Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache. Mobilization versus massage therapy in the treatment of cervicogenic headache: a clinical study. Physical examination and self-reported pain outcomes from a randomized trial on chronic cervicogenic headache. The Prevalence of Cervicogenic Headache in a Random Population Sample of 20–59 Year Olds Reinvestigation of the dysfunction in neck and shoulder girdle muscles as the reason of cervicogenic headache among office workers Lack of efficacy of manual therapy in children and adolescents with suspected cervicogenic headache: results of a prospective, randomized, placebo-controlled, and blinded trial. Effect of Treatment of Temporomandibular Disorders (TMD) in Patients with Cervicogenic Headache: A Single-Blind, Randomized Controlled Study The flexion-rotation test and active cervical mobility--a comparative measurement study in cervicogenic headache. Radiofrequency Denervation of Facet Joints C2-C6 in Cervicogenic Headache: A Randomized, Double-Blind, Sham-Controlled Study A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache A randomized controlled trial of the effect of spinal manipulation in the treatment of cervicogenic headache. Manual treatment for cervicogenic headache and active trigger point in the sternocleidomastoid muscle: a pilot randomized clinical trial. Intertester reliability and diagnostic validity of the cervical flexion-rotation test. Accurate Classification of Chronic Migraine via Brain Magnetic Resonance Imaging. A Randomized Pragmatic Clinical Trial of Chiropractic Care for Headaches With and Without a Self-Acupressure Pillow. [Therapeutic manipulation of episodic tension type headache. A randomized, controlled clinical trial]. Management of headache disorders: design of a randomised clinical trial screening for prognostic patient characteristics
Persistent intermittent headache is a common disorder and is often accompanied by neck aching or stiffness , which could infer a cervical contribution to headache . However , the incidence of cervicogenic headache is estimated to be 14 - 18 % of all chronic headaches , highlighting the need for clear criterion of cervical musculoskeletal impairment to identify cervicogenic headache sufferers who may benefit from treatments such as manual therapy . This study examined the presence of cervical musculoskeletal impairment in 77 subjects , 27 with cervicogenic headache , 25 with migraine with aura and 25 control subjects . Assessment s included a  photographic measure of posture , range of movement , cervical manual examination , pressure pain thresholds , muscle length , performance in the cranio-cervical flexion test and cervical kinaesthetic sense .  The results indicated that when compared to the migraine with aura and control groups who scored similarly in the tests , the cervicogenic headache group had less range of cervical flexion/extension ( P=0.048 ) and significantly higher incidences of painful upper cervical joint dysfunction assessed by manual examination ( all P<0.05 ) and muscle tightness ( P<0.05 ) . Sternocleidomastoid normalized EMG values were higher in the latter three stages of the cranio-cervical flexion test although they failed to reach significance . There were no between group differences for other measures . A discriminant analysis revealed that manual examination could discriminate the cervicogenic headache group from the other subjects ( migraine with aura and control subjects combined ) with an 80 % sensitivity BACKGROUND AND OBJECTIVE Cervicogenic headache ( CGH ) is a common problem associated with neck pain . In this study the effect of cervical mobilizations was compared with that of massage therapy in the management of CGH . DESIGN Thirty-six subjects with CGH , r and omly assigned into two groups , participated in the study . The first group was treated with spinal mobilization techniques of the upper cervical spine , while the second group was treated with massage therapy of the neck region . All subjects underwent active neck range of motion , isometric and dynamic strengthening and endurance exercises in two sessions/week for 6 weeks . Pre- and post-treatment outcomes were assessed with means and st and ard error of the means of measured headache pain intensity , frequency and duration of headache attacks as well as via the functional Neck Disability Index ( NDI ) and active neck range of motion . RESULTS The results of the study showed significant improvement in all measured variables in each treatment group . Comparison between the two groups showed significant differences in all measured variables after intervention in favor of mobilization techniques with the exception of the functional NDI . CONCLUSION Upper cervical spine mobilization demonstrated more clinical benefits than massage therapy with regard to headache pain parameters and neck mobility for CGH subjects OBJECTIVE Objective clinical measures for use as surrogate markers of cervicogenic headache ( CGH ) pain have not been established . In this analysis , we investigate relationships between objective physical examination ( PE ) measures with self-reported CGH outcomes . METHODS This is an exploratory analysis of data generated by attention control PE from an open-label r and omized clinical trial . Of 80 subjects , 40 were r and omized to 8 treatments ( spinal manipulative therapy or light massage control ) and 8 PE over 8 weeks . The remaining subjects received no PE . Physical examination included  motion palpation of the cervical and upper thoracic regions , active cervical range of motion ( ROM ) and associated pain , and algometric pain threshold evaluated over articular pillars . Self-reported outcomes included CGH and neck pain and disability , number of CGH headaches , and related disability days . Associations between PE and self-reported outcomes were evaluated using generalized linear models , adjusting for sociodemographic differences and study group . RESULTS At baseline , number of CGH and disability days were strongly associated with cervical active ROM ( P < .001 to .037 ) . Neck pain and disability were strongly associated with ROM-elicited pain ( P < .001 to .035 ) but not later in the study . After the final treatment , pain thresholds were strongly associated with week 12 neck pain and disability and CGH disability and disability days ( P < or = .001 to .048 ) . CONCLUSIONS Cervical ROM was most associated with the baseline headache experience . However , 4 weeks after treatment , algometric pain thresholds were most associated . No one PE measure remained associated with the self-reported headache outcomes over time Study Design From a r and om population sample , those experiencing frequent headaches were identified . They were examined to determine how many fulfilled the 1990 international Headache Society classification criteria for cervicogenic headache . Objective To estimate the prevalence of cervicogenic headache in the general population and in the group experiencing frequent headaches . Summary of Background Data Only with the publication of the 1990 headache classification criteria did a generally accepted clinical definition of cervicogenic headache emerge . The prevaience of this form of headache has been estimated only in two highly selected in-clinic patient population s. No data exist regading the prevalence in representative unselected population s. Methods . A short question naire on headaches  was mailed to 826 r and omly selected residents of a midsized Danish town . A group of 57 individuale in the age range 20–59 years who reported having headache episodes on 5 or more days in the previous month were identified . Forty-five of the 57 were eventually interviewed and examined with respect to the IHS criteria for cervicogenic headache ( the radiological criteria were omitted on ethical grounds ) . Results Of the 45 persons examined , eight fulfilled the diagnostic criteria for cervicogenic headache , equivalent to a prevalence in the headache group of 17.8 % ( 95 % confidence interval = 8%-32 % ) . Conclusions Cervicogenic headache appears to be a relatively common form of headache , similar to migraine in prevaience Purpose : Dysfunction of cervical and shoulder girdle muscles as reason of cervicogenic headache ( CEH ) was reinvestigated with clinical and neurophysiological studies . Methods : Forty office workers were r and omized into two groups to verify efficiency of supervised kinesiotherapy  ( N = 20 ) aim ed with improvement of muscle ’s activity and headache symptoms releasing . Headache intensity was evaluated with visual analog scale ( VAS ) , range of cervical movement ( ROM ) with goniometer , trigger points ( TrPs ) incidence with palpation and muscle ’s strength with Lovett ’s scale . Reaction of patients for muscle ’s elongation was also evaluated .  Surface electromyographical recordings  were bilaterally analyzed at rest ( rEMG ) and during maximal contraction ( mcEMG ) . Results : Deficits of cervical flexion and muscles strength were found in all patients . TrPs occurred predominantly in painful trapezius muscle . Incidence of trigger points coexisted with intensity of CEH . Results indicated on muscles dysfunction which improved only after supervised therapy . Positive correlations between increase in rEMG amplitudes and high VAS scores , high-amplitude rEMG recordings incidence and increased number of TrPs were found . Negative correlation was detected between amplitude in mcEMG and amplitude of rEMG recordings . Conclusions : Dysfunction of trapezius muscle was most responsible for CEH etiology . Proposed algorithm of kinesiotherapy was effective as complementary method of the CEH patients treatment OBJECTIVE Clinical trials concerning cervical spine manipulation and mobilization in children and adolescents with cervicogenic headache are lacking . METHODS We performed a multicenter , prospect i ve , r and omized , placebo-controlled , and blinded trial in 52 children and adolescents ( 21 boys , 31 girls ) aged 7 - 15 . After prospect i ve baseline documentation for 2 months patients were either assigned to placebo or true manipulation with another 2-month follow-up . Main outcome measures were defined as : percentage of days with headache , total duration of headache , days with school absence due to headache , consume of analgesics , intensity of headache . RESULTS We did not find a significant difference comparing the groups with placebo and true manipulation with respect to the defined main outcome measures . CONCLUSIONS We were not able to show an efficacy of cervical spine manipulation in 52 children and adolescents Abstract The present study was comprised of 43 patients ( 16 men ) with cervicogenic headaches for over three months , diagnosed according to the International Classification of Diagnostic Criteria of Headaches ( ICDH-ll ) . The patients were r and omly assigned to receive either manual therapy for the cervical region ( usual care group ) or additional manual therapy techniques to the temporom and ibular region to additionally influence temporom and ibular disorders ( TMD ) . All patients were assessed prior to treatment , after six sessions of treatment , and at a six-month follow-up . The outcome criteria were : intensity of headaches measured on a colored analog scale , the Neck Disability Index ( Dutch version ) , the Conti Anamnestic Question naire , noise registration at the m and ibular joint using a stethoscope , the Grade d Chronic Pain Status ( Dutch version ) , m and ibular deviation , range of mouth opening , and pressure/pain threshold of the masticatory muscles . The results indicate in the studied sample of cervicogenic headache patients , 44.1 % had TMD . The group that received additional temporom and ibular manual therapy techniques showed significantly decreased headache intensities and increased neck function after the treatment period . These improvements persisted during the treatment-free period ( follow-up ) and were not observed in the usual care group . This trend was also reflected on the question naires and the clinical temporom and ibular signs . Based on these observations , we strongly believe that treatment of the temporom and ibular region has beneficial effects for patients with cervicogenic headaches  , even in the long-term A single blind , age and gender matched , comparative measurement study was design ed to assess  active range of cervical motion  and  passive range of rotation in cervical flexion  in asymptomatic and cervicogenic headache subjects . Both procedures are commonly used in clinical practice to evaluate patients with cervicogenic headache .  We studied 20 women and eight men with side dominant cervicogenic headache ( mean age 43.3 years ) matched with 28 asymptomatic subjects . Two experienced manipulative therapists , who were blind to each other 's measurement , noted active ranges of cervical motion  and passive cervical rotation  performed in the flexion-rotation test using the Cervical Range of Motion Device .  Headache severity was assessed by a question naire . Additionally , one therapist prior to neck motion assessment determined the dominant symptomatic cervical motion segment . Active cervical motion in each direction was identical between the cervicogenic and control groups . In contrast , average rotation in flexion was 44 degrees to each side in the asymptomatic group and 28 degrees towards the headache side in the symptomatic group . C1 - 2 was deemed to be the dominant segmental level of headache origin in 24 of 28 subjects . In those 24 subjects range of rotation during the flexion-rotation test was inversely correlated to headache severity Cervicogenic headache is still a controversial disease entity , and good and reliable treatment is lacking . In the present r and omized , sham-controlled , patient- and evaluator-blinded study , 12 patients with a disabling , long-st and ing and treatment-resistant strictly unilateral cervicogenic headache were included . The diagnosis was based on purely clinical criteria . Six were r and omized to receive radiofrequency neurotomy of facet joints C2-C6 ipsilateral to the pain , and six were r and omized to sham treatment . Patients were followed for 2 years with diary registration of pain for 14-days periods after 1 , 3 , 6 , 12 , 18 and 24 months , and also followed with algometry and neck mobility measurements at 3 , 12 and 24 months . Side-effects were minor and short-lasting , and those patients who were treated with neurotomy were somewhat improved at 3 months , but later there were no marked differences between the groups . In conclusion , the procedure is probably not beneficial in cervicogenic headache Study Design . A multicenter , r and omized controlled trial with unblinded treatment and blinded outcome assessment was conducted . The treatment period was 6 weeks with follow-up assessment after treatment , then at 3 , 6 , and 12 months . Objectives . To determine the effectiveness of manipulative therapy and a low-load exercise program for cervicogenic headache when used alone and in combination , as compared with a control group . Summary of Background Data . Headaches arising from cervical musculoskeletal disorders are common . Conservative therapies are recommended as the first treatment of choice . Evidence for the effectiveness of manipulative therapy is inconclusive and available only for the short term . There is no evidence for exercise , and no study has investigated the effect of combined therapies for cervicogenic headache . Methods . In this study , 200 participants who met the diagnostic criteria for cervicogenic headache were r and omized into four groups : manipulative therapy group , exercise therapy group , combined therapy group , and a control group . The primary outcome was a change in headache frequency . Other outcomes included changes in headache intensity and duration , the Northwick Park Neck Pain Index , medication intake , and patient satisfaction . Physical outcomes included pain on neck movement , upper cervical joint tenderness , a craniocervical flexion muscle test , and a photographic measure of posture . Results . There were no differences in headache-related and demographic characteristics between the groups at baseline . The loss to follow-up evaluation was 3.5 % . At the 12-month follow-up assessment , both manipulative therapy and specific exercise had significantly reduced headache frequency and intensity , and the neck pain and effects were maintained ( P < 0.05 for all ) . The combined therapies was not significantly superior to either therapy alone , but 10 % more patients gained relief with the combination . Effect sizes were at least moderate and clinical ly relevant . Conclusion . Manipulative therapy and exercise can reduce the symptoms of cervicogenic headache , and the effects are maintained PURPOSE To determine whether the isolated intervention of high-velocity , low-amplitude spinal manipulation in the cervical spine has any effect on cervicogenic headache . DESIGN R and omized controlled trial with a blind observer . SETTING Ambulatory outpatient facility in an independent NHS-funded chiropractic research institution . PARTICIPANTS Thirty-nine subjects suffering from frequent headaches who fulfilled the IHS criteria for cervicogenic headache ( excluding radiological criteria ) . These subjects were recruited from among some 400 headache sufferers who responded to newspaper advertisements . INTERVENTION Half of the group received high-velocity , low-amplitude cervical manipulation twice/wk for 3 wk . The other half received low-level laser in the upper cervical region and deep friction massage ( including trigger points ) in the lower cervical/upper thoracic region , also twice/wk for 3 wk . MAIN OUTCOME MEASURE The change from week 2 to week 6 in analgesics use per day , headache intensity per episode and number of headache hr per day . RESULTS Despite a significant reduction in the manipulation group on all three outcome measures , differences between the two treatment groups failed to reach statistical significance . CONCLUSION The results suggest a possible effect of manipulation on cervicogenic headache , but because of method ological problems , such an effect could not be unequivocally demonstrated OBJECTIVE The purpose of this preliminary study was to determine feasibility of a clinical trial to measure the effects of manual therapy on sternocleidomastoid active trigger points ( TrPs ) in patients with cervicogenic headache ( CeH ) . METHODS Twenty patients , 7 males and 13 females ( mean ± SD age , 39 ± 13 years ) , with a clinical diagnosis of CeH and active TrPs in the sternocleidomastoid muscle were r and omly divided into 2 groups . One group received TrP therapy ( manual pressure applied to taut b and s and passive stretching ) , and the other group received simulated TrP therapy ( after TrP localization no additional pressure was added , and inclusion of longitudinal stroking but no additional stretching ) . The primary outcome was headache intensity ( numeric pain scale ) based on the headaches experienced in the preceding week . Secondary outcomes included neck pain intensity , cervical range of motion ( CROM ) , pressure pain thresholds ( PPT ) over the upper cervical spine joints and deep cervical flexors motor performance . Outcomes were captured at baseline and 1 week after the treatment . RESULTS Patients receiving TrP therapy showed greater reduction in headache and neck pain intensity than those receiving the simulation ( P < .001 ) . Patients receiving the TrP therapy experienced greater improvements in motor performance of the deep cervical flexors , active CROM , and PPT ( all , P < .001 ) than those receiving the simulation . Between-groups effect sizes were large ( all , st and ardized mean difference , > 0.84 ) . CONCLUSION This study provides preliminary evidence that a trial of this nature is feasible . The preliminary findings show that manual therapy targeted to active TrPs in the sternocleidomastoid muscle may be effective for reducing headache and neck pain intensity and increasing motor performance of the deep cervical flexors , PPT , and active CROM in individuals with CeH showing active TrPs in this muscle . Studies including greater sample sizes and examining long-term effects are needed OBJECTIVE This article evaluates reliability and diagnostic validity of the cervical flexion-rotation test ( FRT ) to discriminate subjects with headache because of C1/2 dysfunction . In addition , this study evaluates agreement between experienced and inexperienced examiners . METHODS These were 2 single blind comparative measurement study design s. In study 1 , 2 experienced blinded examiners evaluated the FRT in 10 asymptomatic controls , 20 subjects with cervicogenic headache ( CeH ) where C1/2 was the primary dysfunctional level , and 10 subjects with CeH but without C1/2 as the primary dysfunctional level . In study 2 , 2 inexperienced and 1 experienced blinded examiners  evaluated the  FRT  in 12 subjects with CeH and 12 asymptomatic controls . Examiners were required to state whether the FRT was positive and also to determine range of rotation using a goniometer . An analysis of variance with planned orthogonal comparison , single measure intraclass correlation coefficient ( 2,1 ) , and Bl and -Altman plot were used to analyze FRT range of rotation between the examiners . Sensitivity , specificity , and examiner agreement for test interpretation were analyzed using cross tabulation and kappa . RESULTS In study 1 , sensitivity and specificity of the FRT was 90 % and 88 % with 92 % agreement for experienced examiners ( P < .001 ) . Overall diagnostic accuracy was 89 % ( P < .001 ) and kappa = 0.85 . In study 2 , for inexperienced examiners , FRT mobility was significantly greater than for experienced examiners , but sensitivity , specificity , agreement , and kappa values were all within clinical ly acceptable levels . CONCLUSIONS The FRT can be used accurately and reliably by inexperienced examiners and may be a useful aid in CeH evaluation BACKGROUND The International Classification of Headache Disorders provides criteria for the diagnosis and subclassification of migraine . Since there is no objective gold st and ard by which to test these diagnostic criteria , the criteria are based on the consensus opinion of content experts . Accurate migraine classifiers consisting of brain structural measures could serve as an objective gold st and ard by which to test and revise diagnostic criteria . The objectives of this study were to utilize magnetic resonance imaging measures of brain structure for constructing classifiers : ( 1 ) that accurately identify individuals as having chronic vs episodic migraine vs being a healthy control ; and ( 2 ) that test the currently used threshold of 15 headache days/month for differentiating chronic migraine from episodic migraine . METHODS Study participants underwent magnetic resonance imaging for determination of regional cortical thickness , cortical surface area , and volume . Principal components analysis combined structural measurements into principal components accounting for 85 % of variability in brain structure . Models consisting of these principal components were developed to achieve the classification objectives . Tenfold cross validation assessed classification accuracy within each of the 10 runs , with data from 90 % of participants r and omly selected for classifier development and data from the remaining 10 % of participants used to test classification performance . Headache frequency thresholds ranging from 5 - 15 headache days/month were evaluated to determine the threshold allowing for the most accurate subclassification of individuals into lower and higher frequency subgroups . RESULTS Participants were 66 migraineurs and 54 healthy controls , 75.8 % female , with an average age of 36 + /- 11 years . Average classifier accuracies were : ( 1 ) 68 % for migraine ( episodic + chronic ) vs. healthy controls ; ( 2 ) 67.2 % for episodic migraine vs healthy controls ; ( 3 ) 86.3 % for chronic migraine vs. healthy controls ; and ( 4 ) 84.2 % for chronic migraine vs episodic migraine . The classifiers contained principal components consisting of several structural measures , commonly including the temporal pole , anterior cingulate cortex , superior temporal lobe , entorhinal cortex , medial orbital frontal gyrus , and pars triangularis . A threshold of 15 headache days/month allowed for the most accurate subclassification of migraineurs into lower frequency and higher frequency subgroups . CONCLUSIONS Classifiers consisting of cortical surface area , cortical thickness , and regional volumes were highly accurate for determining if individuals have chronic migraine . Furthermore , results provide objective support for the current use of 15 headache days/month as a threshold for dividing migraineurs into lower frequency ( i.e. , episodic migraine ) and higher frequency ( i.e. , chronic migraine ) subgroups OBJECTIVE The purpose of this study was to determine if the addition of a self-acupressure pillow ( SAP ) to typical chiropractic treatment results in significantly greater improvement in tension-type and cervicogenic headache sufferers . METHODS A pragmatic r and omized clinical trial was conducted in a chiropractic college teaching clinic . Thirty-four subjects , including tension-type and cervicogenic headache sufferers , 21 to 60 years of age , male or female , completed the study . Group A ( n = 15 ) received typical chiropractic care only ( manual therapy and exercises ) , and group B ( n = 19 ) received typical chiropractic care with daily home use of the SAP . The intervention period was 4 weeks . The main outcome measure was headache frequency . Satisfaction and relief scores were obtained from subjects in the SAP group . Analysis of variance was used to analyze the intergroup comparisons . RESULTS Owing to failure of r and omization to produce group equivalence on weekly headache frequency , analysis of covariance was performed showing a trend ( P = .07 ) favoring the chiropractic-only group ; however , this was not statistically significant . Group A obtained a 46 % reduction of weekly headache frequency ( t = 3.1 , P = .002 ; d = 1.22 ) . The number of subjects in group A achieving a reduction in headaches greater than 40 % was 71 % , while for group B , this was 28 % . The mean benefit score ( 0 - 3 ) in group B of the use of the SAP was 1.2 ( .86 ) . The mean satisfaction rating of users of the SAP was 10.4 ( 2.7 ) out of 15 ( 63 % ) . CONCLUSION This study suggests that chiropractic care may reduce frequency of headaches in patients with chronic tension-type and cervicogenic headache . The use of a self-acupressure pillow ( Dr Zaxx device ) may help those with headache and headache pain relief as well as producing moderately high satisfaction with use In a r and omized controlled clinical trial , 75 subjects fulfilling the IHS criteria for episodic tension-type headache were treated for four weeks . One group received spinal manipulation plus soft tissue therapy in the neck , the other received soft tissue therapy plus low-power laser therapy to the same region . In the three month follow-up period both groups showed significant improvement , but there were no differences between the groups . Thus , spinal manipulation had no effect on episodic tension-type headache , in contrast to the significant effect of spinal manipulation which has previously been demonstrated in cases of cervicogenic headache . These two headaches should therefore be diagnostically differentiated in the future Background Treatment of headache disorders is not always optimal . Patients are treated in multiple ways , and the lack of scientific arguments for referral and the insufficient implementation of guidelines result in unclear treatment strategies . The coexistence of headache and neck pain can lead to the referral to a musculoskeletal physiotherapist . This treatment can only be successful if an underlying cervical segmental dysfunction is present . In such cases a physical treatment can be a valuable option that should be considered . The aim of this study is to identify prognostic therapeutic patient characteristics and to increase the number of correct physiotherapy referrals . Methods / design This trial is design ed to identify patient characteristics which can influence the prognosis of the patient . Patients with recurrent headache and co-existent neck pain are recruited via a multicenter setup . After screening for eligibility , subjects are tested at baseline and r and omly allocated to one of two treatment groups . Testing includes the administering of question naires ( a  Headache Diagnosis Question naire ,  Headache Inventory List  and the Headache Impact Test ( HIT-6 ) ) and physical tests ( Thermal Stimuli , Manual Cervical Spine Examination and Pressure Algometry ) . Treatment groups are a usual care group ( UC ) administered by the General Practitioner ( GP ) and a usual care plus musculoskeletal physiotherapy treatment group ( UCMT ) . UC is based on the Dutch GP Guideline for Headache . UCMT consists of the UC plus a combination of exercises and spinal cervical mobilisations . Follow-up measurements consist of the completion of the Headache Inventory List , the HIT-6 and scoring of the global perceived effect ( GPE ) . The latter allowing the distinction between responders ( positive effect ) and non-responders ( no effect or worse ) . Logistic regression analysis will be used to identify the specific patient characteristics of the responders and the non-responders . The additional value of the musculoskeletal physiotherapy will be examined . Follow-up measurements up to 52 weeks are scheduled . Discussion This trial aims to identify prognostic patient characteristics , in order to supply a useful diagnostic tool for all health care workers , dealing with headache sufferers
Conclusions : Despite low levels of evidence , manual examination of the cervical spine appears to aid the diagnostic process related to CGH and can be implemented by both experienced and inexperienced examiners
Objective : To evaluate the diagnostic validity of manual examination techniques used to diagnose  cervicogenic headache ( CGH ) .
Background : Cervicogenic headache is a specific type of headache that originates from the cervical spine and is typically chronic in nature .
Diagnostic criteria for CGH have been established by the International Headache Society ( IHS ) and are cited extensively in the literature .
Diagnosis of CGH through manual examination is a more recent practice .
To our knowledge , no systematic review of manual diagnosis of CGH has been performed .