By Dr. Yoon Jeon. MChiro, MB, BSc, Dip.TCM, PGCert.
Case Presentation
A 32-year-old married female presented with a more than 10-year history of chronic headaches.
The headache was described as daily, bilateral, dull, band-like pressure, with occasional severe exacerbations (up to 8/10 intensity). The condition was associated with chronic neck stiffness.
Symptoms were typically worse in the afternoon and closely related to occupational stress. The patient also reported intermittent episodes of nausea, although no consistent aura or neurological symptoms were present.
No red flag features were identified, including:
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Positional headache
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Fever or systemic symptoms
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Focal neurological deficits
The clinical picture was consistent with a chronic tension-type headache with cervicogenic and myofascial components.
Clinical Examination
Findings included:
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Myofascial trigger points in:
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Upper trapezius (bilateral)
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Cervical C3–C4 region (semispinalis capitis)
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Restricted and painful motion at C3–C4 bilaterally
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Dysfunction of the right first rib
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Local pain on cervical Spurling’s test (C3–C4 region)
Neurological examination:
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Sensory, motor, and reflex testing within normal limits
These findings suggested a combination of:
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Cervical joint dysfunction
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Myofascial pain syndrome
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Referred pain contributing to headache presentation
Clinical Impression
The presentation was consistent with:
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Chronic tension-type headache
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With cervicogenic and myofascial pain components
C1–C3 cervical afferents converge with trigeminal nociceptive pathways, which can result in referred pain perceived as headache (trigeminocervical convergence theory).
Treatment
A multimodal conservative treatment plan was implemented:
Chiropractic Cervical Spinal Manipulation (SMT)
High-velocity, low-amplitude manipulation was applied to the C3–C4 segment to restore joint mobility.
Myofascial Therapy
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Trigger point compression and release techniques
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Stretching of upper trapezius and suboccipital muscles
Dry Needling (Acupuncture)
Applied directly to active trigger points to reduce muscular hypertonicity and pain.
Postural & Ergonomic Rehabilitation
Focused on reducing sustained cervical loading during occupational activities.
Clinical Outcome
After 1 week (2 treatments):
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Reduction in headache intensity and frequency
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Headache no longer continuous
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Neck stiffness persisted but improved
After 4 visits:
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Further improvement in both headache and cervical mobility
After 5 weeks:
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Headache nearly resolved
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Marked reduction in neck stiffness
At follow-up (4 months):
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Patient remained asymptomatic
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Only occasional mild stress-related headache episodes reported
Discussion
Chronic tension-type headache is one of the most common primary headache disorders and is frequently associated with cervical musculoskeletal dysfunction.
The trigeminocervical convergence mechanism provides a neuroanatomical explanation for referred pain from the upper cervical spine to the head (Tore A. Jensen / trigeminal-cervical pain pathway literature).
Manual therapy, including spinal manipulation, has been shown to be effective in cervicogenic and tension-type headache. A Cochrane review by Gert Bronfort et al. (2004) reported clinically significant improvement in headache frequency and intensity following spinal manipulation.
Myofascial trigger points are strongly associated with chronic headache syndromes. Research by César Fernández-de-las-Peñas has demonstrated a correlation between trigger point activity and headache severity.
Additional studies support the use of:
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Trigger point therapy
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Acupuncture and dry needling
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Multimodal physical therapy approaches
These interventions may reduce peripheral nociceptive input and improve central pain modulation.
Conclusion
This case demonstrates that chronic long-standing tension-type headache with cervicogenic and myofascial components can respond well to a structured multimodal conservative approach.
The combination of cervical spinal manipulation, trigger point therapy, dry needling, and postural correction resulted in sustained resolution of symptoms in a patient with a 10-year history of headaches.
References
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Gert Bronfort et al. (2004). Non-invasive physical treatments for chronic/recurrent headache. Cochrane Database of Systematic Reviews.
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César Fernández-de-las-Peñas (2009). Myofascial trigger points and tension-type headache. Current Opinion in Neurology.
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David M. Biondi (2005). Cervicogenic headache: diagnostic and treatment strategies. JAOA.
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Janet Travell & David Simons. Myofascial Pain and Dysfunction: The Trigger Point Manual.
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National Institute for Health and Care Excellence. Headache and MSK pain management guidelines.
