CeH preferentially effects female headache patients (Racicki et al., 2013). CeH is
classified as a secondary headache disorder because the source of the pain is thought to
be a consequence of injury to, or disease of, the bony and/or soft tissues of the upper
cervical spine (Kristoffersen et al., 2017). Clinical management of CeH is challenging
for the physician because a pathology that would account for the pain is usually unknown.
The primary diagnostic criteria that physicians use to diagnose CeH is based upon
classification according to the International Headache Society Classification IHSD 3rd
Edition (HIS, 2013). CeH is characterized by unilateral head or face pain without side
shift that is of moderate to severe intensity of varying duration (Antonaci et al.,
2001). CeH may occasionally be bilateral, throbbing, and accompanied by nausea, vomiting,
phonophobia, photophobia, and dizziness when chronic tension-type headache and chronic
migraine attacks are superimposed (Biondi, 2005). If the source of CeH originates in the
upper cervical spine, osteopathic physicians can use head and neck movements and pressure
applied to the suboccipital and lower cervical regions (Anarte-Lazo et al., 2021) to
provoke referred headache. These diagnostic techniques, along with restricted active and
passive range of motion (ROM) of the head and neck (Ogince et al., 2007), provide
additional credibility that the diagnosis of CeH is valid (Avijgan et al., 2020) and
helps ensure that the efficacy of our treatment protocol is not weakened by applying it
to subjects with a different type of headache, such as migraine, that would not be
expected to respond to a treatment protocol designed for CeH patients (Bogduk N, 2014).
The largest study of conservative therapy for cervicogenic headache (Jull et al., 2002)
reported that manual therapy alone was not more effective than exercises alone. The study
reported that headache frequency was reduced by 50% at a 7-week follow up, but figures
for reduction in pain intensity were not reported. They reported that combining
manipulation and exercise was not significantly superior to either therapy alone. Hidalgo
et al., (2017) have reported that combining the 2 therapies is better than either
manipulation or exercise alone. The weakness of Jull et al's. (2002) study was that their
treatment protocol was applied to subjects who would not have had a common etiology for
their headache pain. CeH is defined by injury to, or disease of, the bony and/or soft
tissues of the upper cervical spine (Bogduk N, 2014). MRI is the gold standard for
diagnostic assessment of structures of the upper cervical spine (Sun et al., 2020), but
Jull et, al.'s (2002) study did not include an MRI assessment of the upper cervical spine
in their inclusion/exclusion criteria. The outcome of their study reported that their
treatment protocol showed a positive effect, but not one that rose to a significant
level. I suggest this was due to mixing headache types (CM and CeH) that have different
etiologies and expecting a single treatment protocol to address both pathologies.
Since CeH results from injury to, or disease of, the bony and/or soft tissues of the
upper cervical spine, it is only reasonable to exclude those patients who do not present
with pathology on MRI in the upper cervical spine (Sun et al.,2020). Our study is unique
in that we will test the effectiveness of specific interventions that address a specific
pathology within a specific headache population. By actively restricting the study cohort
to a specific headache population, we will increase our ability to detect a significant
change in the outcomes of treatment by increasing the power of the statistical analysis.
This study is unique in that it proposes to investigate a mechanism responsible for
referred pain in some instances of chronic CeH. The effectiveness of specific
interventions to address a specific pathology within a specific headache population will
be tested. It is proposed that pathology in RCPm muscles has been undervalued, primarily
because of their small size and a misunderstanding of their functional significance. By
actively restricting the study cohort to a specific headache population, the power of the
statistical analysis will be increased. It is hypothesized that the combined use of OMT
and THE will decrease headache measures of frequency, intensity and duration, will
increase the CSA and reduce the percentage of fatty infiltration (FI) of RCPm muscles on
MRI, and will reduce forward head posture (FHP) in female patients diagnosed with CeH.
