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American Headache Institute

Head, Neck, & Facial Pain

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Research

We feel our greatest strength is our commitment to the scientific literature. As the education leaders in our field, we owe it to our medical audience to stay ahead of the curve on breaking research as it relates to headache, migraine, TMJ, and oral-facial pain. While most practitioners read research, we dissect it looking for methodological flaws. We must be sure we cite only the strongest studies.

Here you will find our compilation of direct quotes from a number of world authorities. We know that study results can be skewed, exaggerated, or manipulated by those quoting research to make a point. To avoid this possibility, we present direct quotes from each study making it easy to read with no possible bias injected.

We hope you will take the time to read these short quotes from some of the world’s most respected researchers. We believe you will agree there is compelling evidence to;

1. take the cervical spine seriously

2. follow the evidence on how to treat the cervical spine conservatively.

We do both.

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IMPORTANT CERVICOGENIC HEADACHE &

FACIAL PAIN TOPICS WITH SUPPORTIVE RESEARCH

Cervicogenic Headache; Can the Neck Alone be the Source of Head and Facial Pain?

“The International Headache Institute recognizes cervicogenic headache as a distinct disorder”. (#1 Bogduk)

“It can be concluded that cervicogenic headache is not just a migraine variant triggered by neck dysfunction but a functional entity”. (#9 Frese)

“Cervicogenic headache has been described for many years by clinicians of varying professions and specialties. Most authorities agree that many patients experience neck symptoms associated with headache. Whether the neck is the cause of, or part of, another headache type, careful attention to the neck and its relationship to the headache are extremely important”. (#12 Gallagher)

“There is clear neuroanatomical evidence that demonstrates a relationship between the cervical spine and the facial and head region. (#7 Mark)

“The neck and its muscles can be associated with triggering a cervicogenic headache. Repetitive movements strains, trauma and other nonphysiologic movements of the neck or its related structures are frequently reported to cause headache symptoms”. (#12 Gallagher)

Do Cervical Headaches Present Differently From Other Types of Headaches?

“One of the confusing phenomena about the cervicogenic headache is that its symptoms can present as migraine headaches, tension-type headaches or even cluster headaches”. (#22 - Report #1 Rothbart)

“Cervicogenic headache is widespread. The neck can be the precipitant of tension-type headache, or be the etiology of the headache as with cervicogenic headache”. (#12 Gallagher)

“Headache of cervical origin and migraine often shows similar clinical presentations”. (#11 Goadsby)

“Whether the neck is the cause of, or a part of, another headache type, careful attention to the neck and its relationship to the headache are extremely important”. (#12 Gallagher)

What Role Does the Upper Cervical Spine Play?

“Structures innervated by C1-C3 have been shown to be capable of causing headache”. (#2 Bogkuk)

“Structures innervated by the upper cervical spinal roots (upper cervical neck muscles, joints, ligaments and discs) are established sources of pain. These structures elicit occipital pain sensations, but may also be perceived in trigeminal innervated areas (head , face, mandible). (#3 Goadsby)

“The occipital nerve blockade significantly relieved cervicogenic headache and associated symptoms”. (#4 Naja)

“This observation appears to be the first evidence of a cervical muscular attachment to the dura”. (#5 Hack)

“Any imbalance or abnormality in the suboccipital spine can give rise to problems in the head or face”. (#7 Mark)

“The notion that disorders of the cervical spine can cause headache is more than a century old. In most cases, cervicogenic headache is caused by pathology in the upper aspect of the cervical spine. (#8 Antonaci)

How Sensitive Can Upper Cervical Tissues Be?

“These convergent neurons may be involved in the clinical phenomenon of hypersensitivity and refer pain to the head and face”. (#3 Goadsby)

“The observation in the present report that muscles may have a direct influence on the dura mater, a pain sensitive structure, suggests an alternative mechanism for pain generation for cervical headaches”. (#5 Hack)

“Recent experimental data demonstrating electromyographic changes in the neck muscles of headache patients support our view of an increased trigeminocervical excitability leading to suboccipital muscle stiffness and hyperalgesia. (#11 Goadsby)

“Pronounced levels of neck muscle tenderness were observed in subjects with migraine, tension-type headache, or a combination of both, but not in a non-headache control group”. (#23 - Report #2 Biondi)

What Role Does the Lower Cervical Spine Play?

“After lower cervical selective nerve root blocks (SNRB), 59% of the patients with headache reported 50% or more reduction of headache and of these 69% reported total relief”. (#6 Persson)

“It has been shown that painful impulses from even the lower cervical structures can also be perceived as headaches. This is probably because impulses from these structures travel cephalad to the level of C2-3 before entering the spinal cord”. (#22 - Report #1 Rothbart)

Does Neck Posture Play a Role?

“In the workplace, sedentary work position and repetitive work increased the risk of neck pain”. (#13 Haldeman)

“Differences in neck posture were observed in subjects with migraine, tension-type headache, or a combination of both, but not in a non-headache control group”. (#23 - Report #2 Biondi)

“It was seen by cadaver dissection that alterations of posture are capable of traumatizing the second cervical nerve. With a forward head posture, there is a posterior rotation of the cranium on the cervical spine causing compression of the trigeminal spinal tract, which can give rise to facial or head pain separate from trigger points. It is believed that once the second cervical nerve is damaged or diseased, normal movement of the neck is capable of maintaining the nerve in a painful state”. (#7 Mark)

Where Do the Experts Stand on Examination & Diagnosis of Cervicogenic Headache?

“Because of its prevalence, every physician has a responsibility to be able to assess headaches: either to identify varieties of headache they can manage themselves, or those that require referral. Ultimately headache may require specialist investigation and management”. (#10 Bogduk)

“For the clinician, pain presentations in the headache patient are frequently a diagnostic challenge”. (#11 Goadsby)

“Approximately 800 new headache patients per year are examined at our clinic. An estimated 80% of these patients are diagnosed with cervicogenic headache. Of these patients, almost none are referred with this diagnosis. Physicians are not taught to consider or explore neck structures when investigation headaches. This results in a rarely diagnosed but common condition”. (#22 - Report #1 Rothbart)

“Differential diagnosis is sometimes a challenge and kinematic analysis of neck motion may aid in diagnosing”. (#8 Antonaci)

“The cervical spine must be evaluated to rule out cervical spine dysfunction with patients who have symptoms in the craniocervical-mandibular region”. (#7 Mark)

“In most cases, imaging techniques of the cervical spine are not helpful for the diagnosis of cervicogenic headache. Symptoms and signs of neck involvement, such as a mechanical precipitation of attacks, a restriction in range of motion of the cervical spine, and the existence of ipsilateral neck, shoulder, or arm pain, seem to be reasonably valid for the diagnosis of cervicogenic headache”. (#9 Frese)

(359 articles reviewed, 95 admissible) “There was no evidence that specific MRI findings are associated with neck pain, cervicogenic headache, or whiplash exposure”. (#24 Nordin)

“Evaluation of the neck, determining its role in the patient’s headache problem, establishing a working diagnosis and including the neck in the treatment plan, regardless of diagnosis, is the most helpful for both patient and physician”. (#12 Gallagher)

So If the Neck is Suspect, What Treatment Options Do the Experts Recommend?

Neck Pain Task Force Report; “One thing that became very clear to us is that the classic model we use in clinical practice doesn’t work. We tend as clinicians to see a person with neck pain, try to diagnose the cause of the problem, prescribe treatment, and hope the patient has no more pain. What we found is that this model just doesn’t fit the evidence”. (#13 Haldeman)

“A number of nonsurgical treatments appeared to be more beneficial than usual care, sham, or alternative interventions. These were educational videos, mobilization, manual therapy, and exercises appear to have some benefit”. (#13 Haldeman)

“For probable cervicogenic headache, exercises with or without manual therapy seems to be the best option among conservative therapies”. (#1 Bogduk)

“Successful treatment of cervicogenic headache usually requires a multifaceted approach. Physical Therapy is an important therapeutic modality for rehabilitation of cervicogenic headache. Physical treatment is better tolerated when initiated with gentle muscle stretching and aerobic conditioning”. (#23 - Report #2 Biondi)

“A multicenter, randomized controlled trial with blinded outcome assessment was conducted. The study included 200 participants. At the 12 month follow-up assessment, specific cervical exercise had significantly reduced headache frequency and intensity, and the neck pain and effects were maintained”. (#14 Jull)

(359 articles reviewed, 170 admissible) “Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain; this was also true of therapies which included educational interventions addressing self-efficacy”. (#25 Hurwitz)

“Educating the patient in minimizing strain, tension or injury to the neck can be helpful as a part of comprehensive care. Assisting the patient to identify and avoid awkward or repetitive movements such as nonphysiologic reading positions or computer screen positioning can be helpful. Several times daily the patient can do simple and gentle stretches to allow muscles to reach physiologic length and maintain normal function. Instructing the patient to sleep with the neck supported can be helpful”. (#12 Gallagher)

“A prospective, randomized clinical trial with a 12 month follow-up was done with 149 patients. Our results indicate that individuals with cervicobrachialgia and its typical complaints (pain radiation and sleep disturbances caused by pain) should receive comprehensive physical therapy and an individually selected sleeping neck support. The group with the sleeping neck support showed a significant decrease in cervical spine pain, and sleep disturbances caused by pain were also reduced significantly”. (#21 Bernateck)

“ A 4-year prospective cohort study with 18,031 employees was conducted to find the incidence of sick leave because of neck and shoulder pain. In the final regression model for sick leave cases, the physical risk factors were, repetitive work and sitting positions at work”. (#20 Alipour)

“A 4-month randomized, controlled trial to evaluate the effect of chair design on neck/shoulder pain among 277 sewing machine operators was conducted. The study findings demonstrate that an adjustable height task chair can reduce neck and shoulder pain severity among sewing machine operators. The findings may be generalizable to other seated jobs that are visually demanding”. (#18 Rempel)

A cross-sectional survey among adolescents age 15-16 was conducted to evaluate whether physical activity or sedentary activities associate with neck, shoulder, or occipital pain. Analyses included 3,185 girls and 2,808 boys. Almost half of the girls and one third of the boys reported neck, occipital pain or shoulder pain during the past 6 months. Conclusion: Neck or occipital pain and shoulder pain are very common symptoms among adolescents, and both prolonged sitting and a high level of physical activity seem to be related to them”. (#19 Auvinen)

“Altogether, our results suggest that subjects were able to take advantage of vision and increased neck cutaneous information to improve postural control and cervical joint position sense”. (#14 Pinsault))

“There is scientific support for subjective self-report assessment in monitoring patients’ course and response to treatment”. (#24 Nordin)

“With the person with neck pain firmly in mind, members of the Neck Pain Task Force chose to focus on the second stated goal: “To empower individuals to participate in their own care”. They believe this type of patient-focused approach would yield the greatest positive impact on neck pain among the broadest array of stakeholders”. (#13 Haldeman)

Study #13 Cervical Spine Literature Review (2008) -

The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders

Neck Pain Task Force Committee – comprised of over 50 members, 9 countries, 14 scientific disciplines, 8 universities, 6 years to complete, examined more than 31,000 studies on the cervical spine (the largest review of the evidence on neck pain ever conducted), and produced a 21 chapter, 220 page systematic review and best evidence synthesis (Spine 2008;33:4S,S1-S220).

Neck Pain Task Force Members President, Scott Haldeman, DC, MD, PhD

Members Key Findings:

Haldeman – “One thing that became very clear to us is that the classic model we use in clinical practice doesn’t work. We tend as clinicians to see a person with neck pain, try to diagnose the cause of the problem, prescribe treatment, and hope the patient has no more pain. What we found is that this model just doesn’t fit the evidence”. (The BackLetter, Vol. 23, No. 2, 2008)

Haldeman – Executive Summary: “In the workplace, sedentary work position and repetitive work increased the risk of neck pain. A number of nonsurgical treatments appeared to be more beneficial than usual care, sham, or alternative interventions. These were educational videos, mobilization, manual therapy, and exercises appear to have some benefit”.

Nordin – Assessment of Neck Pain and Its Associated Disorders: (359 articles reviewed, 95 admissible) “There was no evidence that specific MRI findings are associated with neck pain, cervicogenic headache, or whiplash exposure. No evidence supports using cervical provocative discography, anesthetic facet, or medial branch blocks in evaluating neck pain. There is scientific support for subjective self-report assessment in monitoring patients’ course and response to treatment”.

Hurwitz – Treatment of Neck Pain: Noninvasive Interventions: (359 articles reviewed, 170 admissible) “Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain; this was also true of therapies which included educational interventions addressing self-efficacy”.

Haldeman – The Empowerment of People With Neck Pain: Introduction: The World Health Organization proclaimed that the years 2000-2010 would be the Decade of the Bone and Joint. This global initiative, involving the World Health Organization, the United Nations, and the governments of 60 countries, aims to achieve several goals. With the person with neck pain firmly in mind, members of the Neck Pain Task Force chose to focus on the second stated goal: “To empower individuals to participate in their own care”. They believe this type of patient-focused approach would yield the greatest positive impact on neck pain among the broadest array of stakeholders.

Carragee – Research Recommendations: “Given the gaps in - and problems with – the current nonsurgical neck-pain intervention literature, we suggest more high-quality experimental and observational research be done in the following areas”

Neck Task Force – Five Top Research Recommendations:

Self-care approaches in the treatment of neck disorders

Strategies designed for prevention of recurrent neck pain

Treatment for neck pain with radiculopathy

Interventions for cervicogenic headache

Clinically homogenous subgroups

Why Not Trigger Points?

“No study to date has reported the reliability of trigger point diagnosis according to the currently proposed criteria. On the basis of the limited number of studies available, and significant problems with their design, reporting, statistical integrity, and clinical applicability, physical examination cannot currently be recommended as a reliable test for the diagnosis of trigger points”. (#16 Lucas, Bogduk )

“Acceptable studies were required to specifically consider either inter- or intrarater reliability of trigger point identification through manual palpation. The methodologic quality of the majority of studies for the purpose of establishing trigger point reproducibility is generally poor. Clinicians and scientists are urged to move toward simpler, global assessments of patient status”. (#17 Myburgh)

REFERENCES

1. Bogduk N, Govind J. Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. Lancet Neurol. 2009;10:959-68.

2. Bogduk N The Anatomical basis for cervigogenic headache. J Manip. Physio. Ther. 1992;15:67-70.

3. Goadsby PJ, Bartsch T Anatomy and physiology of pain referral patterns in primary and cervicogenic headache disorders. Headache Currents 2005;10:42-48.

4. Naja ZM, et al. Occipital nerve blockade for cervicogenic headache: a double-blind randomized controlled clinical trial. Pain Pract 2006; 6:89-95.

5. Hack G, et al. Anatomic relation between the rectus capitis posterior minor muscle and the dura mater. Spine 1995;20:2484-86.

6. Persson C, et al. Headache in patients with cervical radiculopathy: a prospective study with selective nerve root blocks in 275 patients. Eur Spine J 2007;16:953-59/

7. Mark B Cervicogenic headache differential diagnosis and clinical management: literature review. J Craniomandibular Practice 1990; 8:332-338.

8. Antonaci F, et al. Diagnosing cervicogenic headache. J Headache Pain 2006;7:145-48.

9. Frese A, et al. Biological markers of cervicogenic headache. Cephalalgia 2008;28:Suppl 1:21-3.

10. Bogduk N Anatomy and physiology of headache. Biomed & Pharmacother 1995;49:435-45.

11. Goadsby PJ, Bartsch T Anatomy and physiology of pain referral patterns in primary and cervicogenic headache disorders. Headache Currents 2005;10:42-48.

12. Gallagher R, Cervicogenic Headache; A special report. Expert Rev. Neurotherapeutics 2007;7(10) 1279-83.

13. Haldeman S, Carroll L, and Cassidy D A best evidence synthesis on neck pain: Findings from the bone and joint decade 2000-2010 task force on neck pain and its associated disorders. Spine 2008;33:4S,S1-S220.

14. Jull G, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002;27:1835-43.

15. Pinsault N, Effects of vision and tactile stimulation of the neck on postural control during unperturbed stance and cervical joint position sense in young asymptomatic adults. Spine 2010;35:1589-94.

16. Lucas N, Bogduk N, et al. Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature. Clin J Pain 2009;25:80-9.

17. Myburgh C, et al. A systematic, critical review of manual palpation for identifying myofascial trigger points: evidence and clinical significance. Arch Phys Med Rehabil 2008;89:1169-76.

18. Rempel D, A randomized controlled trial evaluating the effects of new task chairs on shoulder and neck pain among sewing machine operators. The Los Angeles Garment Study. Spine 2007;32:931-38.

19. Auvinen J, Neck and shoulder pains in relation to physical activity and sedentary activities in adolescence. Spine 2007;32:1038-44.

20. Alipour A, Four-year incidence of sick leave because of neck and shoulder pain and its association with work and lifestyle. Spine 2009;34:413-18.

21. Bernateck M, Sustained effects of comprehensive inpatient rehabilitative treatment and sleeping neck support in patients with chronic cervicobrachialgia: a prospective and randomized clinical trial. International J Rehab Research 2008;31:342-46.

22. Rothbart Report #1 Rothbart Pain Management Clinic, Toronto, Ontario.

23. Biondi D, Report #2 Cervicogenic headache: Diagnostic evaluation and treatment strategies. Pain Management Rounds-Harvard Medical School & Massachusetts General Hospital 2004; vol. 1, issue 8.

24. Nordin M, A best evidence synthesis on neck pain: Findings from the bone and joint decade 2000-2010 task force on neck pain and its associated disorders. Spine 2008;33:4S,S101-122.

25. Hurwitz E, A best evidence synthesis on neck pain: Findings from the bone and joint decade 2000-2010 task force on neck pain and its associated disorders. Spine 2008;33:4S,S1123-152.

Research Reference List