ABSTRACT
Background
Cervicogenic headache is a common condition frequently associated with cervical spine disorders. It significantly impairs physical and psychological well-being. To date, no study has prospectively investigated the predictors of Cervicogenic headache. Identifying these predictors is essential for early intervention and the development of targeted management strategies.
Purpose
To examine the predictors of cervicogenic headache in patients with chronic neck pain at the 6-month follow-up period.
Methods
A prospective study was conducted. A total of 321 patients with chronic neck pain were selected for this study. Data were collected at baseline and at the 6-month follow‐up. Cervical X-rays were taken to assess the Cervical Cobb angle, and self-reported questionnaires were used to assess sleep quality, pain intensity, depression, anxiety, fatigue, and disability in patients with chronic neck pain. Binary logistic regression and Mann–Whitney U test were employed for the analysis.
Results
The study found that cervical Cobb angle 95% CI (.85, .96), p = .001, sleep quality 95% CI (1.32, 1.81), p < .001, depression 95% CI (1.09, 1.55), p = .003 and anxiety 95% CI (1.15, 1.59), p < .001 were significant predictors of cervicogenic headache in patients with chronic neck pain at 6-month follow-up period.
Conclusion
Our results suggest that altered cervical Cobb angle, poor sleep quality, and psychological status may serve as potential predictors of cervicogenic headache in patients with chronic neck pain. These findings highlight the importance of a comprehensive approach to managing cervicogenic headache and neck pain that addresses both physical and psychological factors. By targeting these comorbidities, health-care providers may be able to improve outcomes and prevent the development of cervicogenic headache in patients with chronic neck pain.
Registration number (PHRC/HC/1339/23)
The study was registered in August 2023.
KEYWORDS: Chronic neck pain, Cobb angle, cervicogenic headache, sleep, anxiety
Introduction
Cervicogenic headache (CeH) is a prevalent and debilitating condition manifested by headache pain that originates in the area of the cervical spine and radiates to different parts of the head [1]. CeH is typically exacerbated by cervical movement or external pressure and is commonly associated with neck pain [2]. Prevalence estimates of CeH range from 0.17% to 2.5% in the general population [3], but rates can be as high as 53% in patients with a history of whiplash injury [4], and 86–88% in patients with cervical diseases who underwent anterior cervical surgery [5,6]. CeH has a significant burden on patients’ quality of life and it affects daily functioning and overall well-being [7]. The mechanism of this condition is thought to involve the convergence of sensory input from the upper cervical spinal nerves (C1, C2, and C3) and trigeminal nerves within the trigeminocervical nucleus located in the upper cervical spinal cord [8]. Additionally, it was demonstrated that disc prolapse of the lower cervical spine may cause CeH [9]. These findings highlight that CeH is a common comorbidity in patients with cervical spine disorders; however, the potential risk factors for this condition among patients with chronic neck pain are poorly understood.
A recent study has shown that the cervical spine plays a significant role in the mechanism of CeH [1]. Loss or reduction of cervical lordosis (reversal of normal curvature of the cervical spine) has been implicated in different types of headaches. For example, a reduction in cervical lordosis, as indicated by a Cervical Cobb angle of less than 20 degrees, has been associated with CeH [10,11]. It has been suggested that alterations in normal curvature of the cervical spine might lead to increased mechanical strain and stress on different sensitive cervical soft tissues, potentially triggering CeH [1,12]. Comparisons have shown that patients with cervical spine disorders who were scheduled for spinal surgery and had CeH frequently reported higher levels of neck pain, more limited cervical range of motion, and greater disability levels than those with cervical spine disorders without CeH [13]. Furthermore, among cervical spine disorders, CeH prevalence is notably higher in patients with cervical spondylotic myeloradiculopathy and neck pain [13].
Psychological factors such as depression and anxiety have been recognized as risk factors of neck pain [14] as well as symptoms of headache [15]. Anxiety symptoms may increase muscle tension and pain perception [16], thus possibly contributing to the development of headache. Patients with chronic neck pain frequently showed high levels of anxiety and depression [17], indicating a bidirectional association between chronic neck pain and anxiety. Understanding the role of psychological factors in the development of CeH may inform holistic management strategies that address both psychological aspects and physical aspects of CeH and chronic neck pain. Also, sleep disturbance is an important factor associated with both chronic neck pain [18] and headache [19], yet its role in CeH remains unexplored. Understanding sleep quality’s impact on CeH may clarify underlying mechanisms and guide more targeted management strategies of this condition.
Despite the negative consequences caused by CeH, the potential predictors of this condition among patients with chronic neck pain are poorly documented in the literature [13]. Understanding these predictors is important for enhancing diagnostic accuracy and implementing effective treatment protocols for patients experiencing CeH and chronic neck pain. To the best of our knowledge, no study in the English literature has studied the predictive value of cervical Cobb angle, sleep quality, psychological factors, pain intensity and disability for cervicogenic headache in patients with chronic neck pain over 6-month follow-up period. So, we aimed to examine these relationships.
Methods
Study population and procedure
A prospective study with a 6-month follows-up was conducted on 384 patients with chronic neck pain without symptoms of cervicogenic headache. This study forms part of a larger research aimed at identifying the risk factors for CeH. In the subsequent phase, the study will examine the impact of physiotherapy interventions on these identified factors and related clinical outcomes.
Chronic neck pain was defined based on patient self-report of continuous and persisting neck pain for more than 3 months [20], consistent with widely accepted clinical criteria. All patients were referred by specialized health-care practitioners – either orthopedic or neurological doctors – for cervical X-rays and for receiving physiotherapy treatment as part of their management. The patients were recruited from various outpatient clinics, orthopedic and physiotherapy clinics in the Gaza Strip, Palestine. The data were collected at baseline between August 2023 and April 2024. The 6-month follow-up was completed in November 2024.
All patients who attended the physiotherapy outpatient clinics after being referred and had cervical X-ray during the recruitment period were screened for eligibility. Inclusion and exclusion criteria were applied to all patients during the initial screening to ensure that only participants meeting the study requirements were enrolled.
Sample size calculations
A previous study reported that 53% of patients with whiplash-associated neck pain develop CeH [4]. Based on this prevalence estimate, the sample size for the present study was calculated using the OpenEpi online software employing the formula for a finite population with the following parameters: a confidence level of 90% (Z = 1.645), a margin of error of 5%, and an estimated prevalence (p) of 0.53. The resulting minimum required sample size was 270 participants. To ensure adequate power and account for potential dropouts or incomplete data, a total of 321 participants were ultimately recruited.
Inclusion and exclusion criteria
At baseline, the participants were included if they were
1- (1) Aged ≥ 18 and < 60 years.
2- Diagnosed with chronic neck pain (pain ≥3 months).
They were excluded if they had any of the following
1- Spinal pathology, trauma, deformity, or fracture.
2- Any underlying medical disease or disorders.
3- Coexistence of musculoskeletal pain, such as shoulder, knee, or low back pain.
4- Pregnancy.
5- Patients with present/prior history of primary and secondary headache disorders (migraine, tension-type headache, and CeH), any diagnosed psychological or psychiatric conditions, history of sleep disorders or taking medications known to affect sleep patterns or psychological status.
The patients were diagnosed with cervicogenic headache if they met the diagnostic criteria for cervicogenic headache outlined: symptoms of head involvement, unilaterality without shifting of head pain, non-throbbing pain starting in the neck region, pain starting in the cervical area, spreading to oculo-frontotemporal areas and manual provocation of symptoms [21]. At 6-month follow-up, patients were reassessed for their cervicogenic headache symptoms through home visits or in-person assessments at the physiotherapy outpatients’ clinics, depending on the availability of the patients. We assessed the incidence of cervicogenic headache.
After the research details were explained, participants signed the consent form. Participants completed a screening form to assess their characteristics. The form contained the study questionnaires to assess the quality of sleep, pain intensity, fatigue, psychological factors, and disability. A lateral cervical X-ray was taken to assess the cervical Cobb angle.
Outcomes measures
Cervical Cobb angle
The Cervical Cobb angle was assessed using a lateral radiograph (X-ray) of the cervical spine. It was measured between the second and seventh cervical vertebrae. The Cervical Cobb angle was measured by drawing two lines (parallel lines), one toward the lower endplate of the second cervical vertebrae (C2) and the second to the lower end of the seventh cervical vertebrae (C7). The angle was calculated by drawing these two orthogonal lines to each of these lines and calculating the intersection angle [22]. It has been shown that the normal cervical lordosis angle is between 30° and 40° when assessing the two lines intersecting the posterior parts of C2 and C7, and the cervical lordosis angle of less than 20° was associated with the development of cervicogenic symptoms [10,11].
Sleep quality
Quality of sleep was evaluated by using the Pittsburgh sleep quality index (PSQI). PSQI contains 19‐domains, which are divided into seven headings: duration of sleep, sleep disturbance, sleep latency (SL), self‐reported sleep quality, sleep efficiency (SE), taking sleep medications, and daytime dysfunction. PSQI has a score range between 0 and 21. A score of >5 on PSQI indicates a poor sleep quality [23]. The Pittsburgh Sleep Quality Index (PSQI) demonstrated good internal consistency reliability, with a Cronbach’s alpha coefficient of 0.80 across study groups. Additionally, the construct validity of the PSQI was supported by moderate to high correlations between the global score and its component scores [24].
Pain intensity
Intensity of pain was assessed by the Numerical Pain Rating Scale (NPRS). NPRS is a widely used instrument in clinical research. NPRS has a series of numbers (0–10) to indicate the pain intensity where 0 reflects no pain and 10 reflects the maximum pain intensity [25]. The NPRS showed moderate reliability (ICC = 0.72; 95% CI: 0.08–0.90). It also demonstrated good responsiveness (AUC = 0.78–0.93) and acceptable construct validity (p < 0.001) in patients with cervicogenic headache [26].
Psychological factors
The psychological factors (depression and anxiety) were evaluated by using the Hospital Anxiety and Depression Scale (HADS). HADS has 14 domains: 7 domains were used to assess anxiety, and 7 for depression. Each question has four answers (0–3), yielding a global score range between 0 and 21. The higher the score, the higher the severity of anxiety and depression [27]. HADS was a valid and reliable measure of overall emotional distress in patients with chronic pain [28].
Fatigue
The Multidimensional Fatigue Inventory index (MFI) was utilized to assess fatigue severity among the participants. MFI contains a set of 20 questions to assess mainly five domains of fatigue symptoms (general fatigue, reduced activity, physical fatigue, mental fatigue, and motivation). Each domain has five items, with scores ranging from 4 to 20 (total score: 20–100) [29]. A score of ≥13 in the general fatigue domain was identified as the cut‐off for severe fatigue [30]. The MFI-20 is a valid and reliable tool for assessing fatigue in both patients and healthy individuals [31].
Level of disability
The level of disability was assessed by the neck disability index (NDI). NDI has 10 questions to assess the patient’s pain‐related restrictions in daily activities. Each question has a score (0–5). The global score of NDI ranges between 0 and 50, and the higher score implies a higher level of disability [32]. The NDI demonstrated excellent reliability (ICC = 0.92; 95% CI: 0.46–0.97), strong responsiveness (AUC = 0.78–0.93), and good construct validity (p < 0.001) in patients with cervicogenic headache [26].
Statistical analysis
The Statistical Package for the Social Sciences 27.0 (SPSS Inc., Chicago, Illinois) was used for analysis. Descriptive statistics were utilized to present the study sample characteristics. Binary logistic regression was employed to identify risk factors of CeH in patients with chronic neck pain. The dependent variable for the regression model was the binary CeH status (0 = no headache, 1 = CeH). Based on histograms and normality tests, the data did not follow a normal distribution. Thus, Spearman’s correlation was applied before the regression analysis to identify significant relationships between the dependent variable. The variables that showed a significant correlation with the dependent variable were included in the logistic regression model. In contrast, those variables that did not show a significant correlation with the dependent variable were excluded. The Mann–Whitney U test was applied to compare cervical Cobb angle and psychological and clinical variables between patients with and without cervicogenic headache.
Results
Participants
Out of the initial 384 patients with chronic neck pain who were recruited at baseline, 321 were successfully followed up at the 6‐month mark. Therefore, the percentage lost to follow-up was 16.4% (n = 63). They were lost due to non-response. Cervical Cobb angle data were obtained via lateral X-ray. Sleep quality, pain intensity, fatigue, disability, anxiety, and depression were assessed using validated questionnaires. Table 1 explains the participants characteristics and descriptive data, respectively
Table 1.
Demographics and characteristics for patients with chronic neck pain.
| Variable | Category/Statistic | Number (Percentage %) |
|---|---|---|
| Marital Status | Married | 192 (59.8%) |
| Single | 129 (40.2%) | |
| Gender | Female | 221 (68.8%) |
| Male | 100 (31.2%) | |
| Education | Secondary | 89 (27.7%) |
| Undergraduate | 190 (59.2%) | |
| Postgraduate | 42 (13.1%) | |
| Smoking | No | 89 (27.7%) |
| Yes | 232 (72.3%) | |
| Alcohol | No | 301 (93.8%) |
| Yes | 20 (5.2%) | |
| Lordosis (degrees) | ≥40 | 4 (1.2%) |
| 35–40 | 25 (7.8%) | |
| 27–35 | 151 (47.0%) | |
| 17–27 | 141 (43.9%) | |
| Sleep Quality | Normal (0–5) | 194 (60.4%) |
| Mild Disturbances (6–8) | 109 (34.0%) | |
| Moderate Disturbances (9–12) | 18 (5.6%) | |
| Severe Disturbances ( > 12) | 0 (0%) | |
| Depression | Normal (0–7) | 214 (66.7%) |
| Borderline (8–10) | 106 (33.0%) | |
| Case (11–21) | 1 (0.3%) | |
| Anxiety | Normal (0–7) | 200 (62.3%) |
| Borderline (8–10) | 117 (36.4%) | |
| Case (11–21) | 4 (1.2%) | |
| Fatigue | 0–12 | 280 (87.2%) |
| ≥13 | 41 (12.8%) | |
| Headache Incidence | No | 207 (64.5%) |
| Yes | 114 (35.5%) | |
| Treatment received | Exercises + Hot pack + Electrotherapy | 114 (34.1%) |
| Exercises + Hot pack + Electrotherapy + Anti-inflammatory medicine | 138 (41.3 %) | |
| Discontinue physiotherapy sessions | 50 (15 %) | |
| Exercises + Manipulative therapy + Hot pack + Electrotherapy + Anti-inflammatory medicine | 19 (5.7%) | |
| Age (years) | Mean ± SD (95% CI) | 32.49 ± 6.41 (31.79–33.20) |
| Median/IQR | 32/8 | |
| BMI (kg/m2) | Mean ± SD (95% CI) | 24.32 ± 3.21 (23.79–24.67) |
| Median/IQR | 24.2/3.9 | |
| Cervical Cobb angle (degrees) | Mean ± SD (95% CI) | 28.6 ± 5.1 (28.04–29.16) |
| Median/IQR | 28/7.3 | |
| Sleep Quality Score | Mean ± SD (95% CI) | 5.09 ± 2.01 (4.87–5.31) |
| Median/IQR | 5/3 | |
| Depression Score | Mean ± SD (95% CI) | 6.24 ± 1.9 (6.03–6.45) |
| Median/IQR | 6/3 | |
| Anxiety Score | Mean ± SD (95% CI) | 6.42 ± 2.02 (6.2–6.65) |
| Median/IQR | 7/3 | |
| Fatigue Score | Mean ± SD (95% CI) | 10.21 ± 2.16 (9.97–10.44) |
| Median/IQR | 10/3 | |
| Pain Score | Mean ± SD (95% CI) | 4.58 ± 1.35 (4.43–4.72) |
| Median/IQR | 4/2 | |
| Neck Disability Index | Mean ± SD (95% CI) | 0.25 ± 0.11 (0.24–0.23) |
| Median/IQR | 0.23/0.14 | |
| Pain Duration (Months) | Mean ± SD (95% CI) | 4.9 ± 1.69 (4.71–5.09) |
| Median/IQR | 5/2 |
Spearman’s correlation analysis showed that the presence of headache was significantly associated with several clinical and psychological variables. There was a negative correlation with cervical Cobb angle (r = −0.231, p < 0.01), indicating a tendency toward reduced cervical curvature among participants with headaches. Positive significant correlations were observed with sleep quality (r = 0.368, p < 0.01), depression (r = 0.384, p < 0.01), anxiety (r = 0.329, p < 0.01), and pain severity (VAS) (r = 0.168, p < 0.01). Thus, these variables were included in the regression model.
In contrast, non-significant correlations were found with severe fatigue (r = 0.066, p > 0.05), age (r = 0.013, p > 0.05), BMI (r = −0.080, p > 0.05), marital status (r = −0.029, p > 0.05), gender (r = −0.021, p > 0.05), smoking (r = 0.023, p > 0.05), neck disability index (NDI) (r = −0.008, p > 0.05), and duration of symptoms (r = 0.010, p > 0.05). Additionally, the results revealed a non-significant positive correlation between treatment type and incidence of CeH (r = 0.10, p = 0.07), indicating that the type of treatment received was not significantly associated with the development of CeH. Thus, we excluded variables without significant associations with headache incidence at 6-month follow-up to ensure model parsimony and focus on relevant predictors.
When participants were stratified by CeH status (with and without cervicogenic headache), significant differences were observed in several clinical and psychological variables. Significant differences were found between the groups in cervical Cobb angle, sleep quality, depression, anxiety, and pain scores (p < .05), with the headache group consistently showing poorer outcomes Table 2.
Table 2.
Comparison of clinical and psychological outcomes between patients with and without cervicogenic headache.
| Group | Range | Mean | SD | Variance | p | |
|---|---|---|---|---|---|---|
| Cervical Cobb angle | No Headache | 23 | 29.479 | 4.7835 | 22.882 | <.001 |
| Headache | 24 | 27.011 | 5.2974 | 28.062 | ||
| Sleep Score | No Headache | 6 | 4.48 | 1.507 | 2.27 | <.001 |
| Headache | 9 | 6.19 | 2.334 | 5.449 | ||
| Depression | No Headache | 9 | 5.71 | 1.752 | 3.071 | <.001 |
| Headache | 9 | 7.21 | 1.797 | 3.23 | ||
| Anxiety | No Headache | 9 | 5.93 | 1.888 | 3.563 | <.001 |
| Headache | 9 | 7.32 | 1.939 | 3.761 | ||
| Fatigue | No Headache | 11 | 10.05 | 1.999 | 3.998 | 0.236 |
| Headache | 11 | 10.49 | 2.41 | 5.81 | ||
| Pain Score | No Headache | 6 | 4.4 | 1.269 | 1.61 | 0.003 |
| Headache | 6 | 4.89 | 1.441 | 2.077 | ||
| Disability | No Headache | 0.7 | 0.255803 | 0.117105 | 0.014 | 0.887 |
| Headache | 0.46 | 0.245504 | 0.090229 | 0.008 | ||
| Duration of neck pain | No Headache | 6 | 4.879 | 1.6627 | 2.764 | 0.855 |
| Headache | 6 | 4.939 | 1.7437 | 3.04 |
SD = Standard Deviation, p = significant level.
Incidence of CeH in patients with chronic neck pain at 6-month follow-up
At 6-month follow-up, 207 patients (64.5%) patients with chronic neck pain did not develop CeH symptoms, and 114 (35.5%) out of the initial 321 reported CeH symptoms.
Predictor of cervicogenic headache symptoms in patients with chronic neck pain
Binary logistic regression was employed to examine the potential risk factors (cervical Cobb angle, sleep quality, anxiety, depression, and pain) as baseline predictors of CeH in the development of CeH. The results showed that cervical Cobb angle, sleep quality, depression, and anxiety were significant predictors of CeH. The cervical Cobb angle was negatively associated with CeH (B = −0.099, SE = 0.03, p = 0.001), with an odds ratio of 0.90 (95% CI: 0.85–0.96), indicating that each one-degree change in cervical Cobb angle decreased the odds of having CeH by 10%. Sleep Quality showed a positive association (B = 0.43, SE = 0.08, p < 0.001), with an odds ratio of 1.54 (95% CI: 1.32–1.81), indicating that each 1-point increase in PSQI score (worse sleep) increased CeH odds by 54%. Similarly, higher levels of depression (B = 0.27, SE = 0.08, p = 0.003; Exp(B) = 1.30, 95% CI: 1.09–1.55) and anxiety (B = 0.30, SE = 0.08, p < 0.001; Exp(B) = 1.35, 95% CI: 1.15–1.59) significantly increased the odds of CeH. Table 3 explains the regression model.
Table 3.
Predictors of cervicogenic headache in patients with chronic neck pain.
| |
B |
S.E. |
Sig. |
Exp(B) |
95% C.I.for EXP(B) |
|
|---|---|---|---|---|---|---|
| Lower | Upper | |||||
| Cervical Cobb angle | −0.099 | 0.03 | 0.001 | 0.90 | 0.85 | 0.96 |
| Sleep Quality | 0.43 | 0.08 | >.001 | 1.54 | 1.32 | 1.81 |
| Depression | 0.27 | 0.08 | 0.003 | 1.30 | 1.09 | 1.55 |
| Anxiety | 0.30 | 0.08 | >.001 | 1.35 | 1.15 | 1.59 |
| Pain | 0.10 | 0.11 | 0.38 | 1.11 | 0.88 | 1.38 |
Significant at 5%. Abbreviations: B: unstandardized beta; DF: degree of freedom., S.E: Standard Error; Exp (β), the exponentiation of the β coefficient; CI, confidence Interval.
Discussion
Our study intended to examine the predictive value of cervical Cobb angle, sleep quality, psychological status, pain intensity, fatigue, and disability for CeH in patients with chronic neck pain over a 6-month follow-up period. Our results revealed that reduced cervical Cobb angle, poor sleep quality and anxiety were significant predictors of CeH in patients with chronic neck pain at 6-month follow-up. These findings highlighted the multifactorial nature of this condition and underscored the importance of a thorough and comprehensive strategies to its management and treatment. A previous study included 70 patients with cervical spine disorders who had been scheduled to undergo surgery [13]. The study identified potential predictors for CeH including limited cervical range of motion, neck pain severity, and high disability score [13].
The relationship between cervical Cobb angle and CeH is characterized by an inverse correlation, where changes in cervical spine curvature, including the reduction in Cobb angle, are associated with the occurrence of CeH [33]. This relationship is supported by multiple studies that highlight the role of cervical spine alignment in the pathophysiology of CeH [12]. The cervical Cobb angle, which measures the curvature of the cervical spine, is a critical factor in understanding the mechanical and structural contributions to CeH. Our study found that the reduction of cervical Cobb angle emerged as a significant risk factor for CeH. A study found that the narrowing of the craniovertebral angle is associated with increased pain scores in cervicogenic headache patients [34]. Previous study has reported that alternations in cervical alignment were correlated with headache symptoms [35]. Furthermore, it has been demonstrated that cervicogenic headache is associated with altered normal alignment of cervical spine [10,11,36].
The correlation between posture, Cobb angle, and headache severity in individuals with chronic neck pain is complex and multifaceted. Research indicates that abnormal spinal posture, particularly in the cervical region, may influence the severity of headaches. A study on head posture indicated a negative correlation between craniovertebral angle and pain intensity, implying that poor head posture may exacerbate neck pain and potentially headaches [37]. A previous case study supported the relevance of addressing forward head posture and thoracic hyper kyphosis as contributing factors to cervicogenic headache symptoms. The report highlighted that early postural correction could prevent long-term musculoskeletal complications [38]. Another study found that individuals with CeH exhibited significant differences in 3D spinal alignment compared to asymptomatic controls, indicating that postural displacements may be correlated with the presence of headaches [39].
It is feasible that cervical spine malalignment may result in abnormal stresses and strains in the cervical area [2]. Once this state is maintained for a prolonged period, an increase in degenerative changes in the cervical spine can occur [40], which can lead to the development of CeH symptoms. This was partially supported by recent evidence that surgical approaches for cervical spine degenerative disease can relieve associated cervicogenic headache symptoms [41]. This finding highlights the importance of maintaining a normal cervical spine posture and emphasizes the possible benefits of physical therapy programs, exercises, and manual therapy interventions that aim to restore proper alignment of the cervical spine. Such interventions can help prevent or reduce the likelihood of developing CeH symptoms in the future.
Also, our study found that poor sleep quality was a significant risk factor of CeH. Poor sleep quality is common in patients with chronic neck pain [18], and patients suffering from headache symptoms [19]. Limited research has examined the role of poor sleep quality in predicting CeH, leaving this area inadequately researched. A recent study recruited a small number of CeH patients (n = 18) found that patients with CeH reported worse sleep quality and headache-related quality of life compared to the participants in the control group [42]. The relationship between poor sleep quality and headache symptoms have been documented [43]. A literature review recognized poor sleep and oversleeping as triggers of headache symptoms [44]. Also, previous research showed a strong relationship between the severity of headaches and poor sleep [45]. The convergence of poor sleep and headache was believed to be based on common neuroanatomy, primarily in the hypothalamus, influenced by orexins and melatonin [46]. Central sensitization was thought to be a key process in the pathophysiology of the chronic form of tension-type headache [47]. Poor sleep and resulting fatigue symptoms can lead to sympathetic activation to boost metabolic processes for the availability of energy, and the subsequent sympathetic activation may perpetuate and precipitate headache symptoms [46]. It appears that intervention approaches aimed at enhancing sleep, such as physical activity programs, cognitive behavioral therapy and sleep hygiene, may therefore be of benefits for patients with chronic neck pain who are at risk of developing CeH.
Furthermore, our findings showed that the psychological factors (anxiety and depression) were significant predictors of CeH. This result suggests that psychological aspects play a significant role in the development of CeH in patients with chronic neck pain. Previous research has revealed a relationship between psychological factors and CeH. Whether depression and anxiety have a shared mechanism with headache or whether they are just comorbid symptoms linked with a disabling headache remains a topic of ongoing debate [48]. It may be that an improvement in headache severity and frequency enhances anxiety and depression symptoms or vice versa. Regardless of the causal direction of these associations, it is important to consider psychological factors in headache treatment, as these factors are linked to the condition of CeH [48,49].
It has been estimated that 33.4% of individuals with CeH experienced severe to extreme level of stress, while 0% of participants in the control group reported stress symptoms [42]. The authors of the previous study suggested that high level of stress and poor sleep in patients with CeH could be indicative of disturbed pain processing [42]. These sleep problems and poor psychosocial status disrupted pain processing, suggesting that they can sustain and potentially exacerbate the pain experience” for better flow [50]. These risk factors are not only associated with CeH but also with poor responsiveness to physiotherapy treatment plans in patients with CeH, especially when the psychosocial factors and symptoms of central sensitization are present [51]. Also, psychosocial factors such as anxiety and depression are well-established risks for the transition from acute to chronic pain, commonly seen in conditions like headaches and neck pain [52,53].
Conclusion
The result of this study provides evidence that cervical Cobb angle, sleep disturbances and poor psychological status were significant risk factors of CeH. Addressing these modifiable predictors through targeted physiotherapy approaches can improve chronic neck pain outcomes and reduce the likelihood of developing CeH. Future research is required to explore the effectiveness of specific physiotherapy interventions aimed at restoring cervical alignment, improving sleep quality and reducing the severity of anxiety symptoms in preventing the development of cervicogenic headache. Further longitudinal studies with a larger sample are required to validate these results and refine our predictive regression model. Also, exploring the potential mechanisms through which these predictors contribute to CeH can enhance our understanding of this condition and inform the development of effective interventions.
Limitations of the study
Our study has several limitations. The observational design of the study hinders the establishment of causal relationships. Reliance on self-reported measures to assess sleep, pain, and psychological factors introduces the potential for bias. The relatively short follow-up period of 6 months might overlook long-term effects and changes, while the non-representative sample could affect the external validity of our conclusions. Moreover, the study did not include repeated measures, which prevented calculation of reliability metrics such as Intraclass Correlation Coefficient, Standard Error of Measurement, and Minimal Detectable Change. Future research should incorporate repeated testing to properly assess these measurement properties. Furthermore, data on activity levels and other factors that may influence posture and pain were not collected, which we acknowledge as a limitation. Addressing these limitations in future studies can enhance the robustness and generalizability of findings.
Clinical implications
These findings suggest that improving cervical curvature may play a key role in managing cervicogenic headache. Therapeutic interventions aimed at correcting cervical spine alignment – such as manipulative therapy and motor control exercises – have demonstrated effectiveness in reducing CeH symptoms. However, given CeH multifactorial nature, other contributing factors like cervical joint dysfunction and muscle impairments must also be addressed. Consequently, a comprehensive approach targeting multiple aspects of cervical spine health is essential for optimal management.
The cervical Cobb angle serves as a valuable clinical indicator for physiotherapists, reflecting cervical spine alignment and biomechanical function. Assessing this angle enables early identification of patients at risk for developing CeH and related conditions, facilitating timely and targeted treatment. Restoring normal cervical lordosis through therapeutic exercises, manual therapy, and postural education can relieve pain and enhance function.
Moreover, this study emphasizes the importance of a multidisciplinary approach for patients with chronic neck pain and CeH. Effective management requires addressing not only physical symptoms but also psychological factors and sleep quality, which significantly influence headache severity. Integrating physical therapy, manual interventions, sleep hygiene education, and psychological support into rehabilitation programs may reduce the risk of CeH. Early detection of these modifiable predictors followed by appropriate intervention can help prevent the development and progression of cervicogenic headache
Acknowledgements
We thank all participants who participated in the study.
Biographies
Osama N. Alshana is a Lecturer at the University College of Applied Sciences in Gaza and a Senior Physiotherapist with Médecins Sans Frontières–Belgium. He has published three articles in peer-reviewed journals. His clinical and academic work focuses on rehabilitation strategies in conflict-affected populations.
Mosab M. Aldabbas is an Assistant Professor at Al Azhar University, Gaza, Palestine, and a Field Physiotherapy Officer with the International Committee of the Red Cross. He has published over twenty-two peer-reviewed articles. His research primarily explores the relationship between chronic neck pain, sleep disturbances, and the role of cervical spine alignment in neck pain and headache.
Abed El Hamed Qaradaya is the Manager of the Physiotherapy Program at Médecins Sans Frontières–France. He has more than twenty years of clinical experience in the rehabilitation of patients with burns and traumatic injuries, with a strong focus on developing physiotherapy services in humanitarian settings.
Tarushi Tanwar is an Assistant Professor at the Manipal Academy of Higher Education, India. She has published over twenty-six peer-reviewed articles. Her research focuses on understanding the relationship between impaired balance and sleep disturbances in young adults.
Hasan Taha holds a master’s degree in Orthopaedic Physiotherapy and works as a Physiotherapist at the Ministry of Health, Gaza, Palestine. His clinical interests lie in musculoskeletal rehabilitation and orthopaedic physiotherapy practice.
Mohammed Matar holds a master’s degree in Orthopaedic Physiotherapy and works as a Physiotherapist at the Ministry of Health, Gaza. His research focuses on examining the effects of group versus individual therapy among geriatric patients recovering from hip fracture.
Correction Statement
This article has been republished with minor changes. These changes do not impact the academic content of the article.
Funding Statement
No funding was received to assist with the preparation of this manuscript.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Ethical approval
The current study was carried out in compliance with the ethical standards outlined in the Declaration of Helsinki. Prior to commencing the study, the Palestinian Health Research Council committee (PHRC) has revised and granted the ethical approval. The study was registered as (PHRC/HC/1339/23) on 7 August 2023. The study was prospectively registered before the initiation of participant recruitment.
Informed consent
Informed consent was obtained from all participants.
Data availability statement
The data that support the findings of this study are available on request from the corresponding.
References
- [1].Piovesan EJ, Utiumi MAT, Grossi DB.. Cervicogenic headache – how to recognize and treat. Best Pract Res Clin Rheumatol. 2024;38(1):101931. doi: 10.1016/j.berh.2024.101931 [DOI] [PubMed] [Google Scholar]
- [2].Moustafa IM, Diab A, Shousha T, et al. Does restoration of sagittal cervical alignment improve cervicogenic headache pain and disability: a 2-year pilot randomized controlled trial. Heliyon. 2021;7(3):e06467. doi: 10.1016/j.heliyon.2021.e06467 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [3].Knackstedt H, Bansevicius D, Aaseth K, et al. Cervicogenic headache in the general population: the Akershus study of chronic headache. Cephalalgia. 2010;30(12):1468–1476. doi: 10.1177/0333102410368442 [DOI] [PubMed] [Google Scholar]
- [4].Pöllmann W, Keidel M, Pfaffenrath V. Headache and the cervical spine: a critical review. Cephalalgia. 1997;17(8):801–816. doi: 10.1046/j.1468-2982.1997.1708801.x [DOI] [PubMed] [Google Scholar]
- [5].Riina J, Anderson PA, Holly LT, et al. The effect of an anterior cervical operation for cervical radiculopathy or myelopathy on associated headaches. J Bone Joint surg-Am Vol. 2009;91(8):1919–1923. doi: 10.2106/JBJS.H.00500 [DOI] [PubMed] [Google Scholar]
- [6].Schrot RJ, Mathew JS, Li Y, et al. Headache relief after anterior cervical discectomy: post hoc analysis of a randomized investigational device exemption trial: clinical article. SPI. 2014;21(2):217–222. doi: 10.3171/2014.4.SPINE13669 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [7].Suijlekom HAV, Lamé I, stomp‐van Den Berg SGM, et al. Quality of life of patients with cervicogenic headache: a comparison with control subjects and patients with migraine or tension‐type headache. Headache. 2003;43(10):1034–1041. doi: 10.1046/j.1526-4610.2003.03204.x [DOI] [PubMed] [Google Scholar]
- [8].Bogduk N, Govind J. Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. Lancet Neurol. 2009;8(10):959–968. doi: 10.1016/S1474-4422(09)70209-1 [DOI] [PubMed] [Google Scholar]
- [9].Diener H, Kaminski M, Stappert G, et al. Lower cervical disc prolapse may cause cervicogenic headache: prospective study in patients undergoing surgery. Cephalalgia. 2007;27(9):1050–1054. doi: 10.1111/j.1468-2982.2007.01385.x [DOI] [PubMed] [Google Scholar]
- [10].Cao Y, Xu C, Sun B, et al. Preoperative cervical Cobb angle is a risk factor for postoperative axial neck pain after anterior cervical discectomy and fusion with Zero‐Profile interbody. Orthop Surg. 2022;14(12):3225–3232. doi: 10.1111/os.13552 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [11].Griegel-Morris P, Larson K, Mueller-Klaus K, et al. Incidence of common postural abnormalities in the cervical, shoulder, and thoracic regions and their association with pain in two age groups of healthy subjects. Phys Ther. 1992;72(6):425–431. doi: 10.1093/ptj/72.6.425 [DOI] [PubMed] [Google Scholar]
- [12].Becker WJ. Cervicogenic headache: evidence that the neck is a pain generator. Headache. 2010;50(4):699–705. doi: 10.1111/j.1526-4610.2010.01648.x [DOI] [PubMed] [Google Scholar]
- [13].Shimohata K, Hasegawa K, Onodera O, et al. The clinical features, risk factors, and surgical treatment of cervicogenic headache in patients with cervical spine disorders requiring surgery. Headache. 2017;57(7):1109–1117. doi: 10.1111/head.13123 [DOI] [PubMed] [Google Scholar]
- [14].Kim R, Wiest C, Clark K, et al. Identifying risk factors for first-episode neck pain: a systematic review. Musculoskeletal Sci Pract. 2018;33:77–83. doi: 10.1016/j.msksp.2017.11.007 [DOI] [PubMed] [Google Scholar]
- [15].Bihldorff JP, King SH, Parnes LR. Psychological factors in headache. Headache. 1971;11(3):117–127. doi: 10.1111/j.1526-4610.1971.hed1103117.x [DOI] [PubMed] [Google Scholar]
- [16].Pluess M, Conrad A, Wilhelm FH. Muscle tension in generalized anxiety disorder: a critical review of the literature. J Anxiety Disord. 2009;23(1):1–11. doi: 10.1016/j.janxdis.2008.03.016 [DOI] [PubMed] [Google Scholar]
- [17].Aldabbas M, Tanwar T, Iram I, et al. Prevalence of fatigue and its association with pain intensity, psychological status and sleep quality in patients with neck pain. JCDR. 2021. doi: 10.7860/JCDR/2021/48613.15104 [DOI] [Google Scholar]
- [18].Aldabbas MM, Tanwar T, Iram I, et al. Sleep disturbance in neck pain patients: implications to pain intensity and disability. Sleep Vigilance. 2022;6(2):349–357. doi: 10.1007/s41782-022-00216-1 [DOI] [Google Scholar]
- [19].Dosi C, Figura M, Ferri R, et al. Sleep and headache. Semin Pediatr Neurol. 2015;22(2):105–112. doi: 10.1016/j.spen.2015.04.005 [DOI] [PubMed] [Google Scholar]
- [20].Chiu TTW, Lam TH, Hedley AJ. A randomized controlled trial on the efficacy of exercise for patients with chronic neck pain. Spine (Phila Pa 1976). 2005;30(1):E1–E7. doi: 10.1097/01.brs.0000149082.68262.b1 [DOI] [PubMed] [Google Scholar]
- [21].Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. Headache. 1998;38(6):442–445. doi: 10.1046/j.1526-4610.1998.3806442.x [DOI] [PubMed] [Google Scholar]
- [22].Harrison DE, Harrison DD, Cailliet R, et al. Cobb method or Harrison posterior tangent method: which to choose for lateral cervical radiographic analysis. Spine (Phila Pa 1976). 2000;25(16):2072–2078. doi: 10.1097/00007632-200008150-00011 [DOI] [PubMed] [Google Scholar]
- [23].Buysse DJ, Reynolds CF, Monk TH, et al. The Pittsburgh sleep quality index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213. doi: 10.1016/0165-1781(89)90047-4 [DOI] [PubMed] [Google Scholar]
- [24].Carpenter JS, Andrykowski MA. Psychometric evaluation of the Pittsburgh Sleep Quality Index. J Psychosom Res. 1998;45(1):5–13. doi: 10.1016/S0022-3999(97)00298-5 [DOI] [PubMed] [Google Scholar]
- [25].Cleland JA, Childs JD, Whitman JM. Psychometric properties of the neck disability index and numeric pain rating scale in patients with mechanical neck pain. Arch Phys Med Rehabil. 2008;89(1):69–74. doi: 10.1016/j.apmr.2007.08.126 [DOI] [PubMed] [Google Scholar]
- [26].Young IA, Dunning J, Butts R, et al. Psychometric properties of the numeric pain rating scale and neck disability index in patients with cervicogenic headache. Cephalalgia. 2019;39(1):44–51. doi: 10.1177/0333102418772584 [DOI] [PubMed] [Google Scholar]
- [27].Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361–370. doi: 10.1111/j.1600-0447.1983.tb09716.x [DOI] [PubMed] [Google Scholar]
- [28].LoMartire R, Äng BO, Gerdle B, et al. Psychometric properties of short form-36 health survey, EuroQol 5-dimensions, and hospital anxiety and depression scale in patients with chronic pain. Pain. 2020;161(1):83–95. doi: 10.1097/j.pain.0000000000001700 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [29].Smets EMA, Garssen B, Bonke B, et al. The multidimensional fatigue inventory (MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res. 1995;39(3):315–325. doi: 10.1016/0022-3999(94)00125-O [DOI] [PubMed] [Google Scholar]
- [30].Reeves WC, Wagner D, Nisenbaum R, et al. Chronic fatigue syndrome – a clinically empirical approach to its definition and study. BMC Med. 2005;3(1):19. doi: 10.1186/1741-7015-3-19 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [31].Lundh Hagelin C, Wengström Y, Runesdotter S, et al. The psychometric properties of the Swedish multidimensional fatigue inventory MFI-20 in four different populations. Acta Oncologica. 2007;46(1):97–104. doi: 10.1080/02841860601009430 [DOI] [PubMed] [Google Scholar]
- [32].Vernon H, Mior S. The neck disability index: a study of reliability and validity. J Manipulative Physiol Ther. 1991;14(7):409–415. [PubMed] [Google Scholar]
- [33].Aldabbas MM, Alshana ON. Cervical cobb angle, sleep quality and psychological factors in patients with chronic neck pain with and without cervicogenic headache. Eur J Physiother. 2025:1–7. doi: 10.1080/21679169.2025.2466041 [DOI] [Google Scholar]
- [34].Coban G, Coven I, Ciftci BE, et al. The importance of craniovertebral and cervicomedullary angles in cervicogenic headache. Diagn Interv Radiol. 2013. doi: 10.5152/dir.2013.13213 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [35].Ferracini GN, Chaves TC, Dach F, et al. Analysis of the cranio-cervical curvatures in subjects with migraine with and without neck pain. Physiotherapy. 2017;103(4):392–399. doi: 10.1016/j.physio.2017.03.004 [DOI] [PubMed] [Google Scholar]
- [36].Bahar-Ozdemir Y, Ozdemir O. Is it possible to distinguish cervicogenic headache from neck pain with cervicospinal posture? A single-blind, prospective cross-sectional trial. Pain Physician. 2020;23(6):E687–E694. [PubMed] [Google Scholar]
- [37].Soares JC, Weber P, Trevisan ME, et al. Correlação entre postura da cabeça, intensidade da dor e índice de incapacidade cervical em mulheres com queixa de dor cervical. Fisioter Pesqui. 2012;19(1):68–72. doi: 10.1590/S1809-29502012000100013 [DOI] [Google Scholar]
- [38].Fortner MO, Oakley PA, Harrison DE. Alleviation of chronic spine pain and headaches by reducing forward head posture and thoracic hyperkyphosis: a CBP® case report. J Phys Ther Sci. 2018;30(8):1117–1123. doi: 10.1589/jpts.30.1117 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [39].Moustafa IM, Shousha TM, Harrison DE. An investigation of 3D spinal alignment in cervicogenic headache. Musculoskeletal Sci Pract. 2021;51:102284. doi: 10.1016/j.msksp.2020.102284 [DOI] [PubMed] [Google Scholar]
- [40].Harrison DE, Harrison DD, Janik TJ, et al. Comparison of axial and flexural stresses in lordosis and three buckled configurations of the cervical spine. Clin Biomech. 2001;16(4):276–284. doi: 10.1016/S0268-0033(01)00006-7 [DOI] [PubMed] [Google Scholar]
- [41].Verma S, Tripathi M, Chandra PS. Cervicogenic headache: current perspectives. Neurol India. 2021;69(7):194. doi: 10.4103/0028-3886.315992 [DOI] [PubMed] [Google Scholar]
- [42].Mingels S, Dankaerts W, Van Etten L, et al. Exploring multidimensional characteristics in cervicogenic headache: relations between pain processing, lifestyle, and psychosocial factors. Brain Behav. 2021;11(10):e2339. doi: 10.1002/brb3.2339 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [43].Rains JC, Poceta JS. Sleep-related headaches. Neurol Clin. 2012;30(4):1285–1298. doi: 10.1016/j.ncl.2012.08.014 [DOI] [PubMed] [Google Scholar]
- [44].Martin PR, MacLeod C. Behavioral management of headache triggers: avoidance of triggers is an inadequate strategy. Clin Psychol Rev. 2009;29(6):483–495. doi: 10.1016/j.cpr.2009.05.002 [DOI] [PubMed] [Google Scholar]
- [45].Boardman HF, Thomas E, Millson DS, et al. Psychological, sleep, lifestyle, and comorbid associations with headache. Headache. 2005;45(6):657–669. doi: 10.1111/j.1526-4610.2005.05133.x [DOI] [PubMed] [Google Scholar]
- [46].Rains JC, Davis RE, Smitherman TA. Tension-type headache and sleep. Curr Neurol Neurosci Rep. 2015;15(2):520. doi: 10.1007/s11910-014-0520-2 [DOI] [PubMed] [Google Scholar]
- [47].Coppola G, Di Lorenzo C, Schoenen J, et al. Habituation and sensitization in primary headaches. J Headache Pain. 2013;14(1):65. doi: 10.1186/1129-2377-14-65 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [48].Breslau N, Lipton RB, Stewart WF, et al. Comorbidity of migraine and depression: investigating potential etiology and prognosis. Neurology. 2003;60(8):1308–1312. doi: 10.1212/01.WNL.0000058907.41080.54 [DOI] [PubMed] [Google Scholar]
- [49].Zwart J‐, Dyb G, Hagen K, et al. Depression and anxiety disorders associated with headache frequency. The Nord‐Trøndelag Health study. Euro J Neurol. 2003;10(2):147–152. doi: 10.1046/j.1468-1331.2003.00551.x [DOI] [PubMed] [Google Scholar]
- [50].Staffe AT, Bech MW, Clemmensen SLK, et al. Total sleep deprivation increases pain sensitivity, impairs conditioned pain modulation and facilitates temporal summation of pain in healthy participants. PLOS ONE. 2019;14(12):e0225849. doi: 10.1371/journal.pone.0225849 [DOI] [PMC free article] [PubMed] [Google Scholar]
- [51].Liebert A, Rebbeck T, Elias S, et al. Musculoskeletal physiotherapists’ perceptions of non-responsiveness to treatment for cervicogenic headache. Physiother Theory Pract. 2013;29(8):616–629. doi: 10.3109/09593985.2013.783894 [DOI] [PubMed] [Google Scholar]
- [52].Aldabbas MM, Tanwar T, Iram I, et al. Predictors of persistent pain in patients with acute neck pain treated with physical therapy: a prospective study with 2 years follow up. Musculoskeletal Care. 2023;21(4):msc.1775. doi: 10.1002/msc.1775 [DOI] [PubMed] [Google Scholar]
- [53].Fumal A, Schoenen J. Tension-type headache: current research and clinical management. Lancet Neurol. 2008;7(1):70–83. doi: 10.1016/S1474-4422(07)70325-3 [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding.