Physiotherapy and the treatment of Headaches

Primary headaches may occur for no identifiable reason and aren’t caused by an underlying condition.1 Secondary headaches are caused by an underlying condition and have a distinct cause.1 Within these two categories are many different types of headaches. They each present with varying features.

Some headaches are caused by structures in your musculoskeletal system. This body system includes structures such as muscles, bones and cartilage.1 A cervicogenic headache is a secondary headache that arises when there is an issue within your musculoskeletal system. It typically comes from structures in the upper cervical spine.1, 2, 3 The upper cervical spine is made up of the vertebrae at the top of your neck, beneath the base of the skull.

Different headaches often have similar signs and symptoms. This can make diagnosis challenging. Migraines, tension-type headaches and cervicogenic headaches may present in a similar fashion.2 Cervicogenic headaches commonly present with the following signs and symptoms1, 2, 3:

• ​Reduced neck movement
• Worsening headache with neck movement or pressure
• A one-sided headache that doesn’t change sides
• Vague pain that may refer into the neck, shoulder, forehead or behind the ey
• Pain starting after sustained or awkward positioning
• Pain starting after neck trauma
• Pain that is felt first in the neck, before moving into the head
• Other symptoms e.g. nausea, dizziness, light and sound sensitivity, and blurred vision

To decide what type of headache you have, a Physiotherapist will consider your history, including signs and symptoms. They may refer you to have imaging done to rule out non-treatable causes of your headache. They will perform an assessment to determine if you have any factors that may be causing a cervicogenic headache. The physical examination may include2:

• Looking at the movement of your neck
• Assessing the strength and endurance of your neck and shoulder muscle
• Viewing posture in different positions
• Feeling the bones and muscles around your neck

As Physiotherapists treat the musculoskeletal system, they can help treat this type of headache. The assessment findings will help to shape what treatment approaches will be used. For example, someone with poor neck movement will likely be given exercises to improve neck range of motion. There are a range of techniques that can be used to treat cervicogenic headaches. Manual therapy, exercise and education are common strategies that are used.2 Research has shown that using a combination of these approaches is most effective.2, 4, 5 The information below outlines what is involved with these three treatment strategies.

Manual therapy

Manual therapy or ‘hands-on’ treatment is commonly used in Physiotherapy to treat various conditions.2 It has been shown to reduce the frequency, intensity and duration of cervicogenic headache in both the short and long-term.2, 4, 5, 6 Manual therapy techniques used to treat cervicogenic headache include:

• Mobilisations – small, rhythmical movements applied to a joint to improve stiffness and pain.2
• Mobilisations with movement – the combination of a mobilisation with an active movement performed by the patient.2 Research shows that performing this technique daily for a year can reduce headache symptoms in the long-term by 54%.7
• Manipulation – a quick, small movement performed at the end of a joints range of motion. A popping sound is often heard. It is used to improve joint pain and stiffness.2 Physiotherapists need to have special training to perform this technique.
• Massage – the use of hands to relieve muscle tension and improve movement.2

Exercise

Exercise can be used to improve short and long-term outcomes. In the short-term, exercise can help reduce stiffness and pain through improving joint motion. In the long-term, it improves muscle endurance and strength. This can improve your overall posture and reduce the recurrence of headaches. Exercises often target the muscles at the front and back of your neck, and the muscles around your shoulder and shoulder blade. Numerous studies have found that targeting these muscles assists in reducing the frequency and intensity of headaches.4, 5, 6 Combining stretches and strengthening is suggested to be more effective than doing stretches or strengthening alone.2

Education

Providing education helps people to better understand and manage their condition. Education may include advice on:

• Strategies for pain relief when a headache is present
• What to avoid to help prevent headaches
• Postural retraining
• Ergonomic modifications eg: changing desk set-up at work.

Physiotherapists are able to assess and treat cervicogenic headaches. Contact us today if you think you have this condition or need help managing it.

References

1. Cervicogenic Headache. American Migraine Foundation. https://americanmigrainefoundation.org/resource-library/cervicogenic-headache/. Accessed March 24, 2019.
2. Brukner P, Clarsen B, Cook J et al. Brukner & Khan's Clinical Sports Medicine: Injuries. 5th ed. North Ryde: McGraw-Hill Education; 2017.
3. International Headache Society. The International Classification of Headache Disorders 3rd edition. ICHD-3. https://www.ichd-3.org/. Published 2018. Accessed 24/03/2019.
4. Racicki S, Gerwin S, Diclaudio S, Reinmann S, Donaldson M. Conservative physical therapy management for the treatment of cervicogenic headache: a systematic review. J Man Manip Ther. 2013;21(2):113-24. doi: 10.1179/2042618612Y.0000000025.
5. Jull G, Trott P, Potter H et al. A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache. Spine. 2002;27(17):1835-1843.
6. Dunning JR, Butts R, Mourad F et al. Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: a multi-center randomized clinical trial. BMC Musculoskelet Disord. 2016;17:64. doi: 10.1186/s12891-016-0912-3.
7. Hall T1, Chan HT, Christensen L, Odenthal B, Wells C, Robinson K. Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache. J Orthop Sports Phys Ther. 2007;37(3):100-7. doi: 10.2519/jospt.2007.2379