I became remarkably familiar with the diagnosis of cervicogenic headaches after attending an International Headache Society meeting many years ago in Canada. I attended a presentation by Dr. Nikolai Bogduk and learned of his position regarding cervicogenic headaches.
Cervicogenic headache is characterized by pain referred to the head from the cervical spine. Although the International Headache Society recognizes this type of headache as a distinct disorder, some clinicians remain skeptical.1
As you know, chiropractic physicians are trained to evaluate and manage patients with cervicogenic headaches. Yet we may become overconfident with our diagnosis and misdiagnose the condition if we are not inquisitive during our initial patient interview. This putative case report should be most interesting to our chiropractic specialists, especially those who have earned a DABCI.
Subjective
Chief Concern: “I get headaches when I watch a movie at the theater.”
This patient states that for the past five years she has not been able to sit through a movie at the theater because she experiences headaches. The sharp pain is above the eyes. These headaches are rarely a problem except when she goes to see movies at the theaters. At this time, she does not know what makes the headaches worse other than watching a movie in a theater.
She has been whiplashed twice over the past 10 years. Following the whiplash injuries, she has experienced headaches at the base of the skull 2-4 times per month. She described these headaches as dull and throbbing pains. She takes aspirin, which takes about three hours to achieve relief. She rates the severity at 7/10. Chiropractic treatment did relieve her neck pain following the car accidents.
Objective
The 35-year-old female is a mesomorph who appears alert and cooperative. She is a good historian.
Vital signs: Height 64 inches; weight 125 pounds; BP 110/78; pulse rate 66 per minute; respiration 10 per minute.
Posture: Mild rounding of the shoulders and forward head carriage.
Palpation: Reveals hypertonicity of the paravertebral muscles at the suboccipital and upper cervical spine bilaterally. There is point tenderness at the facets of C2-C3 bilaterally. Trigger points are revealed bilaterally in the upper trapezii and levator scapulae.
Active cervical range of motion: Full in all six ranges except for minimal restriction with rotation to the right and left.
Foraminal testing: Maximal foraminal compression testing does not produce pain in the cervical spine.
Cervical: Compression produces mild discomfort in the upper cervical spine; distraction produces a comfortable reaction.
Three-part neurological examination: Sensory is intact for the upper extremities bilaterally; motor is 5/5 bilaterally for the upper extremities; deep tendon reflexes are 2+ bilaterally for the upper extremities.
Hoffman’s sign: Absent.
Posterior joint dysfunction: Identified at C2-3 with pain, reduced range of motion and hypertonicity of the paravertebral muscles.
Assessment / Treatment Plan
Post-traumatic cervicogenic headache syndrome. Address with cervical manipulation of the upper cervical spine to improve joint function and reduce headaches. Recommend cervical spine exercises and postural awareness. Three treatments over a three-week period with the goal of relieving headaches.
Outcomes / Discussion
The patient claimed that her neck felt better with the treatments and the exercises. Three months later she returned for a follow-up evaluation. Unfortunately, she continued to experience headaches at the theater. She saw five movies during the three-month period and experienced a headache each time. She mentioned that she thought she might be allergic to gluten and asked to see our nutrition doctor. Consequently, I referred her to our DABCI associate.
Food sensitivity testing and an elimination diet revealed that indeed she was allergic to gluten and corn. The DABCI asked what she consumed at the theaters. Well, she drank a large Coke and a large box of popcorn. She was advised that the corn syrup in the Coke and the popcorn could cause her headaches. Subsequently, she attended another movie without drinking Coke or eating popcorn and was able to watch the entire movie without experiencing a headache.
This case demonstrates that patients may have more than one type of headache. It also reveals the importance of having chiropractic specialists available to assist the evaluation and management of patients with headaches.
Quiz Time
- Food sensitivity may produce headaches. True or False
- Cervicogenic headaches respond to cervical spinal manipulation. True or False
Answers: 1. True. 2. True.
Reference
- Bogduk N, Govind J. Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. Lancet Neurol, 2009;8(10):959-968.
