Cervicogenic headache. Longitudinal observational study on 553 patients - Pathos

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Cervicogenic headache. Longitudinal observational study on 553 patients

Cefalea cervicogenica.
Studio osservazionale longitudinale su 553 pazienti
Observational study
Pathos 2022; 29, 3. Online 2022, Dec 13
Claudio Santoro,1 Michela D’Oro 2
1 Laboratorio di Neurologia Funzionale
2 Laboratorio di Biomeccanica
Centro Ricerche Disfunzioni Meccaniche, Osteolab Benevento
Cervicogenic headache is a common disorder affecting about 68 per cent of adults in Europe (53 per cent headache and 15 per cent migraine), of which around 2-5 per cent are chronically refractory.1 Patients who suffer from it are often induced to use over-the-counter drugs with even serious consequences: in addition to predisposing complex comorbidities, improper use of medications significantly influence both the progression of the disease (chronicity) and the therapeutic strategies.
The study (longitudinal observational) refers to the 553 requests for intervention for headache (or neck pain) received by our center in the period January-December 2019. The data collected made it possible to recognize the headache as generated by the functional lesions of certain neuro-musculoskeletal and vascular districts (classified as DC1, DC2, DC3), in turn connected to the functional block (also known as joint facet conflict, block in malposition or subluxation) of the articular processes of C0-C1-C2 -C3. Manual medicine has proved to be effective in the treatment of acute, subacute and chronic phases.
Il mal di testa cervicogenico è un disturbo di comune diffusione. Si stima che in Europa colpisca il 68 per cento circa degli adulti (53 per cento di cefalea e 15 per cento emicrania), di cui circa il 2-5 per cento in forma cronico-refrattaria.1 I pazienti che ne sono affetti sono spesso indotti a utilizzare in modo improprio e protratto farmaci da banco, con conseguenze anche gravi: oltre a predisporre quadri di comorbidità complessi, influenzano in modo significativo sia la progressione della malattia (cronicizzazione) che le strategie terapeutiche.
Lo studio (osservazionale longitudinale) si riferisce alle 553 richieste di intervento per mal di testa (o dolore cervicale) pervenute al nostro centro nel periodo gennaio-dicembre 2019. I dati raccolti hanno consentito di riconoscere il mal di testa come ingenerato dalle lesioni funzionali di determinati distretti neuro-muscolo-scheletrici e vascolari (classificati come DC1, DC2, DC3), a loro volta connesse al blocco funzionale (anche noto come conflitto di faccette articolari, blocco in malposizione o sublussazione) dei processi articolari di C0-C1-C2-C3. La medicina manuale è risultata efficace nel trattamento del dolore non solo in fase acuta, ma anche e soprattutto in fase subacuta e cronica.
Key words
Headache, cervicogenic pain, multidisciplinary approach, drug and manual therapy
Parole chiave
Cefalea, dolore cervicogenico, approccio multidisciplinare, terapia farmacologica e manuale

The headache whose onset is determined by alterations in the mechanical function of the cervical spine is defined as "cervicogenic". Cervical myofascial disorders and pain are often ignored or underestimated when recording the medical history of the patient, thus preventing us from assessing their role and influence on the patient's headache. The presence of mechanical alterations entails the presence of neuro-myofascial dysfunctions affecting individual muscles or muscle chains, causing not only a lesion of the nervous, metabolic and circulatory function of the muscle fiber (extremely rigid), but also a consequent limitation of the adjacent vertebrae’s joint mobility and, therefore, of the vertebrobasilar arterial flow or of the transmission of the nerve impulse. Peculiar tendon-muscle, nerve and vascular connections exist between the upper cervical spine (C1-C2-C3) and the head (C0): an accurate evaluation of the cervical spine, especially when presenting with pain and stiffness, would allow not only a better understanding of the nature of headaches, but also the possibility to adopt appropriate intervention strategies. The cervical spine is particularly prone to degenerative changes due to the mobility of this region:
- micro- and microtrauma of everyday life;
- extended periods of immobility;
- incorrect, stereotyped and repeated movements;
- sedentary lifestyle
The persistent state of alteration impairs the motor performance, causing the typical symptoms:
  • Migraine pain, pressure or sharp pain, a throbbing sensation, at times
  • Posteroanterior radiation of pain, extending from the neck or suboccipital region up to
  1. Cranial vertex, in the parietal region of the head (landmark “bregma”, the point on the skull at which the coronal suture is intersected perpendicularly by the sagittal suture).
  2. From the mastoid, along the temple of the same side (landmark “pterion”, the region where the greater wing of the sphenoid bone, the squamous portion of the temporal bone, the frontal bone and the parietal bone join together).
  3. From the occipital fossette, on the eyebrow of the same side (landmark “nasion”, the midline bony depression where the frontal and two nasal bones meet).
The muscles mainly affected by these neuro-myofascial dysfunctions are:
- Levator scapulae muscle
- Splenius capitis muscle and splenius cervicis muscle
- Suboccipital muscles
- Omohyoid muscle
- Sternocleidomastoid muscle
- Trapezius muscles
- Supraspinatus muscle
- Infraspinatus muscle
- Paraspinal and interscapular muscles
- Teres minor muscle and teres major muscle (affecting the radial nerve and radiating paresthesia to the arm, elbow, hand).
The symptoms usually:
- appear or exacerbate between 3:00 a.m. and 5:00 a.m.;
- have moderate or severe intensity, with a fluctuating course.
In subjects less likely engaged in physical activities and sports, this condition is clearly ascribable to a structural stiffening linked to the loss of muscle tone and trophism as a result of a sedentary life (always performing the same movements in the exact same way or prolonged periods of immobility), a condition sometimes also characterized by states of emotional tension, obesity, smoking, alcohol, etc.
The resulting discomfort inevitably leads to a temporary rise in blood pressure values, the effects of which have been identified as potential factors associated to chronic pain.2

Research objectives
Although headache is among the disorders with the greatest social impact and diffusion,3 it is often understood and misdiagnosed.4-6 According to the literature, theerroneous diagnosis is attributed to simultaneous presence of sinusitis, allergies or tension states.7 In evidence-based medicine, these tension states are associated those mechanical disorders which cause functional lesions along the cervical spine, too often concomitant with the onset or exacerbation of headaches. In order to set further parameters for reflection and evaluation, this study aimed to:
Primary endpoint: to define in which terms (quantitative and qualitative) the lesions of the mechanical function (DC1, DC2, DC3) affect the onset of pain.
Secondary endpoint: define functional blockade of C0-C1-C2-C3 headache biomarker (cervicogenic).
Tertiary endpoint: to verify the efficacy of manual medicine in the treatment of pain-related functional injuries.

Materials and methods
All patients who requested an intervention aimed at treating of headaches were admitted to the project. The study developed as follows:
Patient access and registration.
Collection of anamnestic data, therapeutic procedure already undertaken and current clinical situation.
Referred pain.
Picture A
Predominantly migraine headache always present, every day facial: eye, cheekbone, temporal (marked as A1).
Strongest in the morning with hypnic manifestations. Presence of heeling (or postural vertigo) with variable intensity during the day (marked as A2).
Nausea. Exacerbation of pain often accompanied by an increase in blood pressure. Previous pain present on average for at least 3 years.
Picture B
Mainly frontal headache, up to four attacks per week. Strongest in the morning with varying intensity throughout the day. Feeling of dizziness always present. Stiffness in the shoulders, stronger in the morning and in the evening. Exacerbation of pain often accompanied by an increase in blood pressure. Previous pain present for an average of 6-8 months.
Picture C
Mainly suboccipital headache, up to two headache attacks per week. Stronger in the morning. Sensation of heaviness in the head always present. Stiffness of trunk and shoulders always present. Heaviness in the arms and paresthesia in the hand. Previous pain present for 12-16 months.
Evaluation and recording of the functional lesions observed in the affected cervical region (marked as DC):
DC1: restriction in lateral flexion and rotation, unilateral tightness of levator scapulae, splenius cervicis, longissimus capitis, scalene, trapezius and supraspinatus muscles, block malposition of C1/C2/C3/C4, 1^ rib/D1.
DC2: restriction in flexion-extension, bilateral stiffness of paraspinal muscles, longissimus capitis and trapezius muscle, block malposition of C3/C4/C5/C6/C7/D1.
DC3: pain during flexion-extension, lateral bending and rotation of the head, with bilateral stiffness of trapezius muscles, supraspinatus, infraspinatus, interscapular and subscapularis muscles, teres minor muscle and teres major muscle, block malposition of C4/C5/C6/C7/D1/D2/D3/D4, 1^ rib.
Devising a therapeutic procedure.

Diagnosis at presentation
69.43% of patients (384 out of 553) had a previous diagnosis, formulated in centers specialized in the treatment of headaches:
- Migraine without aura, 85 patients (15.37%);
- Chronic tension-type headache, 84 patients (15.18%);
- Chronic migraine, 67 patients (12.11%);
- Mixed headache (migraine + tension-type headache), 41 patients (7.41%);
- Episodic cluster headache, 23 patients (4.15%);
- Trigeminal neuralgia, 17 patients (3.07%);
- Cervicogenic headache, 16 patients (2.89%);
- Migraine with aura, 14 patients (2.53%);
- Hypnic headache, 13 patients (2.35%);
- Chronic cluster headache, 11 patients (1.98%);
- Headache attributed to arterial hypertension, 7 patients (1.26%);
- Episodic tension-type headache, 4 patients (0.72%);
- Chronic paroxysmal migraine, 2 patients (0.36%);
It is relevant to notice that, before entering the clinic, according to consolidated practice, each patient, (with or without the doctor’s or the medical specialist’s advice), had taken specific (triptans and ergot derivatives) or non-specific (analgesics , Fans ), which generally have not proved suitable to produce the desired effects.

Procedural analysis
From a functional-rehabilitative point of view, after having carried out an evaluation of the initial conditions, two treatment arms were structured, defined in relation to the therapeutic needs:
Arm A, primary: manual therapy (osteopathy and chiropractic);
Arm B, integrative (if present): physiotherapy (motor function re-education)
The treatment plan was structured as follows:
• Manual therapy (TM) – all patients have been treated with a number of sessions (on average once a week) and type of techniques defined according to needs presented, with follow-up fifteen days after the end of the last treatment.
• Kinesitherapy (C) – where necessary, the patients underwent muscle tests aimed at assessing the balance and motor coordination skills, to perform a specific motor function (C1) and reducing tension (C2).
The intervention protocol did not include the use of drugs. Manual therapy techniques have been borrowed from osteopathic and chiropractic literature, appropriately combined with each other. The home therapy assigned involved the use of heat sources (patches, pillows or heating ointments) to be applied on site, suitably accompanied by suitable exercises for unloading and muscle stretching.
The following were considered as intervention outcome indicators: the change in headache frequency (defined as a reduction in the number of headache days per month or as a reduction in the frequency of attacks) and in headache intensity (defined by a visual analogue scale or gives the numerical evaluation of a scale from 0 to 10).

Manual therapy
The studies conducted on the efficacy of manual therapy in resolving pain-related motor dysfunctions8 suggest: on the one hand, selecting the manipulative techniques to be used in relation to the patient's current general conditions (state of health, motor skills, reported symptoms, alterations registered functions, etc.); on the other, to use them according to need and opportunity, grading them on the basis of patient feedback, the therapeutic iter (as defined) and the operator's clinical experience. In the treatment of the typical disorders of cervicogenic headache,9 by adequately modulating degree, range of motion, strength, direction and speed, it is considered useful to envisage two phases of intervention:
1. neuromuscular and connective tissue, which involves slow, progressive and prolonged tissue mobilisations, with delicate but decisive movements, respectful or not of the direction of the fiber, for this purpose associated with ischemic pressures, such as to induce:
- the restoration of tissue mobility safeguarding the physiological movement of tissue (resolution of existing adhesions);
- the orientation of the collagen fibers in the most suitable way, in order to resist the loads of a mechanical nature (increase in the elastic capacity of the tissues);
- stimulation of mechanoreceptors to inhibit nociceptive afferent messages (elimination of pain);
- the production of local hyperemia to decrease pain and regulate the flow of substrates and metabolites (elimination of inflammatory toxins), greatly influencing the creep properties of collagen.
2. articular, which initially aims at achieving a painless range of motion such as to stimulate the orientation of the collagen fibers (increase in agitation of the tissue fluid, prevention or resolution of adhesions between the fibers, performing longitudinal stretches, restoring normal function , reduction of any free bodies); then the achievement of the maximum available arch (functional barrier), prolonging the stay in position for a few seconds, in order to determine the permanent lengthening of the collagen (interruption of capsular adhesions, reduction of pain and improvement of function). Ultimately a minimum amplitude and maximum speed maneuver developed at the end of the range of motion (structural barrier), such as to unlock the joint, reducing the intra-articular displacement, eliminating the condition of compression and hyperpressure (interruption of peripheral adhesions), thus limiting any risk factors as much as possible10,11 and restoring complete and painless function.

The statistical data collected through this observational study, in addition to demonstrating the validity of the protocol and the effectiveness of the techniques, showed a significant reduction in initial symptoms. Of 553 patients evaluated (314 female, 239 male), there was an average of:
- 12.5 days of previous suffering (crisis);
- 8.23 ​​incoming sore spots;
- 0.43 sore points on exit;
- 1.3 therapeutic sessions performed, useful for functional recovery.
Treated patients
- 553 total patients
- 314 females,
- 239 males
Types of pain
- 426 cases reported effects as in figure A (temporal headache), of which 177 cases with variant
to. 67 cases, variant A1 (simultigeminal),
b. 89 cases, variant A2 (steering or postural vertigo),
c. 21 cases, both variants A2 and A1 (A 2+1);
- 61 cases, as shown in figure B (frontal headache),
- 66 cases, as shown in figure C (suboccipital headache)

Attack frequency
- 427 cases, pain present on average 6-7 days out of 7
- 60 cases, on average 3-4 days out of 7
- 66 cases, on average 1-2 days out of 7
Sometimes acute pain
- 61 cases with an average period of bad debt exceeding 30 days (+30),
- 66 cases with an average period of suffering between 20 and 25 days (20-25),
- 270 cases with an average period of suffering between 10 and 12 days (10-12),
- 156 cases with an average period of suffering between 3 and 5 days (3-5)
Initial pain
- 160 cases with pain 10 on the VAS scale,
- 299 cases with pain 8 on the VAS scale,
- 94 with pain 6 on the VAS scale
- 426 cases cataloged as DC1,
- 61 cases cataloged as DC2,
- 66 cases cataloged as DC3
Sessions conducted
763 overall of which:
1) 711 ordinary
to. 224 (160 cases) with pain intensity 10
- 3 sessions in 4 cases
- 2 sessions in 56 cases
- 1 session every 100 cases
b. 389 (299 cases) with pain intensity 8
- 3 sessions in 1 case
- 2 sessions in 88 cases
- 1 session in 210 cases
c. 96 (94 cases) with pain intensity 6
- 2 sessions in 2 cases
- 1 session in 92 cases
2) 52 additional
to. 19 with pain intensity 10
b. 22 with intensity 6
c. 11 with intensity 2
Recovery times after manual therapy
- 426 cases, within 6 hours
- 66 cases, within 18 hours
- 61 cases, within 36 hours
Supplementary action
- 517 cases, no pain or discomfort (N) = 0
- 11 cases, state of tension (ST) = 2
- 8 cases, sporadic pain (SD) = 6
- 17 cases, crisis (C) = 8
Integrative sessions of post-manual therapy
- 20 cases, 1 session
- 10 cases, 2 sessions
- 4 cases, 3 sessions
- 1 case, 4 sessions
- 1 case, 6 sessions

The data collected in this study proved to have an evident and unambiguous interpretation: it is possible to obtain a full recovery of functional capacity in total absence of pain in the acute phase, but it goes much further when it comes to the subacute and chronic phase:
- 517 patients (93.47%) achieved full recovery;
- 11 patients (1.98%) a good recovery albeit with some form of muscle stiffness;
- 25 (4.52%) reported episodes of pain at follow-up, of which:
A) 8 patients (1.46%) a good recovery, even if characterized by sporadic and transient painful episodes;
B) 17 patients (3.09%) a good recovery, even if marked by crises that require a new corrective intervention.
Joint maneuvers were used in all patients with physiological limitations of vertebral movement, generally associated with spontaneous vertebral pain and segmental symptoms (all of the sample), even in full inflammatory phase. Performed on the areas directly affected by the lesion, they allowed an immediate restoration of the joint excursion capacity with associated improvement of the referred pain symptoms.10,11,14 The repetitive movement typical of mobilization and the rapid manipulative gesture also had a reflex effect on the muscles intrinsic, paravertebral and cervico-dorso-costal subcapitate, thus overcoming the state of tension that is typical of the joint when it is brought to the maximum degrees of excursion, with or without a final push movement.

Conflict of interest
The authors declare that the article was written without any conflict of interest.
13th December 2022
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