Identification of Movement Dysfunction in Cervicogenic Headaches

Introduction

Headache is a common symptom reported in the population. The World Health Organization Global Burden of Disease study estimated that 47% of the adults reported headaches at least once in the past year. Headache can result from an extensive variety of causes, mostly benign but some may be life-threatening.

International Classification of Headache Disorders (ICHD), classifies headache broadly into two categories: primary and secondary. Primary headache disorders include migraine and tension-type headaches. Secondary headaches can be due to a wide variety of mechanisms ranging from serious medical conditions such as meningitis, subarachnoid hemorrhage, ruptured aneurism, and intracranial tumor, trauma, and others due to less serious disorders such as substance use or withdrawal, medication overuse (rebound headaches), sinusitis, influenza, “ice cream” headache (brain freeze), hangover, and disordered function of the musculoskeletal elements of the head and neck.¹

The concept of headache that occurs from the cervical spine was explained by Hilton in 1860.²

Sjaastad et al., offered a hypothesis for “Cervicogenic Headache” in 1983. The diagnosis of “Cervicogenic Headache” has   been   somewhat   controversial   in the conventional medical community. But there is emerging evidence that supports the view commonly held by manual therapists that the neck is a commonly encountered source of headache. ICHD now considers ‘Cervicogenic Headache’ as a separate unit and classifies it as a secondary headache, “attributed to a disorder of the neck.” A lot of descriptive classification defines it as a “chronic headache that arises from the atlantooccipital and superior cervical joints and perceived in one or more regions of the head and/or faces.”¹

The ICHD describes cervicogenic headache as, “the headache caused by a disorder of the cervical segments and its constituent bone, disc, and/or soft tissue components, usually but not perpetually accompanied by neck pain.” The prevalence of cervicogenic headache (CH) reportedly accounts for 0.4% to 20% of the headache population and reaches up to 53% in headache patients after a whiplash injury.³

The official definition of a cervicogenic headache originates from the North American Cervicogenic Headache Society and was proposed for the third edition of the International Association for Study of Pain. It is defined as “a referred pain observed in any region of the head affected by a primary nociceptive source in the musculoskeletal tissues innervated by cervical nerves.”⁴

The prevailing features of cervicogenic headache usually include unilaterality of headache without side-shift, pain which is triggered by an external pressure over ipsilateral part of upper neck, reduced cervical range of motion, and causing of attacks by various persistent or fixed neck movements.³ Side-locked pain, incitement of typical headache by digital pressure on neck musculatures and by head movement, and posterior-to-anterior radiation of pain are features that help differentiate cervicogenic headache from other primary headaches.⁵ A cervicogenic headache is thought to be referred pain rising from exasperation caused due to cervical structures innervated by spinal nerves C1, C2, and C3. Therefore, any structure innervated by the C1–C3 spinal nerves could be the cause for a cervicogenic headache.⁶

Trigemino-cervical nucleus in the upper cervical spinal cord is thought to be the anatomical site for cervicogenic headache; here the sensory nerve fibers in the descending tract of trigeminal nerve are assumed to interact with sensory fibers of the upper cervical spine. This functional juncture of upper cervical spine and sensory pathways of trigeminal nerve is believed to allow bidirectional transmission of pain signals amid the neck and sensory recording area of trigeminal nerve that are supplied to face and head.⁷ Often, cervicogenic headache results from stiffness in the joints of neck, soreness and inflamed neck musculature. The corresponding nerve fibers become annoyed and refers pain to the neck, shoulder, and head, also including face and area behind an eye.⁸

Cervical headache is a rare chronic headache that occurs in people between 30 and 44 years of age. The frequency of headache patients varies from 1% to 4%, depending on the percentage of people who meet the criteria and the various studies that have been conducted. It equivalently affects males and females with a ratio of 0.97 (F/M ratio). The age of onset is assumed to be early 30s, but the age at which the patients search for a medical care and diagnosis is 49. These patients supposedly have peri- cranial muscle tenderness on painful side as compared to other headache types.⁶

A secondary type of headache is known as Cervicogenic Headache (CGH), where the symptom arises from dysfunction in the cervical spine and an abnormal posture caused by cervical dysfunction is thought to be one particular reason that has been featured to intensify the cause of CGH.⁹ The diagnosis of CGH is probably difficult due to inconsistent definitions of CGH given.¹⁰ Some of the evidence says that CGH occurs with increasing age, and musculoskeletal injury to the neck which is a common clinical feature in patients with cervical headache. Fewer studies also suggest that the structures of neck may encourage or contribute to those  impairments.¹¹

Cervical musculoskeletal abnormalities are traditionally     linked      to      different      headaches An unusual position often noted is an excessive forward position of the head, or forward head posture (FHP). It is usually related to shortening of the posterior cervical extensor muscles and the tension of the anterior cervical muscles. FHP has been related to neck pain, temporomandibular disorders, cervicogenic headache, and post-concussion headache. Limited neck mobility has been considered a the most important feature of CGH.¹²

Aimed for the diagnosis of CGH, both the International Headache Society (IHS) and Cervicogenic Headache International Study Group (CHISG) have implemented criteria. The annual incidence of neck pain within the population as a whole is about 15%. Prevalence numbers for Cervicogenic Headache (CEH) vary between 4.1% and 17.8% during this study.¹³ The CHISG criteria for Cervicogenic Headache were proposed in 1998.¹⁴

Changes in cervical mobility are the criteria used in the diagnosis for cervical headache; however, some studies have proven that active cervical spine mobility is not reliable in the differential diagnosis. Therefore, a manual examination was shown in order to detect symptomatic cervical joint dysfunction in several studies of cervical headache. Most external measurements of cervical    movement    simultaneously    include    both superior and inferior cervical movements. The neck flexion-rotation test is an easy to apply technique of manual examination which is intended to provide a means for determining the presence of joint dysfunction at C1/2 level.¹⁵

The different assessments used also included a photographic measurement of posture, range of motion, manual examination of neck, pressure pain thresholds, muscle length, presentation   of   cranio-cervical flexion test, and cervical kinesthetic movement for cervicogenic headache. Earlier studies investigated one or two characteristics of the cervical musculoskeletal system in patients with cervicogenic headache. Identification of those physical impairments within the musculoskeletal system concomitant to these functions helps to determine and select the method of treatment for cervicogenic headache.¹⁶

Despite the multidirectional quality of human movement, common measurement procedures used in physiotherapy examination are often uni-planar and cannot assess functional complexities involved in daily activities. At present, there is no universally known and accepted standard for assessing the quality of movement. Selective Functional Movement Assessment (SFMA) is a possible system for objectively evaluating complex functional movements.¹⁷

The SFMA is a tool that aims to integrate the concept of posture, muscular balance and movement patterns to identify related musculoskeletal dysfunctions in a clinical population.¹⁸

It has been validated that SFMA as a clinical outcome tool has the probability to function as an adjunct to the present medical/pathoanatomic investigation model, with the potential to serve as a typical for the assessment of functional movement patterns.¹⁷ SFMA aims to incorporate the ideas of posture, muscle balance and basic movement patterns into the practice of musculoskeletal rehabilitation.¹⁹ Therefore, it also helps to diagnose dysfunctional movements in the subsequent area, which are not observed in more traditional examination procedures.¹⁷ The authors from included studies which used SFMA agreed that SFMA is a useful tool for clinicians to evaluate because it provides a wider view of the patient and identifies dysfunction that may cause trauma or pain.²⁰

Zwart (1997) showed that patients with cervical headache have a lower amplitude of active cervical rotation and neck movement in the sagittal plane. It was found that most of the patients with cervical headache are limited to cervical extension and also hypothesized that the range of active cervical movement in the cardinal planes and range of cervical rotation in flexion would be reduced in those subjects

Methods

Study design and procedure

The non-experimental, cross-sectional study design was used in cervicogenic headaches fulfilling the major criteria (I-IV) given by CHISG. Informed consent was obtained from subjects who met the inclusion and exclusion criteria. After meeting the criteria, the subjects were evaluated using seven top-tier tests of SFMA to determine movement dysfunctions. SFMA breakouts were used as soon as the dysfunction or pain was noted to isolate and focus on each pattern that exhibits pain or dysfunction. This method helps to determine the main limitations of the subject’s mobility and stability.²⁵

Study participants and sampling

Convenience sampling was used for selecting the subjects with a known history of cervicogenic headache. Both male and female subjects in the age group of 18- 66 years were suitable to undergo this study. Those with headache not of cervical origin, headache with autonomic involvement, dizziness, visual disturbance, migraine or tension-type headache, any head injury, cardiovascular disease, or recent surgery were excluded.^21-24

Study instrument and measures

Examination couch, chair/stool, wand, pen, pencil, and paper sheets.

Outcome measure

Selective Functional Movement Assessment (SFMA) to identify the movement dysfunction in cervicogenic headaches.

Data analysis

Statistical analysis was performed by SPSS-17 for windows with the alpha value set as 0.05. Descriptive statistics were used to find out the mean, the standard deviation for a demographic variable. Unpaired t-test was used to identify significant differences among demographic variables as age, height, weight, and body mass index (BMI) between groups. Percentage analysis was done to assess the extent of movement dysfunction. MS-Excel and MS-word were used to generate tables.

Results

The result of the present study are as follows: Functional Painful Movement (FPM) was found 21.67% on Cervical Flexion (CF), 2.08% on Cervical Extension (CE), 22.5% on Cervical Rotation (CR), 12.51% on Upper-Extremity Pattern-1 (UEP-1), 32.91% on Upper Extremity Pattern-2 (UEP-2), 18.84% on Multi-segmental Flexion (MSF), 12.08% on Multi-segmental Extension (MSE) and 30% on Multi-segmental Rotation (MSR). Dysfunctional Non-Painful Movement (DNM) was 45.84% on CF, 72.08% on CE, 56.25% on CR, 52.58% on UEP-1, 58.62% on UEP-2, 64.17% on MSF, 69.58% on MSE, 60.62% on MSR, 70.62% on SLS and 71.5% on OHDS. Dysfunctional Painful Movement (DPM) was 32.5% on CF, 6.25% on CE, 19.5% on UEP-1, 16.21% on UEP-2, 5.41% on MSE and 3.34% on MSR.

Discussion

The aim of this study was to identify movement dysfunction in subjects having cervicogenic headache within Bangalore. Sjaastad O, Bakketeig LS (2008) in their study identified the prevalence of CGH and said that it may be one of third largest, recurrent headaches. In this series, there was no female preponderance and the nuchal onset of pain is a characteristic trait.²¹ Boardman et al., (2003) said in their study that, according to statistical data, 90% of the total population suffered from headaches and 66% of men and 57% of women suffered from headaches at least once in a year.²⁶

This study included 240 subjects, with male and female subjects being observed for any movement dysfunction with CGH. Among 240 subjects, there were 103 (42.92%) male subjects and 137 (57.08%) female subjects presenting with CGH. The female subjects were seen to be larger in number compared to male subjects. It has been found that females are more likely to fit into the inclusion criteria and also the female voluntary participation was more in number than males. These results were concurred by Strimpakos (2011) who found that the amount of unpleasant information of patients having neck pain and headaches is increasing, and the proportion of headaches is more common in women than men.²⁶ Since Page P (2011) mentioned that CGH usually affects women, it is important to consider menstruation and hormonal changes as factors that cause headaches. Menstrual-type headaches often occur two days before menstruation and last till the latter day of the cycle. These headaches are usually migraine-type but can be cervicogenic as well.²⁷

In this study, the age of the subjects ranged from 18 to 66 years. The mean and SD of 49.53±7.18 years in males and 44.18±8.80 years in females showing no significant difference were seen to be having more movement disorder i.e., between the middle age group to older age group showed higher results of movement dysfunction compared to young age groups. The age of occurrence is thought to be in their early 30s, but the age at which patients search for medical help and diagnosis is 49.4 years.²⁸ Studies show that CGH increases with growing age. S Uthaikhup, J Assapun, S Kothan, K Watcharasaksilp, J Elliott (2017) evidences suggest that cervicogenic headache is related with increasing age.¹¹

Out of 240 subjects, 154 subjects were overweight i.e., BMI (25-29.9), and six subjects were obese i.e. (30.1-32.4). The mean and SD for BMI in this study was 24.68±1.93 in males and 26.63±1.90 in females; there was no significant difference in BMI between the genders. Recently there has been a suggestion that BMI could be a contributing factor for headache. Shyamal C Bir et al., in their study showed that out of 160 cases,40 (25%) patients were obese (BMI > 30) and risk factors including smoking, gender, depression, and obesity should be taken into consideration when treating patients with cervicogenic headache.²⁹ Although there is a lack of evidence to prove a correlation between BMI and CGH, further investigation in this aspect would help identify the existence of a relation between them. Q Huang, X Liang, S Wangand X Mu (2018) carried out a study to determine the association between BMI and migraine which showed that individuals with episodic headache and obesity developed chronic daily headache (CDH) five times more than normal-weight individuals. A cross-sectional study of the population also confirmed the association between obesity and CDH, indicating that obesity is a risk factor for the transition of episodic migraine (EM) to chronic migraine (CM).³⁰

The subjects in present study were considered only if they strictly fulfilled the inclusion criteria and were found to be voluntarily present to carry out the study. This study describes the use of SFMA to identify movement dysfunction present in the subjects with CGH. The data analysis for the results of this study was carried out using a percentage analysis for each outcome obtained after performing the breakouts of SFMA. SFMA is a diagnostic assessment used to identify the pattern of musculoskeletal and movement dysfunction in subjects with cervicogenic headaches. Riebel M, Crowell M, Dolbeer J, Szymanek E, Goss D (2017) pointed out that SFMA is a clinical model that diagnoses and treats musculoskeletal disorders by identifying dysfunction in movement and the applicability of SFMA are examined to determine whether there is a correlation between changes in self-reported results and assessment criteria.¹⁹ Similarly, Fauntroy V, Fyock M, Hansen-Honeycutt J, Nolton E, Ambegaonkar JP (2018) critically appraised a study which says SFMA is a clinical assessment that aims to systematically identify causes of movement disorders by taking pain into account and using an algorithmic approach. It was created to measure the state of the movement pattern related to pain and dysfunction by using interdependent localized body movements to exacerbate symptoms and identify limitations and dysfunctions. Under the guidance of the Regional Interdependence (RI) Model, clinicians can use SFMA to identify dysfunctions in different parts of the body and determine their relationship to overall trauma.²⁰ This study supports the use of SFMA as a diagnostic method for CGH to identify movement dysfunctions.

Therefore, in this study, the probability of area affected maximally in CGH presented with FPM more in UEP-2, DNM more in CE, and DPM more in CF.

Limitations

Participants in this study were recruited through a self- created questionnaire and not from patients presenting to a clinic or medical center, which could skew the results as the results are limited to CGH only and did not take into account other type of headaches which may bias the results.CHISG recommends the use of diagnostic anesthetic blockades to make a definitive diagnosis of CGH, which was not used in this study.

In addition, the assessment was carried out for all participants using the same method and in the same order, regardless of the participant’s headache status causing CGH or CGH leading to increased dysfunction.

Other factors that can cause symptoms, such as psychosocial variables, were not investigated in this study; therefore, the interpretation of the results is limited to the possible pathology of movement disorders. In addition, the population size was small.

Recommendations

Further investigation should aim to determine whether the movement disorder identified in the current study is a causative factor in CGH or a symptom response, and whether treatment for the possible pathology has an impact on the signs and symptoms or not.

Additionally, a larger multifactorial study can also examine movement disorders with other possible factors (e.g. psychosocial component) that influence the development of signs. In addition, the research into movement disorder and use of SFMA in other headache kinds may assist determine whether or not SFMA is a beneficial diagnostic differentiation tool between different headache types. The study may also focus on possible associations between movement disorders and posture that could guide future treatment strategies in CGH.

Conclusion

This study was aimed to identify the movement dysfunction in subjects with CGH. Hence, this study concludes that the movement dysfunctions commonly prevailing in CGH are the following areas that were maximally affected. Those are, FPM more in UEP-2, DNM more in CE, and DPM more in CF. With this, it was found out that subjects with CGH may have dysfunctions involved in the above three areas. Therefore, considering this as a contributing factor, subjects may have to undergo the following SFMA breakouts in the future.