Execution
- 1Position the patient supine or prone depending on the segmental technique selected.
- 2Palpate C0-C1, C1-C2, and C2-C3 using passive accessory intervertebral movement and passive physiological movement procedures.
- 3Apply graded pressure or segmental movement while monitoring local pain, headache reproduction, resistance, and end feel.
- 4Compare segmental response between sides and between adjacent levels.
- 5Confirm whether the comparable headache is reproduced and whether the suspected segment behaves differently from adjacent segments.
Positive outcome
The examination is positive when manual assessment reproduces the patient's familiar head pain and identify painful dysfunction or restriction at an upper cervical segment. Local tenderness alone is not enough because upper cervical tenderness is common in several headache types. Findings are strongest when they match CFRT restriction and deep neck flexor impairment.
Studies
| Study | Reliability | Sn | Sp | LR+ | LR− |
|---|---|---|---|---|---|
| Jull et al. (1988) | small n=20, single trained therapist vs radiologically-controlled blocks | 100 | 100 | NA | NA |
| Hall et al. (2010) | moderate to substantial for trained examiners | NA | NA | NA | NA |
| Howard et al. (2015) | case-control diagnostic study | NA | NA | NA | NA |
CommentManual upper cervical examination is clinically central in cervicogenic headache, but examiner skill and standardization strongly affect findings. Reproduction of familiar headache is more meaningful than nonspecific tenderness. Jull 1988 reported 100/100 Sn/Sp against radiologically-controlled diagnostic nerve blocks, but this was a small sample (n=20) with one highly experienced manipulative therapist; ordinary clinical performance will be lower. Because migraine and tension-type headache patients can also have neck tenderness, interpret manual findings as part of a pattern, not as a singleton.
Moderate Clinical Value