| The Cervical Spine and
Headache
It has been well known and documented that trauma to the cervical spine is a causative factor with headaches.
The national average (according to the National Safety Council) for high force auto accidents is one accident for every ten years of life.
It behooves us to correlate these two facts and conclude that one of the main causes of headaches is from untreated auto related trauma.
Let us discuss the types of headaches below: Migraine and Cervicogenic Headache
Migraine
The past several years have seen a greatly heightened
research interest in the relationship between the cervical spine and headache.
This research has led to a transition in thinking from the opinion of just
a decade ago that the cervical spine was rarely a cause of headache to
one where the cervical spine is thought to be one of the most common causes
of this disorder. This understanding is coming from two different areas
of research; one examining disorders of the cervical spine and the coexistence
of headache and the other looking at headache outcomes associated with
treatment of the cervical spine.
One of the best studies to date correlating dysfunction
of the cervical spine and headache has been that of Vernon et al.1
Recent studies have emphasized the correlation between
cervical spine motion dysfunction and headaches.
The study examined the presence of cervical spine abnormalities in both
patients with tension or muscle contraction headache and with common migraine.
In both types of headache, the majority of patients exhibited several signs
of cervical spine dysfunction suggesting a correlation between this dysfunction
and their headaches.
The greatest current research emphasis seems to be on the relationship
between the treatment of the cervical spine and the resolution or improvement
of headache disorders. Perhaps the most promising treatment to date is
that of spinal manipulation. Nelson et al2 compared spinal manipulation
to the drug amitriptyline in patients with migraine headache with or without
aura. A third group received both spinal manipulation and the drug treatment
to see if the combination had any benefit over either treatment alone.
The primary outcome measure used was the headache index score which is
based on the number of days per week that headache is present and the headache
intensity. Patients were monitored for a 4 week baseline period to establish
an individual nontreatment headache index. All treatments were given for
8 weeks and followed by an additional 4 week period without treatment.
Outcomes were measured at 4 weeks, 12 weeks (8 weeks treatment), and at
16 weeks (4 additional weeks without treatment).
The 4 week pretreatment observation period found that the
three randomized groups were statistically comparable. Following treatment,
the reductions in headache index scores were 49% for the amitriptyline group,
40% for the spinal manipulation group, and 41% for the combined therapy
group. There were no statistically significant differences meaning that
during active treatment, all groups had similar improvements. However, in
the nontreatment follow-up period, a trend was seen towards a maintained
benefit in the spinal manipulation group, but not in the other two. The
margin, however, did not reach statistical significance. The combined therapy
group had a 25% reduction in the baseline score at follow-up, but this was
a loss of improvement from the 41% seen immediately following the treatment
period. The drug therapy group regressed from 49% to 24%, while the spinal
manipulation group progressed slightly to 42%.
Headache
Index Improvements
| With Treatment |
4 Weeks |
After Treatment |
| Drug therapy |
49% |
24% |
| Combined Therapy |
41% |
25% |
| Spinal Manipulation |
40% |
42% |
OTC drug use was examined as a secondary outcome measure.
Headache is the disorder for which the excessive use of OTC drugs is most
commonly associated. The potentially serious complications associated with
the excessive use of OTC drugs have led headache researchers to use this
measure as a positive treatment effect indicator. While all treatment groups
reported similar reductions in OTC drug use during active treatment, only
the spinal manipulation group maintained significant use reductions during
follow-up.
Although a nontreatment control group was not used in
this trial, the comparative treatment, amitriptyline has been evaluated
in three randomized, placebo-controlled trials. These three trials demonstrated
the drug to be superior to a placebo suggesting a positive treatment effect.
This trial suggests that spinal manipulation is at least as effective and
probably more effective than the drug therapy. This led the authors to
conclude that spinal manipulation is a reasonable treatment option for
migraine headache based both on efficacy and on a "benign side effects
profile". In other words, it works, and it is safe.
Vernon H, Steiman J, Hagino G. CERVICOGENIC DYSFUNCTION
IN MUSCLE CONTRACTION HEADACHE AND MIGRAINE: A DESCRIPTIVE STUDY. JMPT,
1992;15:418-429.
Nelson CF, Bronfort G, Evans R, Boline P, Goldsmith C, Anderson AV. THE
EFFICACY OF SPINAL MANIPULATION, AMITRIPTYLINE, AND THE COMBINATION OF
BOTH THERAPIES FOR THE PROPHYLAXIS OF MIGRAINE HEADACHE. JMPT, 1998;21:511-519.
Cervicogenic Headache
One of the more important changes in the thinking about
headache over the past several years has been the change in the classification
or typing of headache to reflect more current understanding of the pathogenesis
of the disorder. The older classification system classified the common
headaches as either migraine, or tension (including muscle contraction)
. While the differentiation between migraine and non-migrainous headaches
was relatively simple, classification beyond this was not clinically functional
or useful. The term tension implied that it was a headache the result of
muscle tension or contraction. However, muscle tension could not consistently
be demonstrated before the onset of the headache leading to the question
of cause or effect.
Currently, accepted terminology breaks the large majority
of non-migrainous headaches into two groups; tension-type and cervicogenic.
Tension-type is the largest group of headache patients representing approximately
80% of all headache patients. Migraine and cervicogenic headache each represent
about 15% of the headache spectrum. The total is greater than 100% because
of the overlap in headache types between different studies and the coexistence
of more than one type of headache in the same patient.
Cervicogenic headache was first named by Sjaastad
in 19901 and is diagnosed by the following:
> Unilateral headache triggered by
movements of the head or neck or certain head posture.
> Unilateral headache triggered
by pressure on the neck.
> Unilateral headache spreading
to the neck or homolateral shoulder/arm.
Spinal manipulation has been demonstrated to be effective
in the treatment of tension-type headache. In a randomized trial by the
same investigators in the above discussed migraine trial, spinal manipulation
was found to produce significantly better outcomes on almost all measures
compared to typical drug treatment.2 The importance of this finding in
regard to cervicogenic headache is that several investigators are of the
opinion that this headache is actually a variant of the larger group of
tension-type headache. However, as this issue is not totally resolved,
investigation into the efficacy of spinal manipulation for cervicogenic
headache is warranted.
Nilsson et al performed a prospective randomized controlled
trial of spinal manipulation for cervicogenic headache.3 The control treatment
used was soft tissue work comprised of trigger point massage and low power
laser therapy. The laser as used produces no effect and was felt to be
a placebo. The trigger point massage, however, made the control an incomplete
placebo. Patients recorded headache intensities and hours per day of headache
as well as analgesic use during a 1 week baseline period. After 4 weeks
of treatment, the same variables were again recorded for the next week.
All variables were significantly more improved
in the manipulation group at follow-up.
|
Headache Outcomes
|
|
Pretreatment |
Post Treatment |
| Headache Intensity (0-100) |
|
|
|
|
48 |
29 (P<.0015) |
|
|
37 |
31 (NS) |
| Headache hours/day |
|
|
|
|
4.1 |
0.9 (P<.0001) |
|
|
2.9 |
1.9 (P<.04) |
| Number analgesics/day |
|
|
|
|
0.7 |
0.4 (P<.0001) |
|
|
0.6 |
0.4 (NS) |
If it is assumed that the soft tissue therapy represented
a true placebo, the trial demonstrates that spinal manipulation is effective
for cervicogenic headache in its classic presentation. Two other variations
exist, however. The first is that if the soft tissue therapy was counterproductive,
the spinal manipulation may have done nothing but still looked superior
to the control. This hypothesis seems unlikely as the patients in the control
group had clinically important improvements in their outcomes. This suggests
a strong placebo effect or some actual benefit from the control treatment
which may have not represented a pure placebo. The fact that subjects had
to have had headaches for at least 3 months before entering the trial also
suggests that this hypothesis is unlikely.
The second variation may be that the soft tissue therapy
was not a true placebo and had positive effects. This only strengthens
the value of spinal manipulation which performed significantly better.
With any analysis, it appears that spinal manipulation is effective in
the treatment of cervicogenic headache.
This trial alone does little to answer the question about
the relationship between tension-type headache and cervicogenic headache.
Although spinal manipulation appears to be effective for both tension-type
and cervicogenic headache, they still may be two distinct disorders. Many
researchers however, are of the opinion that these two headaches are slightly
different presentations of the same problem. The only significant difference
between the two types of headache is the unilaterality of cervicogenic
headache.
Leone et al4 recently questioned the limitation
of the use of the term cervicogenic headache to the limited definition
group described by Sjaastad. They suggest that it is appropriate to refer
to any headache originating from the cervical spine as a "cervicogenic
headache". They also caution that the importance in this change in
thinking is not just academic, but it is also therapeutically important
as it has treatment implications.
Leone compared the headache population seen at their headache
specialty center to the strict criteria of cervicogenic headache. Unilaterality
was found in 17% of those with migraine, 4% with tension-type headache
and in 27% with nonclassified or mixed type headaches. Only 50% of those
meeting the other criteria of cervicogenic headache had pain radiating
to the neck/occiput. However, 47% with migraine and 70% with tension-type
headache had this feature.
The upper cervical spine scleratogenous referrals involve
the head and face. This area of the spine is a common cause of headache.
Leones basic conclusion was that so many tension-type
and migraine headache patients have one or more of the features of cervicogenic
headache, and that the separation of patients based on these features is
misleading. It may well be that the cervicogenic headache described by
Sjaastad is just a subtype of a larger cervicogenic group which may include
many headaches presenting as migraine or tension-type. The fact that manipulation
of the neck has been found to be equally effective for all three types
supports this hypothesis.
Sjaastad O, Fredriksen T, Pfafferanth V. CERVICOGENIC
HEADACHE: DIAGNOSTIC CRITERIA. Headache, 1990;30:725-726.
Boline PD, Kassak K, Bronfort G, Nelson C, Anderson AV. SPINAL MANIPULATION
VS. AMITRIPTYLINE FOR THE TREATMENT OF CHRONIC TENSION-TYPE HEADACHES:
A RANDOMIZED CLINICAL TRIAL. JMPT, 1995;18:148-154.
Nilsson N, Christensen HW, Hartvigsen J. THE EFFECT OF SPINAL MANIPULATION
IN THE TREATMENT OF CERVICOGENIC HEADACHE. JMPT, 1997;20:326-330.
Leone M, DAmico D, Grazzi L, Attanasio A, Bussone G. CERVICOGENIC
HEADACHE: A CRITICAL REVIEW OF THE CURRENT DIAGNOSTIC CRITERIA. Pain, 1998;78:1-5.
Source: dceducation
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