Not tonight honey, I have a headache!
Establishing the differential diagnosis for headaches can be challenging because of the similar signs and symptoms within the different types of headaches. In particular, discriminating between cervicogenic headaches (CGH) and migraines can be difficult, as both can include neck pain. CGHs account for up to 20% of all recurrent headaches and up to 50% for those with a history of neck trauma.
The neck dysfunction implicated in CGH has been localized to the C1-C3 area and affects the head via trigeminal nucleus afferants. Bogduk suggested that the lateral atlanto-axial joints seem to be commonly involved. Hall and Robinson have studied a clinical test for C1/2 segmental restriction using the cervical flexion-rotation test (FRT) as a possible cause for CGH.
This test involves the patient in supine and passively fully flexing the cervical spine, then assessing the cervical rotation range of motion. Full neck flexion will pick up the slack on the posterior ligamentous structures limiting rotation above and below C1/2. Normal range is about 45° to each side and an eyeball limitation of greater than 10° to one side is a positive test. Stop the test when firm manual resistance is encountered or the patient complains of pain. This test has established validity with high sensitivity (91%) and high specificity (90%). It also has established reliability between experienced and inexperienced examiners to determine C1/2 dysfunction within the CGH population.
Using the FRT, practitioners can be certain of an overall 89% diagnostic accuracy for C1/2 dysfunction, making it easier to refer patients to an appropriate manual or manipulative therapist for treatment. Successful outcomes have been found at our clinic with treatments that include manual and manipulative therapy, soft tissue techniques and dry needling. Treatments will contain specific exercises for the deep long neck flexors; longus colli and longus capitus. Please refer to the archives on our website for the Physio Window on this topic.
Bogduk, N. & Govind, J., Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests and treatment. The Lancet, Neurology, (8)959-968, 2009.
Hall, T., Briffa, K., Hopper, D. & Robinson, K., Comparative analysis and diagnostic accuracy of the cervical flexion-rotation test, J Headache Pain. 11:391-397, 2010.