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Manual Therapy 11 (2006) 118129

www.elsevier.com/locate/math

Original article

Clinical tests of musculoskeletal dysfunction in the

diagnosis of cervicogenic headache
G. Zitoa,, G. Jullb, I. Storyc
a

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

b
Division of Physiotherapy, The University of Queensland, Australia
c
Faculty of Health and Behavioural Sciences, Deakin University, Australia

Received 20 January 2003; received in revised form 22 March 2005; accepted 27 April 2005

Abstract
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 1418% of all chronic
headaches, highlighting the need for clear criterion of cervical musculoskeletal impairment to identify cervicogenic headache
sufferers who may benet 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 exion 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 exion/extension (P 0:048) and signicantly higher incidences of painful
upper cervical joint dysfunction assessed by manual examination (all Po0:05) and muscle tightness (Po0:05). Sternocleidomastoid
normalized EMG values were higher in the latter three stages of the cranio-cervical exion test although they failed to reach
signicance. 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.
r 2005 Elsevier Ltd. All rights reserved.
Keywords: Cervicogenic headache; Migraine; Cervical movement; Muscle function

1. Introduction
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
Corresponding author. Tel.: +613 8344 4171; fax: +613 8344 4188.

E-mail address: g.zito@unimelb.edu.au (G. Zito).

1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2005.04.007

different types of headache such as migraine and tension

type headache (Watson, 1995), studies estimate that
only 1418% 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 efcacy of manual therapy
emphasizes the need for accurate diagnosis to distinguish cervicogenic headache from other causes of

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G. Zito et al. / Manual Therapy 11 (2006) 118129

chronic headache so that the appropriate patients

receive manual therapy treatment.
Comparatively little research has been conducted on
characterizing the physical impairments which might
conrm a cervical cause. The International Headache
Society (IHS) has published criteria for the classication
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 specic 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
exion, extension and rotation ranges were signicantly
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 (C03) (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 signicantly
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 denitive (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 exor muscles have identied 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). Decits in cervical kinaesthesia have been
identied 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

119

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.

2. Methods
2.1. Subjects
Seventy-seven female volunteers aged between 18 and
34 years were invited to join the study. The crosssectional study was conducted under single blind
conditions in that the principal investigator, an experienced musculoskeletal physiotherapist, was blind to the
diagnostic category of the subjects. The subjects were
recruited from neurologists, general medical practitioners and musculoskeletal physiotherapists or by
advertisement (control subjects). They entered one of
three groups, a control group (n 25, mean age
22.973.5 years), a cervicogenic headache group
(n 27, mean age 25.373.9 years) or a migraine with
aura group (n 25, mean age 22.973.5 years) and
comparisons between the three groups were made.
Headache subjects entered their respective groups
according to established diagnostic criteria for migraine
with aura (IHS, 2004) and cervicogenic headache
(Sjaastad et al., 1998). Anaesthetic blockades were not
used as a criterion for cervicogenic headache as the
procedure was considered too invasive and costly for
this study and is not readily accessible to most clinicians.
The total length of the history of the headache ranged
from 9 months to more than 10 years (Table 1). Young
subjects were selected as it is the period of life when
vascular symptoms are more frequently encountered
(Lance and Goadsby, 1998), and when the effects of age
or disease in the musculoskeletal system are still
Table 1
Total length of history of headaches

CEH
Migraine

9 months5 years

510 years

410 years

18 (67%)
6 (24%)

6 (22%)
10 (40%)

3 (11%)
9 (36%)

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120

relatively negligible. The inclusion criteria for control

subjects were no history of headache, cervical pain or
injury for which they had sought treatment. Headache
subjects were deemed ineligible if they had a history of
combined forms of headache, were involved in compensation or, in the case of migraine with aura subjects, if
they had a history of a neck injury or condition. Ethical
clearance for the study was granted by the Human
Research Ethics Committee of The University of
Melbourne and all participants gave their informed
consent.
2.2. Measurements
Questionnaires: Headache subjects completed a questionnaire about the history and nature of headache to
ensure they fullled the diagnostic criteria of their
headache group (Appendix A) as well as the McGill
Pain Questionnaire (Melzack, 1975).
Physical examination: The sequence and content of
the physical examination is summarized in Table 2.
Postural measurement: A photographic measurement
of posture was taken according to the method of
Refshauge et al. (1994). Subjects were photographed
looking straight-ahead in their natural stance using a
Kodak DC50 digital camera and postural angles were
calculated using NIH Image software (National Institutes of Health, USA). The cranio-vertebral angle (CV),
reecting the forward head posture position, was the
acute angle created between the horizontal plane and
the line from the tip of the C7 spinous process to the
tragion. Head posture was measured as the acute angle

between the horizontal plane and the line from the

corner of the eye to the tragion (ETH).
Pressure pain thresholds (PPTs): PPTs were measured
with a pressure algometer (PD&TItaly) applied at a
constant rate of approximately 1 kg/cm2/s until the
subjects reported a change of sensation from pressure to
pain. A familiarization session was rst performed on
the wrist. The following sites were identied and tested
with the subject in prone lying: the areas over the C2
nerve root, the greater occipital nerve, the transverse
process of C4 (Fredriksen et al., 1987; Pfaffenrath et al.,
1988; Sjaastad et al., 1998) and the C2/3 zygapophyseal
joint (Lord et al., 1994). Five readings were taken over
each site and averaged for analysis.
Range of cervical movement: A cervical range of
movement device CROM (Performance Attainment
Associates, St. Paul, MN, USA) was used to measure
the mobility of the cervical spine (Youdas et al., 1991)
using the standard protocol for upper cervical exion/
extension, cervical exion/extension, lateral exion and
rotation. In this study, rotation of the head was also
measured in a position of full exion of the neck as an
estimate of upper cervical spine rotation (Dvorak et al.,
1984). For this measure, the research assistant held the
magnetic yoke of the CROM in a plane parallel to the
compass on the subjects head so that the compass meter
could be seen in between the two magnetic rods. All
movements were performed twice and averaged for
analysis.
Cervicocephalic kinaesthetic sense: The protocol of
Revel et al. (1991) was used to measure the subjects
ability (while blindfolded) to relocate the natural head

Table 2
Domains of assessment
Assessment

Domains

Clinical utility

Postural measurement

Eye-tragion angle (ETH)

Craniovertebral angle (CV)

Head on neck posture Forward head

posture position

Pressure pain threshold

Pressure points associated with CEH

Cervical range of movement

Flexion, extension, rotation lateral exion

Upper cervical rotation, lateral exion

Cervicocephalic kinaesthetic
sense
Manual assessment
Muscle extensibility
Mechanosensitivity of neural
tissues
Craniocervical exion test

C4 transverse process
C2/3 z-joint
C2 nerve root
Greater occipital nerve

Flexion, extension, rotation

O/C1, C1/2, C2/3 and C3/4
Upper trapezius, Scalenes, Levator Scapulae, Short Cx Extensors, Pec
major & minor
Pre-tensioning dura with upper Cx exion whilst adding brachial
plexus provocation test and SLR
Progressively inner range craniocervical exion positions head
nodding tests aiming to reach and hold steadily targeted pressure (22,
24, 26, 28, 30 mm Hg) for 5 s

Decreased mobility associated with

CEH
Assessing repositioning error
associated with cervical dysfunction
hypomobility and pain associated with
cervical z-joints dysfunction
Muscle tightness associated with
cervical dysfunction
Increased sensitivity of neural tissues
associated with cervical dysfunction
To detect excessive synergistic activity
of long neck exors

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posture (NHP) following the movements of left and

right rotation, exion and extension. The relocation
error (joint position error, JPE) was the difference
between the starting position and the NHP after
movement. Five trials were undertaken for each movement and the average JPE was calculated for analysis.
The value was the absolute error, that is, the positive
and negative values (undershoot or overshoot of the
target) were not considered.
Manual examination of the upper cervical joints: A
manual examination of the upper four cervical spine
segments was conducted by the principal researcher as
per the normal clinical procedure (Maitland et al., 2001).
Joint motion was rated on a conventional 7-point scale
(hypermobility (grades 13) normal (4) hypomobility
(grades 57) as proposed by Jull et al. (1994). The
subject rated verbally any pain provoked by the
examination (local or referred) at any joint on an 11point scale (verbal analogue scale: VAS). To emphasize
the essential differences between the groups, the joint
motion rating was collapsed to a 3-point scale prior to
analysis: normal (ratings 3, 4, 5), hypermobile (ratings 1,
2) and hypomobile (ratings 6, 7).
Muscle extensibility: Extensibility of selected cervical
and axio-scapular muscles was assessed using standard
clinical tests of muscle length (Evjenth and Hamberg,
1984; Janda, 1994). Extensibility was initially rated on a
4-point scale as used by Treleaven et al. (1994), normal,
slightly, moderately and very tight which, for analysis,
was collapsed into a 2-point scale: normal (normal and
slightly) and tight (moderate and very).
Mechanosensitivity of neural tissues: Neural tissue
mechanosensitivity was assessed by holding an upper
cervical exion position and then tensioning neural
tissues by placing the upper and lower limbs in the
brachial plexus provocation test and the straight leg
raise test positions respectively (Jull, 1997). A positive
test was a perceived change in tissue resistance with
provocation of neck pain or headache with the added
movements.
The cranio-cervical flexion test: The cranio-cervical
exion test as described by Jull (2000) was used to assess
the cervical exor synergy. In a supine position, the
subject performed cranio-cervical exion (head nod) in 5
progressive stages of increasing range. They were guided
by feedback from a pressure sensor positioned behind
the neck (Stabilizer, Chattanooga, USA) and targeted
2 mm Hg increases in pressure from a baseline of 20 to
30 mm Hg. Each stage was held for 5 s, with a 10 s rest
between stages. Myoelectric signals (EMG) were measured from the sternocleidomastoid muscles (SCM), but
no direct measure of the deep neck exors was made in
this clinical study. Nevertheless, it has been shown that
there are higher signal amplitudes in these muscles in
neck pain patients as compared with control subjects in
this test (Jull, 2000; Jull et al., 2004). The indication that

121

this is a compensatory strategy was conrmed by Falla

et al. (2004) who demonstrated that this higher activity
was associated with lesser measured activity in the deep
neck exors in neck pain patients. In this study, pairs of
standard EMG Red-Dot Bipolar AgAgCl electrodes
were positioned along the muscle bellies of the SCM,
following skin preparation. Signals were amplied
(Associated Measurements Pty Ltd., Australia, Amlab),
passed through a 20500 Hz bandwidth lter and
sampled at 1000 Hz. Data were analysed with a third
party software program (Igor Pro V3). The maximum
root mean squared (RMS) value for signal amplitude
was identied for each trace using a 1 s sliding window,
incremented in 100 m s steps. RMS values were normalized for each subject to the RMS of the resting level for
that subject. Subjects rst practised the cranio-cervical
exion test and then performed the test formally for
measurement.
Repeatability tests: Prior to the commencement of the
main study, the principal investigator undertook repeatability studies for each measure. The ranges of the
ICC and Kappa scores for the tests are summarized in
Table 3. The results indicated that there was acceptable
intra-examiner repeatability for the measures used in
this study.
2.3. Procedure
All potential subjects completed the questionnaire to
conrm that they met the inclusion criteria for their
relevant group and that they were asymptomatic at the
time of testing. The principal investigator performed the
measurements in the same sequence for all subjects and
was blinded to the subjects group status.
2.4. Statistical methods
w2-tests were used to analyse the data obtained from
manual examination and tests of muscle extensibility.
The data for neural tissue mechanosensitivity were
analysed descriptively. One-way analysis of variance
(ANOVA) was used for all other data. The level of
Table 3
Summary of the ranges of ICC and Kappa scores for the reliability
studies
Test

ICC value range

Postural angles
Pressure pain thresholds
Cervico-cephalic kinesthetic
sense
Range of movement
Manual examinatiom
(Jull et al., 1997)
Muscle extensibility

0.960.99
0.820.98
0.510.62

Kappa score
range

0.860.97
0.781.0
0.41.0

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122

signicance was set at Pp0:05. A discriminant function

analysis was conducted to determine if any physical
measures discriminated cervicogenic headache from the
migraine with aura and control subjects.

All subjects fullled the inclusion criteria for their

diagnostic classication and the groups were deemed to
be representative of cervicogenic headache, migraine
with aura and asymptomatic control populations.
The data for the postural, PPT and JPE are presented
in Table 4. The results of the analyses of variance
showed no signicant between group differences in
postural angles and no relationship between CV angle
and ETH angle was evident. There were no between
group differences in PPTs with the exception of the area
over the transverse process of C4 where both the
headache groups had signicantly lower PPTs than did
the control group (Po0:05). There were no signicant
between group differences in JPEs in any movement.
The data for the measurement of cervical range of
movement are presented in Fig. 1. The cervicogenic
headache group demonstrated consistently less movement than the migraine and control groups, although
this was statistically signicant only for cervical exion/
extension (P 0:048). The frequency of ndings of
painful and stiff joints in the manual examination for
the three groups is presented in Table 5. As can be
observed, the cervicogenic headache group had a high
incidence of pain associated with joint hypomobility

160

Subject groups
Measurements

Controls
(n 25)

Cervicogenic
(n 27)

Migraine
(n 25)

Posture (deg)

CV angle
ETH

50.3 (4.6)
13.0 (5.7)

51.1 (5.8)
15.2 (5.0)

53.3 (3.9)
15.9 (4.9)

PPTs (kg/cm2)

C2
GON
C2-3
C4 TP

3.2
4.9
3.6
4.5

3.3
4.3
3.4
3.9

3.0
4.5
3.3
3.8

JPE

Flexion
Extension
(L)
rotation
(R)
rotation

4.1 (1.9)
5.2 (2.1)
6.1 (2.1)

4.3 (2.0)
5.4 (2.7)
5.6 (2.6)

4.3 (1.7)
5.3 (2.7)
5.5 (2.7)

6.2 (2.8)

5.3 (2.5)

4.7 (2.6)

(1.0)
(1.6)
(1.1)
(1.2)

(1.1)
(1.4)
(1.0)
(1.1)*

GON greater occipital nerve; TP transverse process.


po0:05.

(1.1)
(2.0)
(1.2)
(1.2)*

120
100
80
60
40
20
0
UppCx Flex/Ext

Flex/Ext

Lat Flex

Rotation

UpperCx Rot

Direction of movement
Fig. 1. The mean ranges of movement (degrees).

Table 5
The frequency of hypomobile and painful segments and pain score in
each subject group
Level

Groupa

Stiff and painful

segments

Average VAS
score

O/C1

Control
Cervicogenic
Migraine
Control
Cervicogenic
Migraine
Control
Cervicogenic
Migraine
Control
Cervicogenic
Migraine

12
38
14
10
39
14
4
26
10
2
11
8

2
5
2
2
5
2
1
3
2
1
2
1

C1/2

C2/3

C3/4
Table 4
The means (SD) for the postural angles, pressure pain thresholds
(PPTs) and joint position errors (JPE) in the tests of kinaesthetic
sensibility for the three subject groups

Controls
Cervicogenic
Migraine

140

Mean range (degrees)

3. Results

180

Subjects could be assessed to have hypomobility at one or more

segments. Note two joints (left and right sides) were assessed for each
segment.
a
Control (n 50), cervicogenic (n 54), migraine (50).

while in contrast the incidence in both the control and

migraine groups was relatively low. The majority of
joints in these latter two groups were rated as normal
motion (88% control group and 84% migraine with
aura group). The analyses (w2) conrmed the observed
differences for the cervicogenic headache group for all
segments when compared to the migraine and control
groups (all Po0:05). Similarly pain was provoked more
frequently and to a greater extent in the manual joint
examination in the cervicogenic headache group (all
Po0:005) with the exception of the C34 segment, the
segment with least perceived dysfunction in any group
(Table 5). It should be noted that whilst all hypomobile
joints were not necessarily painful, all painful joints were
hypomobile.

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The frequency of muscle tightness in each group is

presented in Fig. 2. The ndings of bilateral muscles
have been summed and results expressed as a percentage
for that muscle. There was a statistically signicant
difference (w2) between the incidence of tightness in the
cervicogenic headache group compared to the migraine
and control groups for the upper trapezius (P 0:003),
levator scapulae (P 0:001), scalenes (P 0:001) and
the suboccipital extensors (P 0:035) but not for the
pectoral muscles. The nding of mechanosensitivity of
neural tissue was rare. Positive ndings (increased
resistance with provocation of pain) were only determined in two of the 27 cervicogenic headache subjects
(7.4%) and in no subjects in the migraine or control
groups. One cervicogenic headache subject complained
of reproduction of the headache with the addition of the
straight leg raise test and the other complained of
reproduction of the headache, neck and arm symptoms
with the addition of the upper limb tension test.
Fig. 3 presents the change in normalized EMG
activity in each stage of the cranio-cervical exion test
for the three subject groups. The cervicogenic headache
group displayed higher normalized RMS values for
signal amplitude in the SCM than the migraine or
control groups at the 26, 28 and 30 mm Hg test targets,
but the differences did not reach statistical signicance
possibly reecting the between subject variance.
For the discriminant analysis, the averages of the left
and right measurements for each test were used along
with other predictors to identify which test would
classify cervicogenic headache subjects from migraine
with aura subjects and asymptomatic volunteers. The
eigenvalue for the discriminant function was 0.462 and
the only variable selected for weighting was the
palpatory nding at the C1/2 level. Classications using
this discriminant function gave poor results with only
25

Controls
Cervicogenic
Migraine

Frequency of occurrence

20

15

10

0
U Trap

Lev Scap

Scalenes

Sub-occ ext

Pec Maj

Pec Min

Muscles
Fig. 2. Frequency (percentage) of muscle tightness in the three subject
groups.

123

half of the cases correctly classied as compared to one

third expected by chance. This level of classication
could reect the fact that 56% of the cases from the
migraine with aura group were classied with the
control group.
The discriminant analysis was therefore repeated
combining the control and migraine with aura subjects
into one group. With this regrouping, the classication
rate was improved with 80% of cases correctly identied
on the basis of the manual palpatory nding at C1/2
level and the muscle length of pectoralis minor.

4. Discussion
Clinical signs of impairment in the articular and
muscle systems identied 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 signicant for exion and
extension only. This nding of reduced movement
supports the current criteria for cervicogenic headache
(Sjaastad et al., 1998; IHS, 2004). Furthermore, our
results reect those of Zwart (1997) who likewise
identied 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 identied 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 identied 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
nding 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 nding given the
higher pain scores in the cervicogenic headache group

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124

EMG amplitude (percent of value at 20 mm Hg)

300
Pressure
20.00
22.00
24.00
26.00
28.00
30.00

250

Standard deviations
Control Cervico Migraine
59.52
76.28
56.13
50.42
105.10
78.30
96.03
193.61
93.46
115.20
269.64
87.93
142.80
268.94
80.94
180.10
296.90
115.37

200

150

Control
Cervico
Migraine
100
20

22

24

26
Pressure (mm Hg)

28

30

32

Fig. 3. Normalized EMG activity for sternocleidomastoid in each stage of the cranio-cervical exion test for the three subject groups.

on manual examination and the ndings 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 signicantly 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 ndings 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 exion 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 signicance and this possibly reects 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 exor

synergy which infers a poorer contractile capacity of

the deep neck exors 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
ndings of Treleaven et al. (1994). In common, this
current study and that of Treleaven et al. (1994) tested

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G. Zito et al. / Manual Therapy 11 (2006) 118129

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 decits
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
conrmed 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).

5. Conclusion
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 signicant) performance at the
higher levels of the cranio-cervical exion. 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 dene those listed by the
IHS (2004). Identication of these physical impairments
in the musculoskeletal system linked to clinical features
will contribute to the justication and selection of
treatment for cervicogenic headache. Further work is
necessary to address issues of generalizability and
reliability of these results.

Acknowledgements
The authors would like to acknowledge the invaluable
contributions of Mrs. Robin Zito and Dr Ross Darnell
(statistician) to this study.

Appendix A. Subjective questionnaire for headache subjects

Reference number:
Name:
Diagnostic group:
Date of birth:
Date of examination:

(1) Cx/Ha
/
/

125

(2) Migraine
/
/

1. PLEASE SHADE IN WHERE YOU FEEL YOUR HEAD/NECK SYMPTOMS

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G. Zito et al. / Manual Therapy 11 (2006) 118129

126

2. Do you suffer any of the following symptoms with your headache?

NEVER
a)

Neck pain

b)

Pins and needles or numbness

c)

Dizziness

d)

Ringing in ears

e)

Sight disturbances (blurring/double vision)

f)

Associated vomiting

g)

Associated nausea

h)

Other, please specify

OCCASIONALLY

ALWAYS

Comments:

3(i)

DO YOU HAVE ANY WARNING SIGNS

THAT YOU ARE ABOUT HAVE A
HEADACHE EPISODE ?

3(ii)

HOW LONG DO THE WARNING

SIGNS LAST?

YES

NO

Hours ............... Mins.. ..............

3(iii) IF YOU HAVE WARNING SIGNS PLEASE DESCRIBE THEM

3(iv) IF YOU HAVE WARNING SIGNS, DO YOUR

HEADACHES COMMENCE IMMEDIATELY
AFTER THE WARNING SIGNS SETTLE ?

YES

NO

4. ARE YOUR HEADACHES/NECK PAINS MADE WORSE BY ANY OF THE

FOLLOWING:
a)

Turning your head?

...............................................................................................

b)

Reading or watching TV? ......................................................................................

c)

Looking up? ............................................................................................................

d)

Driving? ...................................................................................................................

e)

Stress / tension? .......................................................................................................

f)

Tying back your hair? ............................................................................................

g)

Menstruation ? .........................................................................................................

h)

Certain types of food / drink?

i)

...............................................................................

Other triggers? .......................................................................................................

Please specify

5.

HOW LONG DO YOUR HEADACHES LAST?

a)

1 - 3 hours ................................................................................................................

b)

3 - 6 hours ...............................................................................................................

c)

6 - 12 hours .............................................................................................................

d)

12 - 24 hours ...........................................................................................................

e)

Other ........................................................................................................................

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G. Zito et al. / Manual Therapy 11 (2006) 118129

6(i)

127

ARE YOU ABLE TO DO SOMETHING TO RELIEVE YOUR SYMPTOMS?

6(ii)

a)

Yes ..........................................................................................................................

b)

No ...........................................................................................................................

IF YES, WHAT DO YOU DO?

a)

7.

Find an easing position

........................................................................................

b)

Put on a collar, or other support.........................................................................

c)

Take medication ...................................................................................................

d)

None of the above.................................................................................................

HOW DO YOU CONSIDER YOUR GENERAL STATE OF HEALTH?

a)

8(i)

Good .......................................................................................................................

b)

Moderate ................................................................................................................

c)

Poor ........................................................................................................................

ARE YOU TAKING ANY MEDICATION FOR YOUR SYMPTOMS?

8(ii)

a)

Yes ..........................................................................................................................

b)

No ...........................................................................................................................

ARE YOU/HAVE YOU BEEN TAKING ANY OTHER MEDICATION ?

a)

No ...........................................................................................................................

b)

Yes ..........................................................................................................................
Please specify: ______________________________________________________
___________________________________________________________________

9(i)

HAVE YOU HAD ANY X-RAYS OF YOUR HEAD OR NECK TAKEN?

9(ii)

a)

Yes ..........................................................................................................................

b)

No ...........................................................................................................................

IF YES, WHERE?
_________________________________________________________________________

9(iii) WHAT WAS THE RESULT GIVEN TO YOU

_________________________________________________________________________
_________________________________________________________________________

10.

CAN YOU RELATE YOUR HEADACHES/NECK PAINS TO HAVE STARTED WITH:

Yes
a)

An accident (eg, motor car, sporting, fall) .................................................

b)

Following illness...........................................................................................

c)

Following stress............................................................................................

d)

Prolonged sessions at the computer .........................................................

e)

Following adverse events, please specify .................................................

f)

Other ..............................................................................................................

g)

Cannot relate to anything ............................................................................

No

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G. Zito et al. / Manual Therapy 11 (2006) 118129

128

11.

12.

13.

14.

DID YOUR PROBLEM START:

a)

Suddenly? ..............................................................................................................

b)

Gradually?.............................................................................................................

FOR HOW LONG HAVE YOU SUFFERED FROM HEADACHES?

a)

6 months or less....................................................................................................

b)

6 months to one year ............................................................................................

c)

1 year to 5 years....................................................................................................

d)

5 years to 10 years .................................................................................................

e)

Longer (Specify) ....................................................................................................

HAVE YOU HAD ANY PREVIOUS TREATMENT FOR YOUR HEADACHES/

NECK PAINS?
a)

Yes ..........................................................................................................................

b)

No ...........................................................................................................................

WHAT WAS THE NATURE OF THE TREATMENT?

a)

15.

16.

b)

Medicines/tablets .................................................................................................

c)

Heat/ice and exercise ..........................................................................................

d)

Mobilization/manipulation ................................................................................

e)

Other, please specify ............................................................................................

WHAT WAS THE OUTCOME OF PREVIOUS TREATMENT YOU RECEIVED?

a)

Improvement (state %)........................................................................................

b)

No difference.........................................................................................................

c)

Aggravation (state %) ..........................................................................................

OVERALL, IS YOUR CONDITION:

a)

17.

Advice....................................................................................................................

Getting better?.......................................................................................................

b)

Getting worse?......................................................................................................

c)

Not changing.........................................................................................................

ARE YOU REGULARLY INVOLVED IN SPORT?

a)
b)

No ...........................................................................................................................
Yes ..........................................................................................................................
Please specify: ______________________________________________________
___________________________________________________________________

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