This document provides information about cervicogenic headache, including its definition, pathophysiology, clinical presentation, diagnosis, and treatment. A cervicogenic headache is a type of secondary headache that originates from pain-sensitive structures in the neck. It presents as unilateral pain that starts in the neck and can spread to the head or face. Diagnosis involves identifying neck-related symptoms and signs, as well as ruling out other primary headache disorders through examination and diagnostic tests. Treatment focuses on reducing neck pain and inflammation through pharmacological and non-pharmacological approaches like physiotherapy.

1. 1
CONTENT
S NO. TOPIC
1 Introduction
2 Definition
3 Pathophysiology
4 Epidermology
5 Etioloy
6 Clinical presentation
7 Pattern / Area of pain
8 Differential Diagnosis and Similarties
9 Measures
Neck disability index
Headache disability index
10 Examination
Red flag
11 Assesment(pt)
12 Treatment
Pharmacological
Non pharmcological
Surgical
Other interventions
physiotherapy
13 Preventive ergonomics
14 Recent advancements
15 Bibliography

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CERVICOGENIC HEADACHE
A Cervicogenic Headache (CGH) presents as unilateral pain that starts in the neck. It is a common
chronic and recurrent headache that usually starts after neck movement. It usually accompanies a reduced
range of motion (ROM) of the neck. It could be confused with a migraine, tension headache, or other
primary headache syndromes.
Diagnostic criteria must include all the following points:
1. Source of the pain must be in the neck and perceived in head or face.
2. 2. Evidence that the pain can be attributed to the neck. It must have one of the following:
demonstration of clinical signs that implicate a source of pain in the neck or abolition of a headache
following diagnostic blockade of a cervical structure or its nerve supply using a placebo or other
adequate controls.
3. 3. Pain resolves within three months after successful treatment of the causative disorder or lesion.

3. 3
DEFINITION
Cervicogenic headache (CGH) is a chronic headache that arises from the atlanto-
occipital and upper cervical joints and perceived in one or more regions of the head or face.
A cervicogenic headache is a common cause of a chronic headache that is often
misdiagnosed. The presenting features can be complex and similar to many primary
headache syndromes that are encountered daily. The main symptoms of a cervicogenic
headache are a combination of unilateral pain, ipsilateral diffuse shoulder, and arm pain.
ROM in the neck is reduced, and pain is relieved with anesthetic blockades.
The International Headache Society (IHS) has validated cervicogenic headache as a
secondary headache type that is hypothesized to originate due to nociception in the cervical
area.

4. 4
ANATOMY
The cervical spine consists of 7 vertebrae, C1 to C7, the cervical nerves from C1 to C8,
muscles and ligaments .
The first two vertebrae have a unique shape and function. They form the upper cervical
spine.
The upper vertebrae supports the skull (atlas/C1), articulates superiorly with the occiput
(the atlanto-occipital joint) . This joint is responsible for 33% of flexion and extension.The
design of the atlas allows forward and backward movement of the head.
Below the atlas is the axis (C2) that allows rotation.[3] The atlantoaxial joint is responsible
for 60% of all cervical rotation.
The 5 cervical vertebrae that make up the lower cervical spine, C3-C7, are similar to each
other but very different from C1 and C2.

5. 5
PATHOPHYSIOLOGY
The C1-C3 nerves relay pain signals to the nociceptive nucleus of the head and neck,
the trigeminocervical nucleus. This connection is thought to be the cause for referred pain to the occiput
and/or eyes.
Aseptic inflammation and neurotransmission within the C-fibers that is caused by cervical disc pathology
is thought to produce and worsen the pain in a cervicogenic headache.
The trigeminocervical nucleus receives afferents from the trigeminal nerve as well as the upper three
cervical spinal nerves. Neck trauma, whiplash, strain, or chronic spasm of the scalp, neck, or shoulder
muscles can increase the sensitivity of the area which is similar to the allodynia that is seen in late
chronic migraines.
A lower pain threshold makes patients more susceptible to more severe pain. For this reason, early
diagnosis and therapeutic intervention is very important.

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EPIDERMOLOGY
A cervicogenic headache is a rare chronic headache in people who are 30 to 44 years old. Its prevalence
among patients with headaches is 1% to 4%, depending on how many criteria fulfilled and based on
many different studies.
It affects males and females about the same with a ratio of 0.97 (F/M ratio).
Age at onset is thought to be the early 30s, but the age the patients seek medical attention and diagnosis
is 49.4.
When compared with other headache patients, these patients have a pericranial muscle tenderness on the
painful side and a significantly reduced cervicogenic headache.

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PREVALANCE
Rest
B/w
0.4-2.5
Range
General
Prevelance

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GENDER RATIO
0
2
4
6
8
10
Men Women
Cervicogeniocheadache 4times
more in womens
Range

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ETIOLOGY
A cervicogenic headache is thought to be referred pain arising from irritation caused by cervical
structures innervated by spinal nerves C1, C2, and C3; therefore, any structure innervated by the C1–C3
spinal nerves could be the source for a cervicogenic headache.
This may include the joints, disc, ligaments, and musculature.
The lower cervical spine may play an indirect role in pain production if dysfunctional, but there is no
evidence of a direct referral pattern.
Through controlled nerve blocking of various structures in the cervical spine, it appears that the
zygoapophyseal joints, especially those of C2/C3, are the most common sources of CGH pain.
Other causes-
 By repetitive movement of neck.
 Bad posture of neck
 Neck pain
 Degenerative condition – arthritis , traumatic cause
 Whiplash / head / neck trauma
 Sports injuries
 Fall
 Restriction of mobility
 Sprain
 Muscle injuries of neck
 Neck muscle weakness
 Muscle tightness.

10. 10

11. 11
CLINICAL PRESENTATION
 Unilateral dominant headache , (excluding bilateral headache ) .
 Exacerbated by neck movement or posture.
 Tenderness of the upper 3 cervical spine joints.
 Ipsilateral diffuse shoulder.
 Association with neck pain or dysfunction.
 Compared to migraine headache and control groups, cervicogenic headache group patients tend to
have increased tightness and trigger points in upper trapezius, levator scapulae, scales and
suboccipital extensors.
 Weakness in the deep neck flexors.
 Increased activity in the superficial flexors.
 Atrophy in the suboccipital extensors and so the deep muscle , which is important for active support
of the cervical segments becomes impaired.
 Upper trapezius, sternocleidomastoid, scalenes, levator scapulae, pectoralis major and minor, and
short sub-occipital extensors have been implicated.
 Range of motion of neck reduced.
 Arm pain.
 Physiological features -
Irratiblity
Fatigablity.

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PATTERN OF PAIN

13. 13
OR
AREA OF PAIN

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DIFFERENTIAL DIAGNOSIS
AND
SIMILARTIES

15. 15

16. 16
MEASURES
 Numeric pain rating scale
 Pain visual analog scale
 Neck disability index (NDI)
 Headache disability index
NECK DISABILITY INDEX
This questionnaire has been designed to give us information as to how neck pain has
affected ability to manage in everyday life.
Section 1: Pain Intensity
 I have no pain at the moment
 The pain is very mild at the moment
 The pain is moderate at the moment
 The pain is fairly severe at the moment
 The pain is very severe at the moment
 The pain is the worst imaginable at the moment
Section 2: Personal Care (Washing, Dressing, etc.)
 I can look after myself normally without causing extra pain
 I can look after myself normally but it causes extra pain
 It is painful to look after myself and I am slow and careful
 I need some help but can manage most of my personal care
 I need help every day in most aspects of self care
 I do not get dressed, I wash with difficulty and stay in bed
Section 3: Lifting
 I can lift heavy weights without extra pain
 I can lift heavy weights but it gives extra pain
 Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently
placed, for example on a table
 Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are
conveniently positioned
 I can only lift very light weights
 I cannot lift or carry anything
Section 4: Reading
 I can read as much as I want to with no pain in my neck
 I can read as much as I want to with slight pain in my neck
 I can read as much as I want with moderate pain in my neck
 I can’t read as much as I want because of moderate pain in my neck
 I can hardly read at all because of severe pain in my neck
 I cannot read at all

17. 17
Section 5: Headaches
 I have no headaches at all
 I have slight headaches, which come infrequently
 I have moderate headaches, which come infrequently
 I have moderate headaches, which come frequently
 I have severe headaches, which come frequently
 I have headaches almost all the time
Section 6: Concentration
 I can concentrate fully when I want to with no difficulty
 I can concentrate fully when I want to with slight difficulty
 I have a fair degree of difficulty in concentrating when I want to
 I have a lot of difficulty in concentrating when I want to
 I have a great deal of difficulty in concentrating when I want to
 I cannot concentrate at all
Section 7: Work
 I can do as much work as I want to
 I can only do my usual work, but no more
 I can do most of my usual work, but no more
 I cannot do my usual work
 I can hardly do any work at all
 I can’t do any work at all
Section 8: Driving
 I can drive my car without any neck pain
 I can drive my car as long as I want with slight pain in my neck
 I can drive my car as long as I want with moderate pain in my neck
 I can’t drive my car as long as I want because of moderate pain in my neck
 I can hardly drive at all because of severe pain in my neck
 I can’t drive my car at all
Section 9: Sleeping
 I have no trouble sleeping
 My sleep is slightly disturbed (less than 1 hr sleepless)
 My sleep is mildly disturbed (1-2 hrs sleepless)
 My sleep is moderately disturbed (2-3 hrs sleepless)
 My sleep is greatly disturbed (3-5 hrs sleepless)
 My sleep is completely disturbed (5-7 hrs sleepless)
Section 10: Recreation

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 I am able to engage in all my recreation activities with no neck pain at all
 I am able to engage in all my recreation activities, with some pain in my neck
 I am able to engage in most, but not all of my usual recreation activities because of pain in my neck
 I am able to engage in a few of my usual recreation activities because of pain in my neck
 I can hardly do any recreation activities because of pain in my neck
 I can’t do any recreation activities at all
Score: /50 Transform to percentage score x 100 = %points
Scoring: For each section the total possible score is 5: if the first statement is marked the section score =
0, if the last statement is marked it = 5. If all ten sections are completed the score is calculated
Minimum Detectable Change (90% confidence): 5 points or 10 %points
HEADACHE DISABILITY INDEX
Headache Disability Index
Patient Name Date
Please check the correct response about your headaches:
I have a headache: ❍ once per month ❍ more than once but less than four times per month ❍ more than
once per week
My headache is: ❍ mild ❍ moderate ❍ severe
Please read carefully: The purpose of this scale is to identify difficulties you may be experiencing
because of your headaches. Please check Yes, Sometimes or No for each item. Answer each question
only as it pertains to your headache.
Yes Sometimes No
1 Do you feel disabled because of your headache? ❍ ❍ ❍
2 Do you feel restricted in performing your routine daily activities? ❍ ❍ ❍
3 Do you feel no one understands the effect your headaches have on your
life?
❍ ❍ ❍
4 Do you restrict your recreational activities (for example, sports, hobbies)
because of your headaches? ❍ ❍ ❍
5 Do your headaches make you angry? ❍ ❍ ❍
6 Do you feel that you are going to lose control because of your
headaches?
❍ ❍ ❍
7 Are you less likely to socialize because of your headaches? ❍ ❍ ❍
8 Do you feel like your spouse (or significant other), family and friends
have no idea what you are going through because of your headaches? ❍ ❍ ❍
9 Do you feel your headaches are so bad that you will go insane? ❍ ❍ ❍
10 Is your outlook on the world affected by your headaches? ❍ ❍ ❍
11 Are you afraid to go outside when you feel a headache is starting? ❍ ❍ ❍
12 Do you feel desperate because of your headaches? ❍ ❍ ❍
13 Are you concerned that you are paying penalties at work or at home
because of headaches?
❍ ❍ ❍
14 Do your headaches place stress on your relationships with family or ❍ ❍ ❍

19. 19
friends?
15 Do you avoid being around people when you have a headache? ❍ ❍ ❍
16 Do you believe your headaches are making it difficult for you to achieve
your goals in life?
❍ ❍ ❍
17 Are you unable to think clearly because of your headaches? ❍ ❍ ❍
18 Do you get tense (for example, muscle tension) because of your
headaches?
❍ ❍ ❍
19 Do you not enjoy social gatherings because of your headaches? ❍ ❍ ❍
20 Do you feel irritable because of your headaches? ❍ ❍ ❍
21 Do you avoid traveling because of your headaches? ❍ ❍ ❍
22 Do your headaches make you feel confused? ❍ ❍ ❍
23 Do your headaches make you feel frustrated? ❍ ❍ ❍
24 Do you find it difficult to read because of your headaches? ❍ ❍ ❍
25 Do you find it difficult to focus your attention away from your headaches
and on other things? ❍ ❍ ❍
SCORING INSTRUCTIONS: Yes = 4 points, Sometimes = 2, No = 0.
Using this system, a total score of 10-28 is considered to indicate mild disability; 30-48 is moderate
disability; 50-68 is severe disability; 72 or more is complete disability.
CERVICOGENIC HEADACHE ASSESSMENT
 Demographic data
Patient name
Age
Sex
Occupation
Address
 Cheif complaint - severe headache /upper neck pain / overall stiffness .
 Observation - body built
Cervical curve
Shoulder level
posture

20. 20
 Palpation - tenderness
Spasm
 Pain assessment - type
Nature
Onset
NPRS/VAS
Aggrevating factor
Relieving factor
 Examination
Evaluation criteria
AROM of cervical spine
1. Extension:
2. Flexion:
3. Rotation:
4. Side-bend :
5. Strength -
PROM
Criteria findings -
Palpation (Supine & Prone) Occiput:
2. C1-C3:
3. C4-C7:
Mobility
Anterior Mob / Unilateral mob.:
4. Grade I:
5. Grade II:
Special Tests
6. Cervical Distraction:
7. Cervical Compression:
8. Neck Disability Index (NDI)
The NDI Score of 66% would place her at a severe disability. Minimum Detectable Change of NDI: 5
points or 10%. 25% would her at 24: Moderate disability0-4points (0-8%) no disability,5-14points ( 10 –
28%) mild disability,15-24points (30-48% ) moderate disability,25-34points (50- 64%) severe
disability,35-50points (70-100%) complete disability.
 Special test
Flexion Rotation Test (FRT):
Assesses dysfunction at the C1-C2 motion segment.
Test Procedure :Cervical spine is passively fully flexed, to isolate movement to C1-C2.Rotation ROM is
evaluated in this position.
Results: Normal range of rotation motion in end range flexion has been shown to be 44° to each side.In
contrast, subjects suffering from headache with C1-C2 dysfunction have an average of 17° less
rotation.The C1-C2 motion segment accounts for 50% of rotation of the cervical spine.
 Plan of care
Specifics
 Pain Management Heat
 AROM/PROM of Cervical Spine

21. 21
 Manual Therapy
 Cervical Distraction
 Soft Tissue Massage
 Joint Mobilizations (Passive/Active)
 Cervical Flexion Test
 Scapular Retraction Exercises
 Upper trap stretches
 Isometric SB Flex and ExtWork Simulation (prior to D/C)
 Overhead lifting
 STM to sub-occipitals, lateral paraspinals, upper trapezius
 Cranioflexion Test: : Failed at 20 mmHg, used as treatment. Needed tactile and verbal cues to
decrease SCM activation. Progressed from supine to elevated 45 degrees and then to seated. Added
overpressure.
 Scapular Retraction Exercises.

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EXAMINATION
Diagnostic criteria
1. Pain localized in the neck and occiput, which can spread to other areas in the
head, such as forehead, orbital region, temples, vertex, or ears, usually unilateral.
2. Pain is precipitated or aggravated by specific neck movements or sustained
postures.
3. At least one of the following:
 Resistance to or limitation of passive neck movements
 Changes in neck muscle contour, texture, tone, or response to active and passive
stretching and contraction
 Abnormal tenderness of neck musculature
4. Radiological examination reveals at least one of the following:
 Movement abnormalities in flexion/extension
 Abnormal posture
 Fractures, congenital abnormalities, bone tumors, rheumatoid arthritis, or other
distinct pathology (not spondylosis or osteochondrosis)
Patients with cervicogenic headache will often have altered neck posture or restricted
cervical range of motion.16 The head pain can be triggered or reproduced by active
neck movement, passive neck positioning especially in extension or extension with
rotation toward the side of pain, or on applying digital pressure to the involved facet
regions or over the ipsilateral greater occipital nerve. Muscular trigger points are
usually found in the suboccipital, cervical, and shoulder musculature, and these
trigger points can also refer pain to the head when manually or physically stimulated.
There are no neurologic findings of cervical radiculopathy, though the patient might
report scalp paresthesia or dysesthesia.
Diagnostic imaging such as radiography, magnetic resonance imaging (MRI), and
computed tomography (CT) myelography cannot confirm the diagnosis of
cervicogenic headache but can lend support to its diagnosis.
Zygapophyseal joint, cervical nerve, or medial branch blockade is used to confirm the
diagnosis of cervicogenic headache . The first three cervical spinal nerves and their
rami are the primary peripheral nerve structures that can refer pain to the head.
FLEXION ROTATIONTEST - During this test, the neck of the patient is
passively held in end range flexion. The therapist rotates the neck to each side until
they feel resistance or until the patient says they are in pain. At this end point, the
therapist makes a visual estimate of the rotation range and says on which side the FRT
was positive or negative.

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RED FLAG
1. Sudden onset of a new severe headache

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2. A worsening pattern of a pre-existing headache in the absence of obvious
predisposing factors;
3. Headache associated with fever, neck stiff ness, skin rash, and with a history
of cancer, HIV, or other systemic illness;
4. Headache associated with focal neurologic signs other than typical aura;
5. Moderate or severe headache triggered by cough, exertion, or bearing down;
6.New onset of a headache during or following pregnancy.
Patients with one or more red flags should be referred for an immediate medical
consultation and further investigation.
TREATMENT
Multifacet approach
Pharmacological Non pharmacological
Anasthetic Manipulative
Surgical intervention
 Physical therapy is considered the first line of treatment. Manipulative therapy
and therapeutic exercise regimen are effective in treating a cervicogenic headache.
 Another option for treatment of a cervicogenic headache is interventional
treatment, which will differ depending on the cause of a headache.
 There is some evidence that cervical epidural steroid injection has some benefits
in treating pain in a cervicogenic headache. Steroids can work in this setting due
to the theory that the pain continues sensitizing the cervical nerve roots and
initiates a pain-producing loop involving nerve root and microvascular
inflammation as well as mechanically-induced micro-injury.

25. 25
 cervicogenic headaches tend to recur and can significantly affect the quality of
life and some patients may also benefit from simultaneous cognitive behavior
therapy.
 Cervical epidural steroid injections: Indicated for multilevel disc or spine
degeneration. There is some evidence that cervical epidural steroid injection has
some benefits in treating pain in a cervicogenic headache. Steroids can work in
this setting due to the theory that the pain continues sensitizing the cervical nerve
roots and initiates a pain-producing loop involving nerve root and
microvascular inflammation as well as mechanically-induced micro-injury.
PHARMACLOGICAL TREATMENT
Tricyclic antidepressents – amitriptyline hydrochlorine, nortriptyline hydrochlorine.
Antiepileptic drugs – gabapentine , carbemazepine,
Muscle relaxants – tizanidine hydrochloride, beclofen.
Nonsteroidal anti-inflammatory drugs - cox nonselective inhibitors - indomethacin ,
ibuprofen.
Cox selective inhibitors – celecoxib.
NON PHARMACOLOGICAL APPROACH
Osteopathic manipulative treatment or manual modes of therapy.
Physical therapy
SNAG – Sustained Natural Apophyseal glide.
Mulligan's manual therapy technique at peripheral joints, namely mobilization
with movement (MWM).Thin strap was positioned on the posterior arch of C1 and
drawn horizontally forward across the face. The purpose of the strap is to facilitate
rotation at C1-C2 in the same direction as found to be limited in ROM.Possible
physiologic mechanism of mobilization: neuro-modulation effect. IN the gate control
theory, stimulation of mechanoreceptors within the join capsule and surrounding
tissues casues a an inhibition of pain at the spinal cord. In addition, descending pain-
inhibitory systems may be activated, mediated by areas such as the periaqueductal
gray of midbrain. The end range of positioning in rotation with the C1-C2 self-SNAG
may engage these inhibitory systems and decrease pain.

26. 26
TENS (transcutaneous electrical nerve stimulation)
Biofeedback / Relaxation Therapy
Individual psycotherapy

27. 27
OTHER INTERVENTIONAL
NERVE BLOCK -Disrupting the cascade of signals leading to sensitization to central
mechanisms via:
 Anasthetic blockage - spinal roots , rami , nerves and branches.
Muscular triger points.
 Neurolytic procedure -radiofrequency thermal neurolysis.
 Occipital nerve stimulator.
 Nerve modulation.
SURGICAL
 Anterior cervical disectomy and fusion - Anterior cervical discectomy and
fusion (ACDF) is a type of neck surgery that involves removing a damaged disc
to relieve spinal cord or nerve root pressure and alleviate corresponding pain,
weakness, numbness, and tingling. A discectomy is a form of surgical
decompression, so the procedure may also be called an anterior cervical
decompression. The surgery has 2 parts:
 Anterior cervical discectomy. The surgery is approached through the anterior, or
front, of the cervical spine (neck). The disc is then removed from between two
vertebral bones.
 Fusion. A fusion surgery is done at the same time as the discectomy operation in
order to stabilize the cervical segment. A fusion involves placing bone graft
and/or implants where the disc originally was in order to provide stability and
strength to the area.
 Cervical artificial disc replacement
Artificial cervical discs have been developed and are available as a surgical option to
treat cervical disc problems that cause chronic neck pain and other symptoms, such as
arm pain or weakness.


28. 28
PHYSIOTHERAPY TREATMENT
 Modalities - cryotherapy
TENS
Laser therapy
 Manual therapy -
Muscle stretching - stretching of SCM,upper trapezius, levator, scalenes,
suboccipitals, pectoralis minor, and pectoralis major
 Strengthening exercises including deep neck flexors and upper quarter muscles
 Thoracic spine thrust manipulation & exercise
 C1-C2 Self-sustained Natural Apophyseal Glide (SNAG)shown to be effective
for reducing cervicogenic headache symptoms
 Thoracic Manipulation
 Re-education of craniocervical flexion (CCF) movement - The neck flexor
muscle synergy is tested with the Cranio‐ cervical Flexion Test. The patient
palpates the superficial flexors to avoid their inappropriate use. An emphasis on
precision and control is essential.
Training the low-level endurance capacity of the deep neck flexors begins as soon as
the patient can perform the CCF movement correctly. This phase tests the patient’s

29. 29
ability to hold (approximately 10 seconds) the cranio-cervical flexion position in each
stage of the test on repeated occasions. Pressure biofeedback is used to guide training.
Training begins at the pressure level that the patient can achieve and hold steady with
a good pattern, without dominant use or substitution by the superficial flexor muscles.
The patient performs the formal exercise at least twice daily. For each pressure level,
the holding time is built up to 10 seconds and 10 repetitions are performed, eventually
to the desired level of 30 mm Hg.
Retraining the cervical flexors for antigravity function in sitting position[8] The
exercise is a controlled eccentric action of the flexors into cervical extension range
followed by a concentric action of these muscles to return the head to the neutral
upright position. The return to the upright position must be initiated by CCF, rather
than a dominant action of sternocleidomastoid. The exercise is progressed by
gradually increasing the range to which the head is moved into extension as control
improves, and introducing isometric holds through range.

30. 30
Extensors of the Craniocervical Spine
The patient practices eccentric control of the head into flexion followed by concentric
control back to the neutral position in a 4 point kneeling position to train the
coordination of the deep and superficial cervical extensors. These exercises are
incorporated with re-education of the scapular muscles in these positions and are
commenced early in the program. The exercise is progressed by performing
alternating small ranges of craniocervical extension and flexion while maintaining the
cervical spine in a neutral position. Co-contraction of the neck flexors and extensors.

31. 31
Co-contraction of the Neck Flexors and Extensors
The co-contraction is facilitated with rotation and the exercises are introduced once
the patient can activate the deep muscles. The patient uses self-resisted isometric
rotation in a correct upright sitting posture. They look into the palm of the hand,
providing the resistance to facilitate the muscles and perform the alternating rhythmic
stabilization exercises with an emphasis on slow onset and slow release holding
contractions, using resistance to match about a 10–20% effort. Retraining the strength
of the superficial and deep flexor synergy
Retraining the Strength of the Superficial and DeepFlexor Synergy
The head lift must be preceded with CCF followed by cervical flexion to just lift the
head from the bed. Gravity and head load provide the resistance. Care must be taken
that high load exercise is not introduced too early, as it may be provocative of
symptoms.
 Retraining the Scapular Muscles
Retraining scapular orientation in posture A correction strategy is to have the patient
move the coracoids upward and the acromion backward, which results in a slight
retraction and external rotation of the scapula. The aim is to facilitate the coordinated
action of all parts of trapezius and serratus anterior, allowing lower trapezius to
slightly depress the medial border of the scapula, consequently lengthening (and

32. 32
relaxing) the levator scapulae. Once the patient learns correct scapular orientation, he
repeats the correction and maintains the position regularly throughout the day so that
it becomes a habit.
Training the endurance capacity of the scapular stabilisers Repeated repetitions of 10
second holds of the corrected scapular position encourages early endurance retraining.
The endurance of the middle and lower trapezius muscles is also trained by
performing an exercise in the prone lying position against the effects of gravity.
Retraining scapular control with arm movement and load This is important when
activities such as computer or deskwork aggravate pain. The patient is encouraged to
maintain their newly learned scapular position while performing small range (+/- 60
degrees) arm movements, or during, for example, work at a computer. Scapular
control in association with control of cervicothoracic postural position is also trained
for functional activities such as lifting and carrying.

33. 33
Upper Quarter Strengthening Exercises
Middle trapezius strengthening
Lower trapezius strengthening
Adding upper quarter exercises for patients with cervical dysfunction is important in
order to integrate ‘global’ muscles that have connections to the cervical spine through
anatomical chains

34. 34
Re-education of Posture
Posture is an indirect measure of the functional status of the neuromuscular
system. Postural position is trained in sitting and is corrected from the pelvis. The
second aspect of re-education of postural position is the correction of scapular
position. Maintenance of a correct scapular position with appropriate muscle
coordination has the added benefit of inducing reciprocal relaxation in muscles such
as levator scapulae, which reduces muscular pain in the area.
Sensorimotor Training
Because CGHs are thought to be a dysfunction of the sensorimotor
system. Sensorimotor exercises include progressive exercise on unstable surfaces to
promote reflexive stabilization and postural stability. Unstable surfaces such as
exercise balls or foam pads can be used to add challenge to the cervical spine as well
as the whole-body for stabilization exercises. These final stages of the rehabilitation
program for CGH patients can be progressed toward functional activities to return the
patient to full participation.
Trigger Point Therapy
This is composed of different manual approaches, for example, compression,
stretching, or transverse friction massage. Pressure release over the
sternocleidomastoid muscle TrP is applied and pressure is progressively applied and
increased over the TrP until the finger encountered an increase in tissue resistance
(tissue barrier). This pressure is maintained until the therapist sensed a relief of the
taut band. At that moment, the pressure is increased again until the next increase in
tissue resistance. Do this 3x/session. Stretching of the taut band muscle fibers is also
important. This technique has been found to be effective for lengthening the TrP in
the muscle and the associated connective tissue. The therapist apply moderate slow
pressure over the TrP and slides the fingers in the opposite directions. Trigger point

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manual therapy is applied slowly and is performed without inducing pain to the
patients.
(Myofascial) Mobility, Strength, Stability and Postural Exercices
These technics were primarily postisometric relaxation procedures
(A) Myofascial mobilization
(B) Selected elements of McKenzie therapy
(C) Exercises were mainly applied to the muscles with TrPs, showing the
pathological increase in rEMG amplitude. When relaxation of painful, tensed
muscles is achieved, the next step of treatment include strengthening exercises of the
same muscles. All of them are supervised by a physiotherapist. Exercises intensity
shall not increase the pain sensation in the cervical spine, shoulder and girdle muscles.
They aren’t supposed to evoke the headache. There are isometric exercises with the
gradual loading increase
(D) Dynamic exercises
(E) Elastic therabands are commonly used during these exercises.
(F) Additionally, the self-control exercises of the correct body posture are carried
out in front of the mirror relying on the visual feedback .

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Recent advancements
Mohammadreza pourahmadi , PT , PhD, Jan dhommerholt PT, DPT ,.et,
Dry Needling for the Treatment Of Tension-Type, Cervicogenic, or Migraine
Headaches: a Systematic Review and Meta-Analysis; february 21;Physical Therapy,
pzab068, https://doi.org/10.1093/ptj/pzab068
Objective
Dry needling is a treatment technique used by clinicians to relieve symptoms in
patients with cervicogenic headache (CGH). This systematic review's main objective
was to assess the effectiveness of dry needling on headache pain intensity and related-
disability in patients with , CGH .
Conclusion
Dry needling produces similar effects to other interventions for short-term headache
pain relief, whereas dry needling seems to be better than other therapies for
improvement in related-disability in the short-term.
Impact
Although further high methodological quality studies are warranted to provide a more
robust conclusion, our systematic review suggested that for every one to two patients
with CGH, for every three to four patients treating by dry needling, one patient will
likely exhibit decreased headache intensity (NNT = 4; small effect) and improved
related-disability (NNT = 3; medium effect).

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PREVENTIVE ERGONOMICS
 Maintain a good sitting posture
 Avoid prolonged periods of sitting or static postures in general
 Ask your employer about having an appropriate workstation assessment
 Avoid getting overtired to the point of exhaustion
 Keep yourself well hydrated throughout the day
 Exercise regularly to stimulate the circulation of blood to the head and to
maintain neuro-musculoskeletal flexibility.
 Try not to sleep on your stomach. Either sleep on your side with your head
supported so that it is level with your spine, or on your back with a small pillow
or rolled up towel supporting your neck rather than your head.

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BIBLIOGRAPHY
Goodman, C, Fuller, K. Pathology: Implications for the Physical Therapist. 3rd ed. St.
Louis: Saunders Elsevier, 2009.
↑ Headache Classification Subcommittee of the International Headache Society. The
international classification of headache disorders.2nd edition. Cephalalgia 2004;24
UZ Leuven, Anatomie van de cervicale wervelkolom, 2013. (
↑Al Khalili Y, Jain S, Murphy PB. 2019 Headache, Cervicogenic.
Available from:https://www.ncbi.nlm.nih.gov/books/NBK507862/ (last accessed
1.2.2020
Becker WJ. Cervicogenic Headache: Evidence that the neck is a pain generator.
Headache. 2010;4 699-705
↑Jull G, Stanton W. Predictors of responsiveness to physiotherapy management of
cervicogenic headache. Cephalalgia. 2005;25:101-108.

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