Do you have a headache after a whiplash injury? Do you experience pain that seems to start in the neck and then spread to one side of your head or arm? Does moving your head seem to start your headache or exacerbate your pain when you have a headache?
If you answered yes to any of those questions, there’s a high chance you have a type of headache known as a cervicogenic headache. Lucky for you, there’s an extremely qualified healthcare provider (ie a Physical Therapist) who can help alleviate your pain. In addition, we’ll show you some stellar cervicogenic headache exercises for you to try at home.
Anatomy and Physiology of a Cervicogenic Headache
What distinguishes a cervicogenic headache from your more classic headaches like migraines or tension type headaches are that cervicogenic headaches are actually caused from dysfunction in your neck. Cervicogenic headaches are a form of referred pain – meaning that although the source of the pain is in the cervical spine, the sensation of pain is felt in the head as a headache. This happens because there are nerves in the upper cervical region (C1, C2, and C3) that have connections to nerves of the head (cranial nerve V via the trigeminal nerve spinal tract).
Although some controversy exists, a vast majority of the literature agrees that the most common cause of cervicogenic headaches is dysfunction from the C2-3 zygapophysial joints (facet joints). However, there is also literature to support that cervicogenic headaches can arise from dysfunction in the C2-3 and C3-4 intervertebral discs of facet joints, as well as the atlantoaxial (C1-2) and atlanto-occipital (C0-1) joints. The most common causes of these upper cervical dysfunctions are whiplash associated trauma as well as prolonged neck flexion or poor static postures (READ: poor posture and upper cross syndrome)
So what can YOU do to help alleviate your pain?
First off, see your local physical therapist. They can create a specific plan of care tailored to treat your upper cervical dysfunction. A recent systematic review in 2013 by Racicki et al came to the conclusion that “conservative physical therapy treatment techniques are an effective interventions for decreasing cervicogenic intensity and frequency, as well as neck pain.” In particular, utilizing a combination of mobilization, manipulation, and cervicogenic headache exercises like cervico-scapular strengthening exercises, are the most effective intervention based on the results of that systemic review.
A physical therapist will first identify which specific upper cervical segments are dysfunctional through a segmental motion exam. Typically, palpation of the dysfunctional segment will recreate symptoms similar to the headache you experience, letting the physical therapist know that he or she is on the right segment. From there, a physical therapist may perform soft tissue mobilization to the suboccipital muscles with the intention of relaxing them. You can’t address the dysfunctional joints if the muscles around them are tense and guarded! From there, a physical therapist can either employ joint mobilizations or manipulation to the dysfunctional segments. We are advocates of joint manipulations (if the patient is appropriate) because we can quickly “get in and get out” and treat the area of interest without provoking the tissue for too long.
Upper Cervical Soft Tissue Work, Mobilization, and Manipulation
In the video above, I demonstrate a general upper cervical manipulation. While a manual therapist likes to be as specific as possible with their joint mobilizations, it’s difficult to say whether we are gapping C0-C1 or C1-C2 or even C2-C3 joint. Next, I demonstrate some general soft tissue mobilization to obliquus capitis superior and inferior. Finally, I demonstrate one of many ways to mobilize the C0-C1 joint. The particular technique shown is a mobilization of the occiput, while stabilizing at the transverse process of the atlas. Another favorite of mine is the subcranial shear distraction, shown here by Dr. Erson Religioso III.
Cervicogenic Headache Exercise: SNAGs
Following manual therapy, a physical therapist should teach you how to perform a Sustained Natural Apophyseal Glide, or SNAG, for short. This SNAG cervicogenic headache exercise is a way to provide yourself your own form of manual therapy. Essentially this exercise mimics the manual therapist’s hands and provides a joint mobilization to the dysfunctional joint.
- Use the EDGE of a towel. Using the edge, and not the middle or folded up towel, is important as you don’t want the towel to slip off of your skin.
- Place the edge of the towel on the dysfunctional segment.
- Anchor the towel with your the hand on the same side as your dysfunctional segment as shown.
- With your opposite hand, reach up and grab the edge of the towel. If you give it a slight tug, you should feel a pulling/stretching sensation behind your neck at the dysfunctional segment. You should not feel any of your symptoms.
- While pulling the towel (towards your opposite ear), turn your head towards your hand at the same time and hold this position for 3 seconds. Only turn your head in your pain-free range of motion. Your line of pull should be horizontal, to just below the eye (I said towards the eye in the video on accident)
- That’s 1 rep. Now repeat 10 times.
- Perform this exercise twice a day.
If you didn’t follow our initial advice to go see a physical therapist or you’re waiting to get an appointment scheduled, give this SNAG cervicogenic headache exercise a try…but be warned, BE GENTLE! At this point, we don’t know if you’re treating the right segments, or even the right problem in the first place! If you think you have a cervicogenic headache, go schedule an appointment with your local physical therapist.
Cervicogenic Headache Exercises – Neuro-Reducation and Strengthening
Last but not least, you need to follow up all the manual therapy with some cervical and scapular strengthening as well as postural re-education. We’ll highlight a few of our favorite “bang-for-your-buck” exercises that accomplish both strengthening and postural re-education as shown below,
Quadruped Deep Neck Flexor and Extensor Exercise
While training the deep neck flexors in patients with cervicogenic headaches or neck pain is important, we believe that the deep neck extensors are far too often forgotten during rehabilitation. The deep cervical extensors (semispinalis cevicis, multifus, and rotators) along with the cranio-cervical extensors (rectus capitis posterior major/minor and obliquus capitis superior/inferior) are key muscles for cervical spine segmental support due to their relatively small moment arms, attachments to adjacent vertebrae, and high proportion (~70%) of slow twitch fibers.
Start with low load exercises like this one with the aim of inducing neurophysiological adaptations by specifically activating deeper muscles it the cervical spine. Then, progress to high-load exercises with the aim of inducing morphological adaptations in order to increase the strength and endurance of the selected muscles and movements.
- Start in the quadruped position, watch this video to see how to properly engage the scapular stabilizers in quadruped
- Start first with a chin tuck in the quadruped position. This will activate your deep neck flexors. You should be able to see wrinkles in your chin.
- While maintaining the chin tuck, work slow and controlled into cervical flexion. Cue here is to “use your eyes” to follow an object (iPhone shown in video)
- Now here comes the best part of the exercise, the cervical extensors are already engaged in the quadruped position simply due to gravity. However, we can further preferentially activate the deep neck extensors in a segmental fashion on the return from cervical flexion (see video). Cue here with manual resistance at the spinous process or articular pillars.
Inhibiting The Upper Traps
According to Cools et al. (2014), “the prevalence of neck and shoulder pain is known to increase with computer workload. There is a strong relationship between chronic neck and shoulder pain and dysfunction of the scapula. The scapula functions as a ‘bridge’ between the shoulder complex and the cervical spine and plays a very important role in providing both mobility and stability to the neck/shoulder region.” According to Bogduk and Govind (2009), “noxious stimulation of the atlanto-occipital and lateral atlanto-axial joints, the C2–3 zygapophysial joint, and the C2–3 intervertebral disc can produce pain in the occipital region.” We also know the upper trapezius muscle originates on the occipital bone and upper cervical C1-C3 spinous processes. Taking this information into consideration, it would be wise to address the upper trapezius for trigger points, muscle length deficits, and/or overuse.
- Lay on your stomach and get into a comfortable position. Consider a pillow under your stomach, or under your chest, if your spine goes into excessive lordosis or kyphosis when you lay on your stomach.
- Rest your forehead on your heads and relax your arms on the table. Your head and arms should be fully supported so that you can relax.
- Push your hands into the table and pull your shoulder blades down towards your feet.
- Hold this position for 5s, and repeat for a total of 5 reps.
- Your neck and the region of the upper traps should be relaxed while you perform this exercise.
The goal of this exercise is to primarily inhibit the upper traps from working. To promote muscular inhibition, you want to cue the shoulder blades into depression and downward rotation as this is the opposite muscle action of the upper traps. Keep your neck ‘long and relaxed’ during this exercise. If you feel your head rising off the table and wanting to extend, take a break and try again with less force.
Improve Your Posture at Work!
As always, maintaining good posture while seated for countless hours at work is always beneficial. Not just for cervicogenic headache prehab, but also for overall musculoskeletal health. Here are two of our favorite work posture hacks:
According to the literature, most patients treated conservatively with physical therapy see significant improvements in headache frequency, duration, and intensity within the first four weeks, so don’t be dismayed if you don’t see immediate results!
In summary, cervicogenic headaches are a particular subset of headaches that are caused by dysfunction in the upper cervical spine. Dysfunctional segments can be made functional again with manual therapy techniques such as soft tissue mobilizations or joint mobilizations and manipulation. Manual therapy should always be followed up with exercise. In the case of upper cervical manual therapy, SNAGs are the perfect exercise to combat cervicogenic headaches. Last but not least, strengthening the cervical and scapular muscles in addition to facilitating proper posture, are imperative in keeping your headache at bay.