractic care, she no longer experiences sharp ear or jaw pain. She did relate to me during this examination that she holds her head to the right at work in order to cradle a telephone headset. Objective Findings:
Palpation revealed tenderness in the left upper trapezi musculature, sternocleidomastoideus, sub occipital muscles, and the left greater occipital nerve. Capsulitis was again revealed bilaterally in the temporomandibular joints. Temporomandibular joint deviation with “cracking” was revealed. Cervical active range of motion was within normal limits, except there was reduced right lateral flexion with a pulling sensation in the contralateral left upper trapezius musculature. Diagnostic Impressions:

1. Cervicogenic headache syndrome due to upper trapezius strain and temporomandibular joint dysfunction, responding very well to care.

1. Chiropractic management one time per month for the next three months.
2. Allermax for environmental allergic rhinitis.
3. Dental care for temporomandibular joint dysfunction.
4. Avoid head cradling position with the phone. This patient did return one time per month for the three month period and complained of experiencing two mild headaches during that time. Conclusion:
   Chiropractic manipulation for the treatment of cervicogenic headache due to biomechanical joint dysfunction should be the preferred approach by all managed care organizations. Modalities such as electrical muscle stimulation, moist heat and deep tissue manipulation should also be implemented with the presence of myofascial trigger points. “Integrative medicine” efforts should include the dental specialist when temporomandibular joint dysfunction presents as a complicating condition. The chiropractic physician providing managed care services is the best trained physician for the episodic management of cervicogenic headache in my professional opinion.

   
   Table 1:
   
   Differential Diagnosis of Migraine and Cervicogenic Headache

   Headache	Migraine	Cervicogenic
   Pain Location	Unilateral headache that shifts sides; starts in frontal region and spreads posteriorly.	Unilateral or bilateral; does not shift sides; starts in occiput region and spreads anteriorly.
   Photophobia	Severe and bilateral; may have aura	None to moderate; unilateral, dim blurry.
   Vomiting	Profuse.	None – moderate.
   Response to medication	No response to analgesics; responds to ergotamine and beta blockers.	Initially provide relief; no response to responds to ergotamine and beta blockers.
   Frequency of headache and duration	Infrequent episodes, headache and headache days per year (range 4 hr 1 day).	Frequent episodes often causes daily headache (range 1-3 days).
   Mechanical precipitation	None.	Neck motion reduced; motion, positions, and palpation of neck reproduce headache; ipsilateral shoulder and arm pain.
   Diagnostic - greater occipital or C2 nerve block	Negative.	Relieves headache.
   Cervical radiographs	Normal.	Decreased motion C0-C1.
   Cervical spine manipulation	Limited response but may possibly abort during prodome.	May provide lasting headache relief in some subtypes.

   
   
   References:
   [i] Sjaastad, O., Saunte, C., Hovdohl, H., Gronbaek, E., “’Cervicogenic’ Headache, An Hypothesis.” Cephalgia, 1983; 249-256
   [ii] Bogduk, N., “The Anatomical Basis of Cervicogenic Headache,” J. Manipulative Physical Therapy; 1992; 15:67-70
   [iii] Bogduk, N., “Cervical Causes of Headache and Dizziness,” In: Grieve, GP, ed. Modern Manual Therapy of the Vertebral Column; Edinburgh; Churchill-Livingston, 1986: 289-302
   [iv] Hubka, H.J., Hall, T.A., “Classification of Headaches: A New Look,” In: Curl, DD, ed. Chiropractic Approach to Head Pain, Baltimore: Williams and Wilkins, 1994: 182-189
   
   
   

   Back to Spine Center of New Mexico Articles Written by Our Doctors