By Dr. Yoon Jeon. MChiro, MB, BSc, Dip.TCM, PGCert.
A 32-year-old, married lady presented complaining of more than 10 year history of headache. The headache is daily basis and dull aching generally, although it sometimes is quite severe (8/10) . She also reported stiffness of the neck.
The headache is chronic, recurrent, bilateral, “band-like” and continuous dull aching. It is classic manifestation of tension headache. There are no associated visual or neurologic signs or symptoms, even though she had 2 times experiences of nausea with the headache. She also complained about her work stress and generally the headache comes in the afternoon.
There are no red flags noticed such as positional headache, increased temperature and focal neurological sings.
In the physical examination, the tender trigger points on bilateral Cervical 3/4 regions (semispinalis capitis – the middle neck muscles) and upper trapezium causing the referral headache are noted. C3/4 ROM (Neck movement) are restricted and painful bilaterally with the painful restricted right 1st rib in the motion palpation. The cervical and shoulder orthopaedic/ neurologic tests are not remarkable except the right and left spuring test (Neck test for cervical nerve root disorder) causing local pain C3/4. The SMR(sensory, motor, reflex) of upper/lower limbs are within the normal limit.
Based on this patient’s history, physical examination findings, it seems that cervicogenic (neck) and myogenic (muscle) components provoked the headache.
Upper cervical spine adjustment
Myofascial therapies - Trigger point therapy and stretching suboccipital muscles
Dry needling (Acupuncture)
Self home stretching exercises
Posture and ergonomic advice
Chiropractic spinal adjustment was applied to the C3/4 facet joint with a high velocity and low amplitude thrust. There is evidence to show the benefit of spinal manipulation for cervicogenic headache (Bronfort G, Nilsson N, Haas M, Evans R, Goldsmith CH, Assendelft WJJ, Bouter LM, 2004). Compression of nodules in taut bands of the neck/shoudler muscles was applied, fallowing stretching the muscles. Many studies show that various trigger point treatments can significantly reduce headache frequency, intensity. (Lattes K, Venegas P, Lagos N, et al. 2009; Hesse J, Møgelvang B, Simonsen H, 1994; Giamberardino MA, Tafuri E, Savini A, et al.2007; Fernández-de-las-Peñas C, Schoenen J. 2009). Dry needling (Acupuncture) was applied to the tender points & spasmed muscles directly. Putting a needle into a spasmed muscle causes the muscle to relax. This can be seen with an electromyogram. (Cummings & White, 2001). Postural & ergonomic advice also was given.
In the initial week after two treatments, the patient reported that there had been improvement in her headache; it was not continuous and there was a reduction in the severity, but her neck was still stiff. These complaints were still present on the fourth visit although improved. At the following treatment, she reported that her headache was almost gone and also her stiff neck was much better. She was seen three more times over the course of the next five weeks and reported only an occasional mild headache with the stress of her work. She was last seen for these complaints four months after onset and was asymptomatic.
Cervicogenic headache is a quite common with tension headache and arising from structures in the neck & shoulder. In patients with this disorder, attacks or chronic fluctuating periods of neck/head pain may be provoked/worsened by sustained neck movements or stimulation of ipsilateral tender points. The pathophysiology of cervicogenic headache probably depends on the effects of various local pain-producing or eliciting factors, such as intervertebral dysfunction. (Martelletti P, van Suijlekom H. 2004). The mechanism of the headache for cervical dysfunction is that C1-3 spinal segments have afferent nociceptive (pain) input which shares vast interconnections with nerve fibres from cranial nerve 5. Because of this convergence pain signals may be poorly localised and pain due to upper cervical dysfunction and nociception may be felt / interpreted as headache. (Souza, T.A. 2001).
The successful treatment of this headache requires a multifaceted approach using pharmacologic, manipulative, anesthetic, and occasionally surgical interventions. Medications alone are often ineffective or provide only modest benefit for this condition. (David M. Biondi, DO. 2005)
According to recent studies published in the Journal of Manipulative, And Physiological Therapeutics, the results indicated that spinal manipulation had a significant positive effect in cases of cervicogenic headache. In this study, 53 participants who were sufferers of cervicogenic headaches were studied closely. Half of the subjects were given chiropractic manipulation as treatment, while the other half of the subjects received deep friction, and low laser massage. The manipulation group showed improvement in all three of the measurement criterion being studied. Those who received chiropractic treatment in the study noticed a 36% decrease in their pain medication usage; their headache hours were decreased by 69% and their headache intensity had also decreased by 36%.
Chiropractors acknowledge that there are many causes of headaches. Where they are related to dysfunction in the cervical spine, there is evidence to show the benefit of spinal manipulation. Headaches of this nature can be unilateral or bilateral and are often located in the back of the head and above the eyes. They are mild-moderate in intensity. Certain activities and posture can worsen the headache, including sustained head position or external pressure over the cervical spine or occipital region. (BCA. 2010).
Chiropractic treatment provides excellent care for cervicogenic or tension headache , especailly when the condition is chronic or not responding to initial pharmacologic treatment.
Martelletti P, van Suijlekom H. Cervicogenic headache: practical approaches to therapy. CNS Drugs. 2004;18(12):793-805
Bronfort G, Nilsson N, Haas M, Evans R, Goldsmith CH, Assendelft WJJ, Bouter LM. Non invasive physical treatments for chronic/recurrent headache (review). Cochrane Database of Systematic Reviews 2004 issue 3.
Souza, T.A. (2001). Differential Diagnosis and Management for the Chiropractor. 2nd edition. In: Neck complaints. p35-37, In: Headache. p432-434. An aspen publication.
Travell J, Simons D. Myofascial Pain and Dysfunction: The Trigger Point Manual. 1983.
Fernández-de-las-Peñas C, Schoenen J. Chronic tension-type headache: what is new? Curr Opin Neurol. 2009 Jun;22(3):254-61.
David M. Biondi, DO. Cervicogenic Headache: A Review of Diagnostic and Treatment Strategies, JAOA. 2005 April; 105:16-22
Calandre EP, Hidalgo J, Garcia-Leiva JM, et al. Myofascial trigger points in cluster headache patients: a case series. Head Face Med. 2008 Dec 30;4:32.
Giamberardino MA, Tafuri E, Savini A, et al. Contribution of myofascial trigger points to migraine symptoms. J Pain. 2007 Nov;8(11):869-78.
Hesse J, Møgelvang B, Simonsen H. Acupuncture versus a beta-blocker in migraine prophylaxis: a randomized trial of trigger point inactivation. J Intern Med.1994 May;235(5):451-6.
Lattes K, Venegas P, Lagos N, et al. Local infiltration of gonyautoxin is safe and effective in treatment of chronic tension-type headache. Neurol Res. 2009 Apr;31(3):228-33