14 March 2023: Clinical Research
Headache Characteristics in Chronic Neck Pain Patients with Loss of Cervical Lordosis: A Cross-Sectional Study Considering Cervicogenic HeadacheVeysel Delen 1ABCDEFG*, Server İlter 2BCDEFG
Med Sci Monit 2023; 29:e939427
BACKGROUND: Loss of cervical lordosis and cervicogenic headache have similar tissue abnormalities, including weakness and atrophy in the neck muscles. Cervicogenic headache is mainly unilateral and is perceived in the occipito-temporo-frontal regions. However, it is not clear whether loss of cervical lordosis is a sign of headache with cervical origin. Herein, we aimed to assess and compare headache characteristics in patients with and without loss of cervical lordosis.
MATERIAL AND METHODS: This was a cross-sectional study conducted on chronic neck pain patients with (n=38; F/M: 28/10; mean age 33.34±7.73 yrs; range 18 to 45 yrs) and without loss of cervical lordosis (n=38; F/M: 29/9; mean age 33.13±6.41 years; range 20 to 45 years), between May 2019 and November 2019. The 2 groups were assessed and compared for headache characteristics such as frequency, severity, localization, lateralization, duration, and spread scores. Cervical lordosis was assessed on the lateral cervical radiographs by using posterior tangent technique measuring the C2-C7 total cervical spine angle.
RESULTS: The 2 groups were similar for individual features, including age, sex, employment status, and duration of neck pain (P>0.05). The duration of headache attack was longer in patients with loss of cervical lordosis (5.72±8.12) than in those with normal cervical lordosis (3.29±3.92) (P=0.009). However, there were no significant differences between the 2 groups for headache characteristics, including frequency, severity, localization, lateralization, and spread scores (P>0.05).
CONCLUSIONS: Patients with loss of cervical lordosis have longer duration of headache attack than those without. Loss of cervical lordosis may be a specific finding associated with longer cervicogenic headache attacks.
Keywords: Neck Pain, Lordosis, Myofascial Pain Syndromes, Headache Disorders, Pain Clinics, Humans, Adult, Post-Traumatic Headache, Cross-Sectional Studies, Headache, Cervical Vertebrae
Loss of cervical lordosis leads to mechanical overload, structural degeneration, and reduced vertebral artery hemodynamics in the cervical region [1,2]. Although its etiology has not been fully elucidated, neck extensors’ weakeness or atrophy may be causative factors [3,4]. Some treatment options such as neck extensor exercises, cervical spinal manipulation, and extension traction have been found to be useful in correcting loss of cervical lordosis and alleviating clinical symptoms, including neck pain and dizziness [1,5,6].
It has been suggested that loss of cervical lordosis may be related to cervicogenic headache . Really, it was shown that loss of cervical lordosis and cervicogenic headache have similar soft-tissue abnormalities, including weakness and atrophy in the neck muscles [3,4,8,9]. Also, neck-targeted therapies have been found to be useful in the treatment of both conditions [1,5,6,10–13]. However, the effectiveness of treatments for cervicogenic headache depend on the true etiopathogenesis, proper clinical approach, and definitive diagnosis [12–14].
Although cervicogenic headache shows heterogeneous clinical features , it is mainly unilateral and perceived in the occipito-temporo-frontal regions . However, headache characteristics of patients with loss of cervical lordosis are not known, and it is not clear whether the clinical features of cervicogenic headache occur in the presence of loss of cervical lordosis. In addition, unilateral headache may arise from facial, cervical, or cranial structures, and due to clinical overlaps between headaches, cervical origin requires evidence [17,18]. Therefore, there are many challenges of definitive and differential diagnosis of headaches, and a more specific finding is required for cervical origin of headache . In this respect, loss of cervical lordosis has been put forward as a diagnostic biomechanical biomarker for cervicogenic headache . However, it is not known whether headache characteristics in the loss of cervical lordosis are compatible with cervicogenic headache.
Herein, we hypothesized that loss of cervical lordosis may be related to headache characteristics, and headache characteristics may be different in the presence of loss of cervical lordosis. Therefore, we aimed to assess and compare the headache characteristics in neck pain patients with and without loss of cervical lordosis.
Cosidering its similar features with cervicogenic headache [3,4,8,9], and given its negative effects on cervical structures and functions [1,2], it is important to explore headache characteristics for loss of cervical lordosis. If a difference in its headache characteristics can be revealed, loss of cervical lordosis may be accepted as a sign of headache with cervical origin. There is a need for a specific finding of cervicogenic headache , and determining headache characteristics of loss of cervical lordosis may facilitate diagnosis and treatment processes.
Materıal and Methods
This was a cross
A total of 76 patients with chronic neck pain (pain duration >3 months) who had a headache experience at least once within the last month included were in the study (n=76; 19 males, 57 females; mean age 33.24±7.05 years; range 18 to 45 years).
The study group consisted of chronic neck pain patients with loss of cervical lordosis (n=38; 10 males, 28 females; mean age 33.34±7.73 years; range 18 to 45 years). The comparison group consisted of age-, sex-, and body mass index-matched chronic neck pain patients with normal cervical lordosis (n=38; 9 males, 29 females; mean age 33.13±6.41 years; range 20 to 45 years).
Headache characteristics were determined and recorded in a structured interview. The patients were questioned by an experienced expert clinician (physician and physiatrist) about their headache characteristics such as frequency, severity, duration of attack, and localization, lateralization, and spread features including unilateral, occipital, temporal, frontal, and orbital. Headache intensity was evaluated using a validated visual analog scale (VAS). The patients selected their pain level on a horizontal line between 0 (no pain) and 10 cm (very severe pain) . The 2 groups were analyzed and compared in terms of the headache characteristics.
EVALUATION OF CERVICAL LORDOSIS:
Standard cervical radiographs of the patients were taken to evaluate the cervical spine. To diagnose loss of cervical lordosis, the total cervical curvature was measured using posterior tangent technique, which refers to the angle between 2 lines drawn along the posterior surfaces of the C2 and C7 vertebrae [1,20]. We defined and classified the total cervical curvature as follows: lordotic (less than −4°) (Figure 1A), loss of cervical lordosis (+4° to −4°) (Figure 1B), and kyphotic (more than +4º) (Figure 1C) [1,20]. Harrison et al  have shown that the posterior tangent technique has better intra- and inter-observer reliability than the four-line Cobb methods.
Patients aged <18 or >45 years or who had the following medical conditions were excluded: acute neck pain (pain duration ≤3 months), cervical kyphosis (lordosis angle >+4º), cervical vertebral anomalies, sigmoid cervical spine, cardiovascular disorders such as hypertension, inflammatory rheumatic diseases, neck injury or surgery, iron-deficiency anemia, pregancy, lactation, and psychiatric illness.
Patients aged ≥18 or ≤45 years, female or male, who had the following medical conditions were included: chronic neck pain (pain duration >3 months), who had a headache experience at least once within the last month. Also, written informed consent was obtained for participation and for cervical radiographs. The exclusion and inclusion criteria were applied by an experienced expert clinician (physician and physiatrist) (V.D.).
G*Power version 3.08 software (Heinrich-Heine Universität Düsseldorf, Düsseldorf, Germany) was used to evaluate the study power. The study power was calculated based on the sample size. For each group, a total of 38 patients were provided to achieve an effect size of 0.7, a power of 0.85, and a significance level of 0.05 .
All statistical analyses were conducted using SPSS 20.0 for Windows (Armonk, NY: IBM Corp.). Normal distribution of continuous variables was assessed using the Kolmogorov-Smirnov normality test. In the comparisons, the
Figure 2 presents the flow diagram demonstrating the study progression. A total of 130 chronic neck pain patients who had a headache experience at least once within the last month were screened for eligibility. Out of the 109 patients who meet the eligibility criteria, 76 were included in the study (38 cases and 38 controls) (Figure 2).
Table 1 presents individual features of participants. In both groups, most patients were female (73.7–76.3%. The 2 groups were similar with respect to individual features such as age (
Figure 3 and Table 2 present headache characteristics of participants. There were no significant differences between the 2 groups in headache characteristics such as frequency (
No significant linear correlation was found between cervical lordosis angle and the headache characteristics, including frequency, severity, and attack duration scores (for all,
In this study, headache characteristics in chronic neck pain patients were assessed and compared according to the presence and absence of loss of cervical lordosis. The results showed that there was no a difference between patients with and without loss of cervical lordosis in terms of the headaches characteristics, including frequency, duration, severity, localization, lateralization, and spread scores. However, the duration of headache attack was longer in patients with loss of cervical lordosis.
The longer duration of headache attack in patients with loss of cervical lordosis may be associated with weakened neck extensors and decreased vertebral artery hemodinamics, which have been detected in patients with loss of cervical lordosis [2,3]. However, the correlation between cervical lordosis angle and headache attack duration was not statistically significant. For this reason and considering the finding that longer headache in patients with loss of cervical lordosis has been found, the results need to be confirmed by new studies. Previous studies have stated that cervicogenic headache is mainly unilateral and is perceived-spread in the occipital, temporal, frontal, and orbital regions [16,23]. We found that orbital pain frequency tended to increase in patients with loss of cervical lordosis but did not reach statistical significance. As a result, the 2 groups in our study were similar for headache regions.
It has been suggested that loss of cervical lordosis may be a diagnostic biomechanical biomarker for cervicogenic headache . Indeed, both loss of cervical lordosis and cervicogenic headache have similar soft-tissue abnormalities, including weakness and atrophy in the neck muscles [3,4,8,9]. Moreover, loss of cervical lordosis is associated with structural and functional negative effects on the cervical region such as mechanical overload, degenerative changes, disc herniation, and reduced vertebral artery hemodynamics [1,2,24]. These suggest a potential of loss of cervical lordosis as a sign of headache with cervical origin. However, headache characteristics of patients with loss of cervical lordosis are not clear, and it is not known whether headache in patients with loss of cervical lordosis is compatible with cervicogenic headache. Therefore, it was important to explore headache characteristics for loss of cervical lordosis.
The data explained above suggest a logical suspicion for researching a possible association between loss of cervical lordosis and headaches characteristics. Although a positive association of headaches with neck pain and a high prevalence of neck pain in individuals with headache have been reported [25,26], to our knowledge, no known previous study has investigated headaches characteristics in patients with chronic neck pain, considering loss of cervical lordosis specifically. It was important to reveal a difference in headache characteristics, and this could have been a sign of headache with cervical origin for loss of cervical lordosis.
On the other hand, there are certain potential limitations to this study that should be discussed in terms of generalizability of the findings. The present study has the advantages and disadvantages of a cross-sectional design. Because this study was performed on patients with chronic neck pain and since we did not include a painless control group, a possible effect of chronic neck pain on headache characteristics cannot be ruled out. Considering that patients older than 45 years are often affected by degenerative changes, only patients below 45 years old were included in this study. Thus, a possible effect of age-related cervical osteoarthritis on headache has been eliminated. In addition, thanks to selection criteria used in the study design such as age (>18–<45 years), diagnosis angle for loss of cervical lordosis (+4° to −4°), and neck pain duration (chronic, >3 months), the study has a strong homogeneity. Due to lack of prior studies on the topic, we could not compare different studies. This limitation also shows a need for further research. Finally, this study is based on self-reported data used to evaluate headache characteristics experienced within the last month. Therefore, new studies with prospective design are required on the topic. Further research is needed to assess the frequency of loss of cervical lordosis in patients with cervicogenic headache and its effects on cervicogenic headache severity.
In conclusion, the duration of headache attack is longer in neck pain patients with loss of cervical lordosis than in those with normal cervical lordosis. However, it seems that loss of cervical lordosis, as a specific finding, is not related to headaches characteristics, including frequency, severity, localization, lateralization, and spread. Loss of cervical lordosis may be a specific finding relating with longer cervicogenic headache.
FiguresFigure 1. (A) Normal cervical lordosis. (B) Loss of cervical lordosis. (C) Cervical kyphosis. Figure 2. Flow diagram of the study. * Chronic neck pain patients who had headache experience within last month. Figure 3. Headache characteristics in patients with and without loss of cervical lordosis.
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