In school children, primary headache is by far the most common cause of recurrent headache. However, symptomatic headaches of cervical, dental or eye-related origin have repeatedly been discussed as well.
The colleagues Dr. Fege and Dr. Falkenau draw our attention to the potential role of cervical structures in the etiology of these headaches. Besides hypermobility of the craniovertebral joints, also caused by prolonged anteflexion of the head during school hours, a functional block of these joints is regarded as an etiological factor. So far, however, there is a lack of meaningful studies evaluating this approach, one reason being that no definition of cervicogenic headache syndrome is available. Cervicogenic headache meeting to the criteria described by Sjaastad (1) has been evaluated most frequently. However, even using these criteria it is not possible to clearly define this condition, as evidenced by the significant variability in the published prevalence rates (0.17 – 13.8 %) (2, 3). It comes as no surprise that the substantially less clear criteria applied by manual therapy have not led to a definition of a distinct syndrome which could be used in studies.
A fundamental aspect to be considered here is that the primary cause of neck pain is not necessarily related to an abnormality in this region, since the anatomical convergence of cervical and trigeminal afferences in the caudal trigeminal nucleus will result in a projection of the pain to the neck region, even if the primary activation is purely trigeminal. It is crucial to prepare and verify operationalized criteria which are independent of the examiner for potentially primary cervicogenic headache. Here, the “Who proposes it must prove it” motto has to be strictly applied. It is necessary to caution not to overinterpret pain with a maximum intensity in the neck in a one-side, monodimensional fashion as “cervicogenic”; this also applies to dizziness. It has to be taken into consideration that any type of stress will result in an unconscious increase in pericranial muscle tension (mimic as well as masticatory and neck muscles) which may trigger musculoskeletal pain.
Dr. Gorzny highlights the potential relationship between binocular vision disorders and headache. Any impairment of binocular coordination may result in increased fusion work in the sense of latent, still compensated heterophoria which, on the one hand, may give rise to early fatigue and, on the other hand, lead to intermittent double vision; this also applies to very different refractive anomalies. Here, the aim should be to achieve the best possible correction. Reliable epidemiological studies about the occurrence of heterophoria and headache are not available. In addition, the published prevalence rates for heterophoria in the general population vary widely (1–6%, up to 70% max.) (4). Furthermore, chronic daily headache is not as common among school children as in adults and the majority of those affected suffer from paroxysmal headache, a fact that cannot easily be explained by chronic fusion abnormalities. In cases of chronic daily headache, strabological investigations should be considered.
The take-home message is – as long as attention is paid to the red flags, i.e. headaches with acute onset or acute changes in character and accompanying neurological symptoms or signs of inflammation – not to overdiagnose or overinterpret alleged “organic” causes as this will impede the path to successful treatment based on the available guidelines.
Prof. Dr. med. Andreas Straube
Neurologie, Campus Großhadern
Universität München, Germany
Conflict of interest statement
The authors of all contributions declare that no conflict of interest exists.
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