Cervicogenic Headache and Migraine

by | Sep 2, 2021 | Headache, Migraine

Headaches affect up to 50% of the population at some stage in their lives. At least 20% of all headaches and migraines can be attributed to the neck and some studies show this number may be significantly higher.

What is a cervicogenic headache?

A cervicogenic headache is essentially referred pain from the neck that, due to a miscommunication of the nerves that supply the head and neck, the pain is perceived in the head, rather than the true source in the neck. The pathophysiological basis for the referred pain isa “convergence” of nerves. To try to put it simply, the nerves that supply the head come into close proximity to the nerves that supply the neck. As the nerves from the neck make there way into the brain to communicate the message of neck dysfunction, they “converge” with the nerves that are carrying messages from the head and thus the end result is that the brain thinks the message is coming from the head, rather than the neck.

What can a physiotherapist do?

Our jobs, as physiotherapists, are to:

  1. correctly identify headaches that are caused by a neck (cervical) dysfunction;
  2. correctly identify what type of dysfunction it is and;
  3. treat the underlying cause of the dysfunction to promote good, long-term outcomes.

How can we correctly identify a cervicogenic headache?

It can take 60-90mins to thoroughly assess and diagnose a headache as the symptoms and physical findings are complex and differ from patient to patient. The first step is to look at the history and symptoms. These typically include:

  • Gradual onset of symptoms (won’t come on sharply or suddenly)

  • Episodes are similar to each other i.e. symptoms do not worsen episode to episode

  • Location

  • Will generally by one-sided and will not shift sides within the same episode

  • Can be one of, or a combination of, neck, occipital (at the back), parietal (at the side) or orbital (around and behind the eye)

  • Can last anywhere from 1 hour to 1 week

  • Feels non-throbbing

  • Aggravated by neck movements or sustained postures

  • Other symptoms can include nausea, vomiting, visual disturbances and sensitivity to light and sound

If your symptoms fit the above criteria then the next step is to conduct a thorough musculoskeletal exam. This includes, but is not limited to,

  • Posture assessment

  • Ergonomic assessment if work seems to be an aggravating factor

  • Neck range of motion and strength testing

  • Shoulder and scapular range of motion

  • Thoracic range of motion

  • Palpation assessment, particularly looking for stiffness, position, tenderness and/or referred pain from the top 3 cervical joints

  • Cervical flexion rotation test (CFRT)

  • This test has been found to have good reliability in diagnosing cervicogenic headache (Hall et al, 2008)

If your symptoms still fit the criteria for a cervicogenic headache, we can then move on to addressing the findings from the physical assessment.

Treatment

Treatment will depend on the findings from the subjective history as well as the physical exam and can include, but are not limited to,

  • Neck and thoracic spine mobilisations

  • Thoracic manipulations

  • Ergonomic adjustments to workstation

  • Strengthening exercises for the deep neck stabilisers, neck and thoracic extensors and upper trapezius/shoulder girdle muscles.

  • Sustained Natural Apophyseal glides (SNAGs) for the C0- or C1-2segments (see video)

  • 2 recent systematic reviews released in The European Spine Journal (Varatharajan et al, 2016) and the Journal of Manual Therapy (Gross et al 2016) both found that exercise combined with mobilisations is an effective treatment option for headache and can also decrease medication intake in the short and long term.

If the above signs and symptoms sound familiar, then please do yourself a favour and book an appointment with an experienced physiotherapist.

 

Ankle dorsiflexion knee to wall measure for squat

How to Treat and Manage Stiff Ankles

If your ankle mobility isn’t up to par, the next steps depend on the source of the restriction. Generally, if the limitation is felt at the front of the ankle, it may be due to joint-related issues.

  • Banded Ankle Mobilizations: This technique involves using a resistance band tied to a stable surface while performing ankle flexing exercises on a step. Check out this quick helpful video for guidance.

Conversely, if the tightness is located in the back of your ankle around the Achilles tendon region, consider:

  • Contract/Relax Stretches: A simple exercise like the bent-knee calf raise can effectively relieve restrictions in this region.

Lastly, for an immediate solution, consider using a wedge or support under your heels during a squat. Two papers from The Journal of Strength and Conditioning Research have shown that wedges can enhance squat depth without negatively impacting biomechanics. While some may see this as a “cheat,” the science supports it. If you struggle to achieve that 12 cm in the knee-to-wall test and find it challenging to squat low, use that wedge!

Hip Range of Motion

How Much Flexibility Do I Need and How Do I Test It?

For effective squatting, studies have determined that achieving 125 degrees of hip flexion is necessary—this is 35 degrees beyond a right angle. To test your hip mobility, you can use an inclinometer available on your iPhone. Simply follow these steps:

  1. Lie down on your back with your legs extended.
  2. Place the inclinometer length-ways on your thigh,
  3. Gently lift your knee towards your chest to measure the maximum angle, without moving the opposite leg.

     

    measuring hip flexion

    How to Treat and Manage Stiff Hips

    The hip joint is mostly passive during a squat, so if you’re experiencing limitations, it’s most likely due to an issue with the hip joint itself. There is up to 20% of the population that may be limited by the shape of their hip joint and the way it developed during childhood and adolescence. If that is the case, it makes if very difficult to improve the range of motion. Things like acetabular retroversion or a lower femoral head/neck offset ratio cannot be changed.

    For the rest of the population, here are some effective strategies for improving hip mobility:

    • Banded Hip Mobilisations: These exercises can help increase the range of motion in your hips by stretching and mobilizing the joint. Look for a demonstration in this video.
    • Inner Range Hip Flexor Strengthening: Strengthening your hip flexors can counteract tightness and enhance your ability to squat lower.
    • Like with ankle mobility, adding a heel wedge can help. By elevating your heels, you may experience a reduction in trunk forward bend, minimizing the hip flexion required and facilitating a more comfortable squat position.

    Conclusion

    Mastering a deep squat requires more than just strength; it hinges on sufficient ankle and hip range of motion. The studies from 2015 and 2022 have made it clear: flexibility in these joints is paramount for optimal performance.

    By regularly assessing your mobility and implementing these targeted exercises and techniques, you can improve your squat depth, enhance your overall strength training, and reduce the risk of injury. Remember, every body is unique, so listen to yours and adjust your approach accordingly. Happy squatting!