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

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Eric Chun Pu Chu at New York Medical Group
Eric Chun Pu Chu
  • New York Medical Group
Andy Fu Chieh Lin at New York Medical Group
Andy Fu Chieh Lin
  • New York Medical Group
Valerie Kok-Yan Chu 朱珏欣脊醫 at Health Sciences University
Valerie Kok-Yan Chu 朱珏欣脊醫
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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 C2–7 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
Creative Commons Attribution (CC-BY) license 4.0
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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Article
  • Oct 2009
Systematic reviews of randomized controlled trials suggest that spinal manipulative therapy (SMT) is efficacious for care of cervicogenic headache (CGH). The effect of SMT dose on outcomes has not been studied. To compare the efficacy of two doses of SMT and two doses of light massage (LM) for CGH. Eighty patients with chronic CGH. Modified Von Korff pain and disability scales for CGH and neck pain (minimum clinically important difference=10 on 100-point scale), number of headaches in the last 4 weeks, and medication use. Data were collected every 4 weeks for 24 weeks. The primary outcome was the CGH pain scale. Participants were randomized to either 8 or 16 treatment sessions with either SMT or a minimal LM control. Patients were treated once or twice per week for 8 weeks. Adjusted mean differences (AMD) between groups were computed using generalized estimating equations for the longitudinal outcomes over all follow-up time points (profile) and using regression modeling for individual time points with baseline characteristics as covariates and with imputed missing data. For the CGH pain scale, comparisons of 8 and 16 treatment sessions yielded small dose effects: |AMD|</=5.6. There was an advantage for SMT over the control: AMD=-8.1 (95% confidence interval=-13.3 to -2.8) for the profile, -10.3 (-18.5 to -2.1) at 12 weeks, and -9.8 (-18.7 to -1.0) at 24 weeks. For the higher dose patients, the advantage was greater: AMD=-11.9 (-19.3 to -4.6) for the profile, -14.2 (-25.8 to -2.6) at 12 weeks, and -14.4 (-26.9 to -2.0) at 24 weeks. Patients receiving SMT were also more likely to achieve a 50% improvement in pain scale: adjusted odds ratio=3.6 (1.6 to 8.1) for the profile, 3.1 (0.9 to 9.8) at 12 weeks, and 3.1 (0.9 to 10.3) at 24 weeks. Secondary outcomes showed similar trends favoring SMT. For SMT patients, the mean number of CGH was reduced by half. Clinically important differences between SMT and a control intervention were observed favoring SMT. Dose effects tended to be small.
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Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment
Article
  • Oct 2009
Cervicogenic headache is characterised by pain referred to the head from the cervical spine. Although the International Headache Society recognises this type of headache as a distinct disorder, some clinicians remain sceptical. Laboratory and clinical studies have shown that pain from upper cervical joints and muscles can be referred to the head. Clinical diagnostic criteria have not proved valid, but a cervical source of pain can be established by use of fluoroscopically guided, controlled, diagnostic nerve blocks. In this Review, we outline the basic science and clinical evidence for cervicogenic headache and indicate how opposing approaches to its definition and diagnosis affect the evidence for its clinical management. We provide recommendations that enable a pragmatic approach to the diagnosis and management of probable cervicogenic headache, as well as a rigorous approach to the diagnosis and management of definite cervical headache.
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A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache
Article
  • Sep 2002
  • SPINE
A multicenter, randomized controlled trial with unblinded treatment and blinded outcome assessment was conducted. The treatment period was 6 weeks with follow-up assessment after treatment, then at 3, 6, and 12 months. To determine the effectiveness of manipulative therapy and a low-load exercise program for cervicogenic headache when used alone and in combination, as compared with a control group. Headaches arising from cervical musculoskeletal disorders are common. Conservative therapies are recommended as the first treatment of choice. Evidence for the effectiveness of manipulative therapy is inconclusive and available only for the short term. There is no evidence for exercise, and no study has investigated the effect of combined therapies for cervicogenic headache. In this study, 200 participants who met the diagnostic criteria for cervicogenic headache were randomized into four groups: manipulative therapy group, exercise therapy group, combined therapy group, and a control group. The primary outcome was a change in headache frequency. Other outcomes included changes in headache intensity and duration, the Northwick Park Neck Pain Index, medication intake, and patient satisfaction. Physical outcomes included pain on neck movement, upper cervical joint tenderness, a craniocervical flexion muscle test, and a photographic measure of posture. There were no differences in headache-related and demographic characteristics between the groups at baseline. The loss to follow-up evaluation was 3.5%. At the 12-month follow-up assessment, both manipulative therapy and specific exercise had significantly reduced headache frequency and intensity, and the neck pain and effects were maintained (P < 0.05 for all). The combined therapies was not significantly superior to either therapy alone, but 10% more patients gained relief with the combination. Effect sizes were at least moderate and clinically relevant. Manipulative therapy and exercise can reduce the symptoms of cervicogenic headache, and the effects are maintained.
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Cervicogenic headache: A review of diagnostic and treatment strategies
Article
  • May 2005
Cervicogenic headache is a syndrome characterized by chronic hemicranial pain that is referred to the head from either bony structures or soft tissues of the neck. 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. A functional convergence of sensorimotor fibers in the spinal accessory nerve (CN XI) and upper cervical nerve roots ultimately converge with the descending tract of the trigeminal nerve and might also be responsible for the referral of cervical pain to the head. Diagnostic criteria have been established for cervicogenic headache, but its presenting characteristics occasionally may be difficult to distinguish from primary headache disorders such as migraine, tension-type headache, or hemicrania continua. This article reviews the clinical presentation of cervicogenic headache, proposed diagnostic criteria, pathophysiologic mechanisms, and methods of diagnostic evaluation. Guidelines for developing a successful multidisciplinary pain management program using medication, physical therapy, osteopathic manipulative treatment, other nonpharmacologic modes of treatment, and anesthetic interventions are presented.
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