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Cervicogenic Headache Alleviating by Spinal Adjustment in Combination with Extension-Compression Traction

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Cervicogenic headache (CGH) is a type of secondary headache where the symptoms originate from a dysfunction in the cervical spine. Mechanical cervical spine pathologies and dysfunction in the neck muscles may lead to CGH. This report presents a case of a female with fluctuating headache related to cervical disorders. Her headache was concurrently eliminated with resolution of the cervical disorder following spinal adjustment in combination with extension-compression traction. The efficacious response was attained over a year after completion of treatment. Strategies to release the strain of the supporting cervical extensors can be beneficial for alleviating CGH.
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Arch Clin Med Case Rep 2019; 3 (5): 269-273 DOI: 10.26502/acmcr.96550090
Archives of Clinical and Medical Case Reports 269
Case Report
Cervicogenic Headache Alleviating by Spinal Adjustment in
Combination with Extension-Compression Traction
Eric Chun Pu Chu*, Valerie Kok Yan Chu, Andy Fu Chieh Lin
New York Chiropractic and Physiotherapy Centre, New York Medical Group, Hong Kong, China
*Corresponding Author: Dr. Eric Chun Pu Chu, New York Chiropractic and Physiotherapy Centre, 41/F Langham
Place Office Tower, 8 Argyle Street, Hong Kong, China, Tel: +852-3594-7844; Fax +852-3594-6193; E-mail:
eric@nymg.com.hk
Received: 20 June 2019; Accepted: 08 July 2019; Published: 13 September 2019
Abstract
Cervicogenic headache (CGH) is a type of secondary headache where the symptoms originate from a dysfunction in
the cervical spine. Mechanical cervical spine pathologies and dysfunction in the neck muscles may lead to CGH.
This report presents a case of a female with fluctuating headache related to cervical disorders. Her headache was
concurrently eliminated with resolution of the cervical disorder following spinal adjustment in combination with
extension-compression traction. The efficacious response was attained over a year after completion of treatment.
Strategies to release the strain of the supporting cervical extensors can be beneficial for alleviating CGH.
Keywords: Anterior head posture; Cervicogenic headache; Extension-compression traction; Spinal adjustment
1. Introduction
According to the International Classification of Headache Disorders 3rd edition (ICDH-3) [1], cervicogenic
headache (CGH) is defined as a secondary headache caused by a disorder of the cervical spine and its component
bony, disc and/or soft tissue elements, usually but not invariably accompanied by neck pain. Although the exact
pathophysiology of CGH is unknown, it is likely that pain is generated by structures innervated by the upper three
spinal nerves [2]. The convergence of nociceptive pathways may refer pain signals from the neck to the trigeminal
sensory receptive fields of the face and head. Mechanical cervical spine pathologies and dysfunction in the neck
muscles may lead to CGH [2]. Upper cervical spine mobility restriction (hypomobility), cervical pain, and muscle
tightness are clinical findings associated with CGH during physical examination [3]. The evidence of a cervical
pathology is an obligatory requirement for a definite diagnosis [1]. Treatment strategies include medications,
anesthetic injections, physical therapy and occasionally surgical interventions. Medications alone are often
Arch Clin Med Case Rep 2019; 3 (5): 269-273 DOI: 10.26502/acmcr.96550090
Archives of Clinical and Medical Case Reports 270
ineffective or provide only modest benefit for this condition. The results of most of the randomized controlled trials
[4-7] indicate manipulation/mobilization or corrective exercises as promising interventions.
2. Case Presentation
A 37-year old female was referred to chiropractic therapy by her neurologist with episodes of pains in the head and
neck and numbness in the right lateral forearm, which had been ongoing for 3 years. The patient could not recall a
specific incident which caused the pain. She described her symptoms as an aching pressure on the back of her
neck that extended into the right occipital, temporal and frontal regions. The most intense headache was rated as
7/10 and neck pain was rated 5/10 on the numeric pain rating scale (NPRS). The pain occurred as often as several
times a week and could last for hours. She was employed as an investment banker, which required her to work at a
computer most of the day. She attributed these symptoms to long periods of working at her desk. Nonpharmaceutical
approaches such as psychotherapy for reducing stress and acupuncture for ameliorating pain had been tried, which
did not change the symptoms. Her medication included non-steroidal anti-inflammatories, tricyclic antidepressants,
and sleep aids over the past 3 years.
Visual inspection revealed a forward head and moderate hunched posture. Cervical range of motion (ROM) was
limited to 20° at extension (normal> 60°) and 45°at rotations (normal> 80°) causing pain. Palpation revealed
hypertonicity of the suboccipital triangle (R>L), bilateral cervical paraspinal and suprascapular muscles. Passive
mobility assessment revealed restrictions at C1-2, C5-6, T1-2, T3-4 and T7-8 segments. Dermatome testing revealed
perceived dullness in the C6 distribution of the right upper extremity. The patient’s radiographs (Figure 1A)
exhibited a loss of cervical lordosis, cervical spondylosis with C5-6 osteophyte formation. She scored 60% on the
headache disability questionnaire and 44% on the neck disability index. The patient was diagnosed with lower
cervical spondylosis and probably right C6 radiculopathy related cervicogenic headache.
At the initial phase of care, the treatment sessions included spinal manipulation and thermal ultrasound therapy to
restore the mechanical functioning of the cervical spine, and normalize the muscular functioning of the
neck. Treatment was given three times a week for 3 months. Her paraesthesia disappeared and pains were reduced to
3/10 on NPRS at 3 months from the beginning of the treatment. The goal of her second phase of treatment was to
normalize the head position. An extension-compression traction (BioPhysics® technique) was applied twice a week
for further 3 months. The chiropractic therapy goals had been met following a 6-month treatment. Her head posture
was corrected and cervical curvature was restored. The patient displayed normal ROM of the neck without any
provocation of pain. She no longer had headaches as well. One year after treatment completion (Figure 1B) the
patient remained pain-free and was completely off her medications.
Arch Clin Med Case Rep 2019; 3 (5): 269-273 DOI: 10.26502/acmcr.96550090
Archives of Clinical and Medical Case Reports 271
Figure 1: A. Initial cervical radiograph exhibited lower cervical spondylosis, osteophyte formation at C5 and C6,
and straightening of the normal cervical lordosis; B. Upon re-assessment, the cervical curvature returned to a
concave curve. Magnitude of cervical lordosis at C27 remained stable over one year after the completion of
treatment.
3. Discussion
The prevalence of cervicogenic headache in the general population is estimated to be 4.1%, but is as high as 20% of
patients with chronic headache [3, 8]. The most general cause of cervicogenic headache (CGH) is the alteration of
structure in the neck due to bad posture [8]. It is noted that CGHs can often be related to forward neck and head
posture, which is accompanied by a high muscular tone of the supporting extensors to keep the head from gravity [9,
10]. Such unstable state causes overstrain of the cervical muscles, and induces headache and neck pain [11]. Office
workers of being sedentary for prolonged periods are liable to adopt forward head posture and thus generating neck
strain, sprain and pain. Moreover, forward head posture is commonly found in people spending long periods on
computers, mobile phones and game consoles. A study conducted in 369 subjects of different occupations,
researchers observed that straightening of the normal cervical lordosis is the commonest alteration in individuals
with forward head posture, which predisposes them to various neck pains and even to compression of cervical nerve
roots [12].
The International Classification of Headache Disorders, 3rd Edition (ICHD-3) [1] is the widely accepted
classification system and diagnostic manual for the headache disorders. According to ICHD-3, CGH is defined as
headache symptoms attributed to cervical disorders, and is coded as 11.2.1 [1]. A definitive diagnosis requires at
least two out of the following four evidences of a cervical source of pain. The evidences of cervical causation
proposed by ICDH-3 are: 1. Headache is related to the onset of the cervical disorder; 2. Headache has improved in
parallel with resolution of the cervical disorder; 3. Headache is provoked by cervical maneuvers; 4. Headache is
abolished following diagnostic blockade of a cervical structure or its nerve supply. Our patient had fluctuating
headache related to cervical disorders and headache was concurrently eliminated with the resolution of the cervical
disorder. She fulfilled the ICDH-3 criteria for a diagnosis of CGH. CGH has been accepted, in principle, as a
Arch Clin Med Case Rep 2019; 3 (5): 269-273 DOI: 10.26502/acmcr.96550090
Archives of Clinical and Medical Case Reports 272
pathologic syndrome attributed to cervical disorders. Whereas, the debate on the underlying mechanism of CGH is
more of theoretical interest rather than of direct practical relevance.
Pharmacotherapy is often the first approach for treating most primary headaches, such as migraine, tension-type
headache, etc. For patients with secondary headaches, such as CGH, often do not respond sufficiently to medications
[9, 11]. A multifaceted approach, including transcutaneous electrical nerve stimulation, radiofrequency neurolysis,
manipulative therapy, mechanical traction and therapeutic exercise is recommended to address individual
impairments in CGH patients [9, 10]. Clinical results from randomized controlled trials [4-7] and retrospective
cohort chart review [13] suggest that physical, manual and corrective modes of therapy can lead to an effective,
evidence-based relief of headache in CGH patients. However, due to heterogeneity in treatment regimens these
results should be interpreted cautiously [3, 8]. Our patient had headaches related to strain of posterior cervical
muscles in the clinical setting of cervical hypolordosis. This pattern of cervicogenic headache appeared to be a well-
defined condition that could be treated conservatively and effectively by manual regimens. The limitation of the
current report is that it is just a single case. Further research regarding the manual approaches to alleviating
cervicogenic headache and reversing anterior head posture is needed to clarify these issues.
Conflicts of Interest
No conflicts of interest to declare.
References
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This article is an open access article distributed under the terms and conditions of the
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Citation: Eric Chun Pu Chu, Valerie Kok Yan Chu, Andy Fu Chieh Lin. Cervicogenic Headache Alleviating
by Spinal Adjustment in Combination with Extension-Compression Traction. Archives of Clinical and
Medical Case Reports 3 (2019): 269-273.
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