Differentiating migraine, cervicogenic headache and asymptomatic individuals based on physical examination findings: a systematic review and meta-analysis

DOI: https://doi.org/10.1186/s12891- 021- 04595- w

Abstract-Summary Migraine and cervicogenic headache (CGH) are common headache disorders, although the large overlap of symptoms between them makes differential diagnosis challenging.

To strengthen differential diagnosis, physical testing has been used to examine

for the presence of musculoskeletal impairments in both conditions.

This review aimed to systematically evaluate differences in physical examination

findings between people with migraine, CGH and asymptomatic individuals.

The results revealed: a) decreased range of motion [°] (ROM) on the flexion- rotation test (FRT) (17.67, 95%CI:13.69,21.65) and reduced neck flexion strength [N] (23.81, 95%CI:8.78,38.85) in CGH compared to migraine; b) compared to con- trols, migraineurs exhibit reduced flexion ROM [°] (− 2.85, 95%CI:−5.12, −0.58), lateral flexion ROM [°] (− 2.17, 95% CI:−3.75, −0.59) and FRT [°] (− 8.96, 95%CI:−13.22, −4.69), reduced cervical lordosis angle [°] (− 0.89, 95%CI:−1.72, −0.07), reduced pressure pain thresholds over the cranio-cervical region [kg/cm2], reduced neck extension strength [N] (− 11.13, 95%CI:−16.66, −5.6) and increased activity [%] of the trapezius (6.18, 95%CI:2.65, 9.71) and anterior scalene muscles (2.87, 95%CI:0.81,4.94) during performance of the cranio-cervical flexion test; c) compared to controls, CGH patients exhibit decreased neck flexion (− 33.70, 95%CI:−47.23, −20.16) and extension (− 55.78, 95%CI:−77.56,-34.00) strength [N].

The FRT and neck flexion strength could support the differential diagnosis of

CGH from migraine.

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Several physical tests were found to differentiate both headache types from

asymptomatic individuals.

All amendments performed during the review were registered in PROSPERO,

indicating the date and what and why was changed.

Extended: Migraine and cervicogenic headache are common primary and sec-

ondary headaches, respectively [88].

Introduction Migraine and cervicogenic headache are common primary and secondary head- aches, respectively [88].

A previous systematic review analysed the relevance of manual examination in the diagnosis of cervicogenic headache [226] and another compared differences in physical testing between migraine and asymptomatic individuals [227].

No systematic review has summarized all the information available regarding the usefulness of different forms of physical testing to differentiate between each head- ache type and asymptomatic individuals, and especially, between both head- ache types.

The purpose of this systematic review was to determine whether physical exami- nation can be used to: (1) differentiate between people with cervicogenic headache from those with migraine, (2) distinguish people with migraine from asymptomatic individuals and (3) differentiate people with cervicogenic headache from asymp- tomatic individuals.

Methods The inclusion and exclusion criteria of the studies to be included in the review were defined using the PICOS (P: Population; I: Intervention; C: Comparator; O: Outcome(s); S: Study design) framework [228, 229].

Any study about the physical examination of an adult population (> 18 years old) with migraine or cervicogenic headache, as defined by the IHS [88] or CHISG [230, 231], was included.

Studies that included other headache types such as tension-type headache, were considered if data on cervicogenic headache or migraine were reported independently.

Studies which included people suffering from a serious disease or another diag- nosed headache condition not described in the inclusion criteria were not considered. For diagnostic accuracy studies, a different data extraction sheet was used includ- ing author names, year of publication, clinical test assessment, sensitivity and speci- ficity, LR+/LR− and PPV/NPV [232].

Two reviewers (AS and EA) assessed the risk of bias of each study

independently.

Results Reduced range of rotation during FRT in cervicogenic headache patients when compared to migraine patients was shown in the meta-analysis for the FRT (17.67 [95%CI 13.69, 21.65]), which was verified after post-hoc sensitivity analysis, since similar studies were included [233, 234].

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Significant differences were found for the reduction of the CLA in patients with migraine when measured in a standing position (− 0.89, [95%CI −1.72, −0.07]), but not in sitting, both after meta-analysis and post-hoc sensitivity analysis [235, 236].

The assessment of the posterior region of the temporalis muscle (− 0.95 [95%CI −1.15, −0.75]) [237–239], an average of the PPT over multiple sites including the splenius capitis, trapezius, and temporalis (− 0.87 [95%CI 1.44, 0.31]) [240–242] and over the suboccipital muscles (− 0.80 [95%CI −0.85, −0.75]) [239, 243] revealed a significant and homogenous difference between migraine and controls, both before and after the sensitivity analysis.

The only balance measure which could be included for meta-analysis (but not for post-hoc sensitivity analysis) was the average reaction time, measured in seconds, and significant differences were not found [244, 245].

Discussion Our findings suggest that these two physical tests could support the differentiation of cervicogenic headache from migraine; people with cervicogenic headache are more likely to present with reduced range of motion during the FRT and reduced neck flexor strength.

A further finding of the current review was the identification of tests of cervical musculoskeletal impairment which could be used to support the differentiation of people with headache (either cervicogenic headache or migraine) compared to asymptomatic individuals.

Our review of studies highlights previous findings that a positive FRT, but also a pattern of palpable painful upper cervical joint dysfunction associated with a restric- tion of ROM (extension) and with muscle impairment (measured through CCFT) appear to be the best clinical tests in terms of sensitivity and specificity for the detection of cervicogenic headache [234, 246, 247].

Conclusion We identified two measures of cervical musculoskeletal impairment that could help to differentiate between cervicogenic headache and migraine: the FRT and neck flexion strength.

Given the presence of a wide range of musculoskeletal impairments in both headache types, physical findings alone cannot provide a definitive diagnosis of cervicogenic headache versus migraine.

Further high-quality studies are required before definitive conclusions can be made about the role of physical testing in the differentiation of cervicogenic head- ache and migraine.

Acknowledgement A machine generated summary based on the work of Anarte-Lazo, E.; Carvalho, G. F.; Schwarz, A.; Luedtke, K.; Falla, D. 2021 in BMC Musculoskeletal Disorders.

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