Clinical Test of Musculoskeletal Dysfunction in the
Diagnosis of Cervicogenic Headache

This section is compiled by Frank M. Painter, D.C.
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FROM:   Manual Therapy 2006 (May);   11 (2):   91–166

Zito G, Jull G, Story I

School of Physiotherapy,
The University of Melbourne,
Vic. 3010, Australia.

Persistent intermittent headache is a common disorder and is often accompanied by neck aching or stiffness, which could infer a cervical contribution to headache. However, the incidence of cervicogenic headache is estimated to be 14 - 18% of all chronic headaches, highlighting the need for clear criterion of cervical musculoskeletal impairment to identify cervicogenic headache sufferers who may benefit from treatments such as manual therapy.

This study examined the presence of cervical musculoskeletal impairment in 77 subjects, 27 with cervicogenic headache, 25 with migraine with aura and 25 control subjects. Assessments included a photographic measure of posture, range of movement, cervical manual examination, pressure pain thresholds, muscle length, performance in the cranio-cervical flexion test and cervical kinaesthetic sense.

The results indicated that when compared to the migraine with aura and control groups who scored similarly in the tests, the cervicogenic headache group had less range of cervical flexion/extension (P=0.048) and significantly higher incidences of painful upper cervical joint dysfunction assessed by manual examination (all P<0.05) and muscle tightness (P<0.05). Sternocleidomastoid normalized EMG values were higher in the latter three stages of the cranio-cervical flexion test although they failed to reach significance. There were no between group differences for other measures. A discriminant analysis revealed that manual examination could discriminate the cervicogenic headache group from the other subjects (migraine with aura and control subjects combined) with an 80% sensitivity.

From the FULL TEXT Article:


Headache is a common disorder with an estimated lifetime prevalence of 96% and a point prevalence of 16% (Rasmussen et al., 1991). Henry et al. (1987) determined that approximately 70% of persons with frequent intermittent headache report neck symptoms associated with their headache, which may encourage delivery of treatment to the cervical region. Whilst it is proposed that the cervical spine may contribute to different types of headache such as migraine and tension type headache (Watson, 1995), studies estimate that only 14–18% of chronic headaches are cervicogenic, that is, headaches which actually result from musculoskeletal dysfunction in the cervical spine (Pfaffenrath and Kaube, 1990; Nilsson, 1995). There is the potential for many headache patients to receive ongoing physical treatments even when there is a high possibility that such treatments are likely to be unsuccessful (Parker et al., 1978; Tuchin et al., 2000; Astin and Ernst, 2002). The call for substantiation of efficacy of manual therapy emphasizes the need for accurate diagnosis to distinguish cervicogenic headache from other causes of chronic headache so that the appropriate patients receive manual therapy treatment.

Comparatively little research has been conducted on characterizing the physical impairments which might confirm a cervical cause. The International Headache Society (IHS) has published criteria for the classification of headache (IHS, 2004) although Sjaastad et al. (1998) has provided more detailed criteria for cervicogenic headache. Such criteria are based mainly on the history, temporal pattern and aggravating features of headache. However, there is considerable overlap in symptoms of headache of various origins. Furthermore, the musculoskeletal criteria to identify a cervical cause of headache are general in nature. More specific descriptions might assist differential diagnosis.

Research has begun to identify impairments in the musculoskeletal system, which could assist in diagnosing cervicogenic headache. Studies have investigated features of the articular, muscle and neural systems. For example, Zwart (1997) using Cybex dynamometry (albeit without reported reliability), showed that cervical flexion, extension and rotation ranges were significantly less in subjects with cervicogenic headache in comparison to those with migraine and tension headache. Additionally, a number of studies have consistently linked cervicogenic headache to painful dysfunction in the upper three cervical segments (C0–3) (Trevor-Jones, 1964; Bogduk and Marsland, 1986; Bovim et al., 1992; Dreyfuss et al., 1994; Lord and Bogduk, 1996). Tenderness is also a feature. Bovim (1992) measured pressure pain thresholds (PPTs) at 10 points on the head and suboccipital region in subjects with cervicogenic, tension and migraine headaches and found that when all PPT values were summed, the score was significantly lower in the cervicogenic headache group than for the tension and migraine headache and control groups. A relationship has been proposed between a forward head posture and cervicogenic headache although the evidence is not definitive (Watson and Trott, 1993; Treleaven et al., 1994; Haughie et al., 1995). In relation to muscle function, several studies using different tests of the cervical flexor muscles have identified dysfunction in this muscle group in neck pain and headache subjects (Watson and Trott 1993; Treleaven et al., 1994; Jull et al., 1999). Two studies have noted a higher prevalence of cervico-brachial muscle tightness, assessed clinically, in cervicogenic headache subjects as compared to control subjects (Treleaven et al., 1994 Jull et al., 1999). Deficits in cervical kinaesthesia have been identified in various neck syndromes (Revel et al., 1991; Loudon et al., 1997; Heikkila¨ and Wenngren, 1998) but no studies to date have investigated cervical kinaesthesia in cervicogenic headache. There is little knowledge of the prevalence of mechanosensitive neural tissue, although its occurrence has been described (Rumore 1989) and its involvement alluded to in a small pilot study, which suggested altered mechanosensitivity in patients with cervicogenic headache (Rankin, 1993).

Previous studies have examined one or two features of the cervical musculoskeletal system in cervicogenic headache patients. The aim of this study therefore was to investigate the sensitivity of these tests as a group to determine if there was a pattern of musculoskeletal dysfunction, which might better characterize cervicogenic headache for differential diagnosis. Three groups of subjects were compared, cervicogenic headache, migraine with aura and a non-headache control group. Migraine with aura was chosen as there is no evidence that cervical musculoskeletal dysfunction has a role in its pathogenesis.


Clinical signs of impairment in the articular and muscle systems identified the cervicogenic headache subjects in this study from the migraine and control subjects. However, no differences were evident between the groups with respect to static posture, PPTs mechanosensitivity of neural tissues, and measures of cervical kinaesthetic sense.

The results of this study determined that range of cervical movement was reduced in the cervicogenic headache subjects, albeit significant for flexion and extension only. This finding of reduced movement supports the current criteria for cervicogenic headache (Sjaastad et al., 1998; IHS, 2004). Furthermore, our results reflect those of Zwart (1997) who likewise identified reduced neck motion in cervicogenic headache subjects but found similar motion in migraine and nonheadache control groups.

The presence of painful segmental dysfunction in the upper three cervical joints as detected with manual examination most clearly identified the cervicogenic headache subjects in this study. The upper cervical segments in both the control and migraine groups were rated as normal and non-painful for the vast majority of joints assessed. Gijsberts et al. ( 1999) also found that manual examination successfully identified the 38 cervicogenic headache subjects within a cohort of 105 headache subjects on the basis of painful joint dysfunction. Upper cervical joint arthropathy is regarded as a common cause of cervicogenic headache (Trevor-Jones, 1964; Bogduk and Marsland, 1986; Bovim et al., 1992; Dreyfuss et al., 1994; Lord and Bogduk, 1996) but there is no evidence of its role in the pathogenesis of migraine with aura. This is supported in this study by the lack of finding of painful segmental dysfunction in the migraine subjects, who were no different from control subjects.

There were no group differences in measures of PPTs over sites in the cervical region, except for those over the C4 transverse process where both the migraine with aura and cervicogenic headache groups had lower PPTs than the control groups. This was a curious finding given the higher pain scores in the cervicogenic headache group on manual examination and the findings of reduced PPTs in other studies of cervicogenic headache and migraine (Bovim, 1992).

In relation to the muscle system, the incidence of muscle tightness was significantly higher in the cervicogenic headache group (34.9% of all muscle length tests) than the migraine with aura or controls groups, where the incidence was low (16.7% and 16.3%, respectively). No one cervico-brachial muscle predominated and tightness in the pectoral muscles was not common in the cohort of this study. These findings concur with those of Treleaven et al. (1994) and Jull et al. (1999).

The cervicogenic headache group also demonstrated poorer performance in the cranio-cervical flexion test, as indicated by the higher RMS values for signal amplitude for the SCM, which were evident in the latter three stages of the test. However, these differences failed to reach significance and this possibly reflects the large variance and the patient sample size in this study. The higher RMS values for signal amplitude of the SCM indicate an altered pattern within the neck flexor synergy which infers a poorer contractile capacity of the deep neck flexors in patients with cervical disorders (Jull et al., 1999; Jull, 2000; Falla, 2004; Falla et al., 2004; Jull et al., 2004).

The dura mater of the upper spinal cord and posterior cranial fossa are supplied by the upper cervical nerves and thus are capable of contributing to a cervicogenic headache syndrome. However, the occurrence of positive tests for mechanosensitivity of neural structures was rare and occurred in only two subjects in the cervicogenic headache group (7.4%) in this study. No positive tests were determined in the migraine with aura or control subjects. A low incidence of mechanosensitivity of neural structures (10%) was also determined by Jull (2001) in a study of 200 cervicogenic subjects.

No between group differences were found in the static postural measurements of forward head posture (CV angle) and head inclination (ETH). This is in contrast to other studies (Watson and Trott, 1993) but parallels the findings of Treleaven et al. (1994). In common, this current study and that of Treleaven et al. (1994) tested younger subjects, and it is possible that postural factors may only be involved in an older subject cohort, as it is known that the FHP is age related (Dalton and Coutts 1994).

No between group differences were found in cervical kinaesthetic sense (JPE). This could also be a factor of the age group studied, or could possibly relate to the extent of the cervical pathology. For example, Sterling et al. (2004) found that only whiplash subjects with higher levels of pain and disability indicative of more severe injuries demonstrated kinaesthetic deficits whereas those with lesser scores of pain and disability did not.

A discriminant function analysis was used to determine if there were physical measures, which most discriminated cervicogenic headache from the migraine and control subjects. Not unexpectedly, when considering the overall results of this study, the analysis confirmed that the factors of upper cervical joint dysfunction, principally at the C1/2 segment and pectoralis minor muscle length, were able to discriminate the cervicogenic headache group from the migraine and control subjects (as a whole) with a sensitivity of 80%. A current criterion for diagnosis of cervicogenic headache is the elimination of headache by anaesthetic blocks nerve or joint blocks (Sjaastad et al., 1998). Manual examination could be considered as a simple, conservative and inexpensive clinical alternative to anaesthetic blocks for the large population of headache sufferers to diagnose the presence of painful joint dysfunction through pain provocation. In this respect, this study adds to the evidence of other studies of the sensitivity of manual examination for this purpose (Jull et al., 1988, 1997; Gijsberts et al., 1999).


This study determined that the presence of upper cervical joint dysfunction most clearly differentiated the cervicogenic headache sufferers from those with migraine with aura and control subjects. The cervicogenic headache group also presented with restriction in cervical motion, a higher frequency of muscle tightness and a poorer (albeit non significant) performance at the higher levels of the cranio-cervical flexion. Such musculoskeletal dysfunction was not apparent in the group with migraine with aura who did not differ from the control group. These musculoskeletal criteria are in accordance with, but better define those listed by the IHS (2004). Identification of these physical impairments in the musculoskeletal system linked to clinical features will contribute to the justification and selection of treatment for cervicogenic headache. Further work is necessary to address issues of generalizability and reliability of these results.


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