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Cervical Afferents and Primary Headache: An investigation of the potential role of cervical nociceptors in sensitising the trigemino-cervical nucleus in primary headache

Watson, Dean (2016) Cervical Afferents and Primary Headache: An investigation of the potential role of cervical nociceptors in sensitising the trigemino-cervical nucleus in primary headache. PhD thesis, Murdoch University.

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An underlying disorder in the migraine condition is an apparent subclinical sensitization of the trigemino cervical nucleus (TCN) indicated, for example, by an interictal deficient habituation of the nociceptive blink reflex (nBR). This has ramifications for tension-type headache (TTH), as there is considerable support for a pathogenesis of TTH which overlaps with that of migraine. The aim of this thesis was to investigate the upper cervical (C1-3) afferents as a potential sensitising source of the TCN in migraine and TTH, thereby addressing the hypothesis that upper cervical afferents evoke sensitisation of the TCN in migraine and TTH.

Firstly, manual examination of the upper cervical (atlanto-occipital and C2-3) joints was performed in 20 migraineurs, 14 TTH patients and 14 controls. The reproduction of customary head pain in 100 and 95 per cent of TTH patients and migraineurs, respectively, supports a role of the upper cervical spine in primary headache, perhaps involving sensitization of the TCN.

The second study employed the nociceptive blink reflex (nBR) to assess processing of trigeminal nociceptive information during reproduction and resolution of customary head pain (as the examination technique was sustained) in 15 migraineurs interictally. Reproduction and resolution of head pain was repeated over four 90 second trials; each trial was separated by 30 seconds. Migraineurs reported significant lessening of reproduction and increasing resolution of customary head pain over the four trials. In parallel was a significant increase in latency and decrease in amplitude of the nBR. The desensitizing effect of this examination technique on head pain implies that modulation of cervical afferent information may benefit migraineurs during manual cervical reproduction of customary head pain.

Whiplash of the neck is considered a musculo skeletal event and subsequent headache implies involvement of upper cervical (C1-3) afferents. The symptomatic profile of chronic whiplash associated headache (CWAH) mirrors that of primary headache, inviting speculation that CWAH shares a pathophysiology similar to that of primary headache. This prompted us to assess trigeminal nociceptive processing in CWAH patients in the third study. The symptomatic profile of 22 CWAH patients confirmed previous studies demonstrating similar profiles to primary headache. Furthermore, when compared to controls (n=25), CWAH patients had significant photophobia and allodynia. In addition, analysis of the nBR revealed hyperexcitability in central nociceptive pathways in CWAH patients, thus reinforcing the hypothesis that CWAH could be driven by central sensitization from upper cervical afferents.

Together, these studies support the view that upper cervical (C1-3) nociceptive information may contribute to sensitising the TCN in primary headache. Thus, therapeutic strategies that aim to alleviate aberrant discharge of cervical afferents may play a role in the management of primary headache.

Publication Type: Thesis (PhD)
Murdoch Affiliation: School of Psychology and Exercise Science
Supervisor: Drummond, Peter
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