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The General Practitioner

And Cervicogenic Headache

A recent (and frequent) query from a colleague(s): “I wonder if general practitioners are aware of that (i.e. the natural progression of cervicogenic (neck) headache… If it is left untreated, cervicogenic headache becomes more frequent, more severe, requiring stronger and stronger medication, and eventually becomes continuous see Cervicogenic Management Decreases Migraine Progression). I am often amazed of the amount of pills the patient consumed before visiting a PT. With that background knowledge is there any specific advice for the doctors regarding cervicogenc headache patients?”

The role of the General Practitioner

Arguably the role of the General Practitioner is the most difficult role of all health professionals. They see the widest range of conditions of any specialty, requiring a satisfactory knowledge of 167 disorders to cover 85% of the conditions seen most frequently.  A thorough knowledge of all diseases is not possible. In excess, of 11000 conditions are currently described1 with around five new diseases being described each week!2

Headache remains the most common cause of neurological consultation in clinical practice for which correct diagnosis and treatment are essential.3,4

However, globally, on average, only 4 hours of undergraduate medical education is dedicated to education on headache conditions,5 and this preparation is framed by the current International Headache Society’s (IHS) Classification system (and dare I say dominated by the pharmaceutical industry). Unfortunately though, the IHS classification system of primary headache lacks biological validity and therefore hampers progress in understanding of headache.6,7 The IHS system is in disarray, hence the multiple revisions; 8–12 it is still not meeting clinicians’ needs with many receiving multiple diagnoses.13,14

Debate Continues as to whether cervicogenic headache exists

Furthermore, debate continues as to whether cervicogenic headache (classified as a secondary headache) exists15,16 (because there are no demonstrable validated lesions12 – i.e. secondary to what?). Notwithstanding this debate, those advocating for its existence, suggest cervicogenic headache represents only 4.1% of headache.17

So, cervicogenic headache (in the medical headache world) is bordering on extinction.

This is driven by the fact; cervicogenic headache and migraine share many characteristics (suggesting a common underlying mechanism?), prompting internationally recognised authorities’ perspectives:

‘Approximately 800 new headache patients per year are examined at our clinic. An estimated 80% of these patients are diagnosed with cervicogenic headache. Of these patients, almost none are referred with this diagnosis. Physicians are not taught to consider or explore neck structures when investigating headaches. This results in a rarely diagnosed but common condition.’18 … ‘One of the confusing phenomena about the cervicogenic headache is that its symptoms can present as migraine headaches, tension-type headaches or even cluster headaches.’18

and

‘For the clinician, pain presentations in the headache patient are frequently a diagnostic challenge.’…‘Headache of cervical origin and migraine often shows similar clinical presentations.’19

Clinical Features suggestive of cervicogenic headache

Clinical features suggestive of cervicogenic headache for e.g. history of trauma, onset in the neck, associated nuchal symptoms, temporary reproduction of typical head pain when examining upper cervical structures, are also present in primary headache syndromes.  Therefore, the assumption is (because of the erroneous premise that cervical afferents are not involved in primary headache) that these features do not define cervicogenic headache.12

A key diagnostic criterion of cervicogenic headache is side-locked unilaterality17 (so is 17% of migraine),20,21 whilst 83% of migraine alternates19,20 (and I have made the case for alternating unilateral headache being a ‘musculoskeletal event’, i.e. cervicogenic headache, elsewhere22) contradicting orthodox medical perspectives.  Determining alternating unilaterality is within the scope of the GP, but changing what they have been taught (i.e. cervicogenic headache does not alternate) is the barrier – medical thinking does not change for decades.

So, coming back to the question… ‘is there any specific advice for the doctors regarding cervicogenc headache patients?’

Raising the profile of cervical afferents in primary headache

The above medical/headache environment is difficult to overcome – the past 25 years of my life(!) has been devoted to raising the profile of cervical afferents in primary headache (C1-3 afferents contribute to the trigemino cervical nucleus, the doorstep of the common final pathway in primary headache conditions).

It is not the role of the GP or Neurologist to rule out cervical relevancy – their training is not in the musculoskeletal arena; GPs and Neurologists are not skilled in detailed examination of the upper cervical spine,15 the upper cervical spine is complex requiring specific expertise and experience.

I have treated successfully those with migraine many times (therefore it cannot be a migraine!) who have subsequently provided feedback to their GP/Neurologist to which their reply to patients was (and I paraphrase) ‘… it was coincidental.’

I approach GPs with surveys and what medical researchers are saying i.e. ‘… it can be difficult to differentiate cervicogenic headache from other forms of headache/migraine. I can help you with this as I have the expertise/skill to determine relevancy of disorders in the upper neck to a headache/migraine presentation.’ … invite yourself to be a part of their team… actions are more powerful than words.    

If possible, book (and pay for) a long consult with the GP and take along someone with headache or migraine (preferably one of their patients) and show them how you go about it.  Of course, examining and treating (successfully) a Neurologist/GP/GPs family member/colleague/friend, is the most cogent demonstration.

I am encouraged that feedback from attendees of Watson Headache® Institute courses indicates new relationships are being forged with referring GPs and Neurologists in relation to the role of the neck in headache and migraine. For example, there is a group of Level 2 Course Attendees in The Netherlands who now receive referrals from Neurologists asking ‘… is this person suitable for the ‘Watson Headache® Approach?’ (this is exciting because Manual Therapists are now being consulted regarding cervical relevancy in headache and migraine). Furthermore, GPs who ‘Optin’ for the Professional Education: Complimentary Guide For Health Professionals, ‘10 Misconceptions When Treating Headache and Migraine’ are second only to You, my Manual Therapy colleagues. In the past year, we have had GPs call the Watson Headache® Institute asking for Manual Therapists who have attended a course… .. we are making a difference! 

References:

  1. Meader CR, Pribor HC, Kerendian S. DiagnosisPro. 2012.  https://www.racgp.org.au/afp/2013/januaryfebruary/common-general-practice-presentations/
  2. Orphanet. 2012. Available at www.orpha.net/consor/cgi-bin/Education_AboutRareDiseases.php?lng=EN Accessed 25 September 2012
  3. https://www.racgp.org.au/afp/2014/march/chronic-headache/
  4. https://www.racgp.org.au/afp/2013/januaryfebruary/common-general-practice-presentations/
  5. https://www.who.int/news-room/fact-sheets/detail/headache-disorders
  6. Spierings EL. Migraine, big and small. Headache. Oct 2001;41(9):918-922.
  7. Shevel E SD. The international headache society classification of migraine headache-A call for substantiating data. Journal of Biomedical Science and Engineering. 2014;7(3):112-114.
  8. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Headache Classification Committee of the International Headache Society. Cephalalgia. 1988;8 Suppl 7:1-96.
  9. Classification of chronic pain: description of chronic pain syndromes and definition of pain terms. In: Mersky H BN, ed. Seattle, WA: IASP Press; 1994.
  10. The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24 Suppl 1:9-160.
  11. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. Jul 2013;33(9):629-808.
  12. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. Jan 2018;38(1):1-211.
  13. Abstracts of the 14th Congress of the International Headache Society. September 10-13, 2009. Philadelphia, Pennsylvania, USA. Cephalalgia. Oct 2009;29 Suppl 1:1-166.
  14. Sun-Edelstein C, Bigal ME, Rapoport AM. Chronic migraine and medication overuse headache: clarifying the current International Headache Society classification criteria. Cephalalgia. Apr 2009;29(4):445-452.
  15. Becker WJ. Cervicogenic headache: evidence that the neck is a pain generator. Headache. Apr 2010;50(4):699-705.
  16. Vincent MB. Cervicogenic headache: the neck is a generator: con. Headache. Apr 2010;50(4):706-709
  17. Fredriksen TA, Antonaci F, Sjaastad, O. Cervicogenic headache: too important to be left un-diagnosed. J Headache Pain; 2015 16(1):6
  18. Rothbart P. The cervicogenic headache: A pain in the neck. Can J Diagnos 1996; 13: 64–71.
  19. Goadsby PJ, Bartsch T. Anatomy and physiology of pain referral patterns in primary and cervicogenic headache disorders. Headache Currents 2005;10:42-48.
  20. Prakash S, Rathore C. Side-locked headaches: an algorithm-based approach. Headache Pain 2016;17(1):95
  21. Ramon C, Mauri G, Vega J, Rico M, Para M, Pascual J. Diagnostic distribution of 100 unilateral, side­locked headaches consulting a specialized clinic. European Neurology 2013;69(5):289-291
  22. Watson DH. Alternating Headache: C2-3 Guilty Or Not? Physiofirst In Touch Summer 2018 May 25