Later that week, Watson and his colleague catch up over morning tea. “Did you discuss his bilateral headache further with your colleague?’ “Yes,” he said, “While it is symmetrical across the forehead, it sometimes felt stronger on one side and then on the other. He also reiterated that he believes his neck is the issue, but his doctor is adamant his neck is not the issue because he has a ‘tension headache’. “
“Well, this behaviour rules out CGH,”1-4 a bemused Watson replies. “I mentioned two recent articles reviewing CGH last time.3,4 The latter4 reflects the commonly held perspective that ‘The diagnosis of Cervicogenic Headache (CGH) is usually complex’. (p. 3). This is ascribed to the shared symptom expression of CGH with Primary headache forms. Therefore, a physical examination of the upper cervical spine is critical to diagnosing – agreed! Do you know if the doctor examined his neck?”
The Critical Physical Examination
“No, but he has just walked into the cafeteria—you can ask him.” After being introduced, Watson asks, “Did your doctor examine your neck?” “Yes, he explained that to confirm my neck being the issue, it was key during this part of the examination to reproduce my head pain.”
“Yes, that is correct. Can you describe the examination?” comes Watson’s mischievous query.
“I recall he looked at my neck movements – which he said were fine. Then he pushed ‘over the upper cervical or occipital region’1 on both sides because ‘pressure on the C1-2 level reproduces cervicogenic headaches more frequently’.”4,5 (p. 5). “Was there any response?” Watson’s colleague asks.
“Well, apart from some local tenderness… nothing occurred,” comes Watson’s colleague’s associate’s frustrated reply. Watson’s colleague’s intuitive reading of Watson urges his query, “What do you make of that Watson?”
No Reproduction of Typical Head Pain: Where to from Here?
“Applying pressure over the upper cervical spine or occipital region is not good enough. Similarly, ‘pressure on the C1-2 level reproduces cervicogenic headaches more frequently’. Respectfully, what does this mean? Firstly, this is incongruent with seminal, contemporary (anaesthetic block) research6, which demonstrates the most common segment head pain referring segment is C2-3 at 62% and C1-2 at 7%.6 Secondly, this is a ‘broad-brush’ approach. Applying pressure to the deeply located C1-2 segment is problematic. What isn’t problematic is palpating C1 and C2 vertebrae in various head positions, enabling stress to be applied selectively to C0-C1, C1-2 or C2-3 segments. Patently, this is a more comprehensive examination, as evidenced in an earlier clinical study,7 in which characteristic head pain was reproduced in 95% and 100% of migraine and tension headache cohorts, respectively. Until this is done, a non-reproduction palpation of the upper examination is ambiguous,” explains Watson.
“Are you saying that despite there being no reproduction of my head pain, it could still be my neck,” comes a relieved reply.
The Excited Expectation Extinguished
“Yes. Reproduction of typical head pain is not complex if the practitioner has an intimate understanding of the anatomy and biomechanics, specific training in palpation, and dedicated experience with the upper cervical spine. However, this expertise typically falls beyond the scope of medical training. Regrettably, even within the manual therapy disciplines at the undergraduate level, the emphasis on training for palpation examination is waning, with only a select few advanced postgraduate programs striving to bridge this educational gap,” comes Watson’s measured answer.
But Wait… There is Hope!
Watson, recognising his colleague’s associate’s confused state, hastily adds, “However, what doesn’t require a specific skill-set is establishing the area and behaviour of head pain – this alone can confirm cervical relevancy.”
“Really… does my head pain confirm that my neck is the underlying cause?”
References:
- Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. The Cervicogenic Headache International Study Group. Headache. Jun 1998;38(6):442-445.
- Sjaastad O, Fredriksen TA. Cervicogenic headache: criteria, classification and epidemiology. Clin Exp Rheumatol. Mar-Apr 2000;18(2 Suppl 19):S3-6.
- Antonaci F, Inan LE. Headache and neck. Cephalalgia. Apr 2021;41(4):438-442.
- Piovesan EJ, Utiumi MAT, Grossi DB. Cervicogenic headache – How to recognize and treat. Best Pract Res Clin Rheumatol. Feb 21 2024:101931.
- Rubio-Ochoa J, Benítez-Martínez J, Lluch E, Santacruz-Zaragozá S, Gómez-Contreras P, Cook CE. Physical examination tests for screening and diagnosis of cervicogenic headache: A systematic review. Man Ther. Feb 2016;21:35-40.
- Govind J, Bogduk N. Sources of Cervicogenic Headache Among the Upper Cervical Synovial Joints. Pain Med. Jan 23 2021.
- Watson DH, Drummond PD. Head pain referral during examination of the neck in migraine and tension-type headache. Headache. Sep 2012;52(8):1226-1235.
