Cervicocranial syndromes including Barré-Lieou Syndrome

Cervicocranial syndrome can occur as a result of ligament weakness in the neck. Weakness of the neck ligaments commonly occurs because most people spend a good portion of their days looking down at phones and hunched over while working at their computers. Their work may consist of typing on a computer or being constantly tethered to their mobile devices for many hours per day, as well as the huge surge in computer gaming. Increasing amounts of patients have suffered from “text neck.” All of these tech activities precipitate the head-forward position and put the cervical vertebral ligaments in a stretched position. Over time, these ligaments weaken and cause pain (creep). The cervical spine ligament laxity causes an even more head-forward position, as the ligaments can no longer keep the cervical vertebrae in their proper posterior alignment. The paracervical muscles (the neck muscles) tighten to stabilize the joints and head. As the muscles tighten, they create more pain.

Eventually, the muscles can no longer stabilize the vertebrae and the ligaments are stretched even more. Neck pain increases and the cycle continues to repeat itself. Massage therapy, physical therapy, chiropractic/osteopathic manipulation , and pain medicines all help to temporarily relieve the pain. They do not, however, correct the underlying problem of ligament laxity.

What symptoms are produced in the face, head, and neck when the sympathetic nervous system is not working well in these areas? The primary symptom is a headache, since headaches are caused by dilation of blood vessels, as in cervicocranial syndrome.

Another symptom of cervicocranial syndrome is tinnitus (ringing in the ears). A decrease in sympathetic output to the inner ear will cause an accumulation of fluid in the inner ear. When fluid accumulates in the inner ear, as is often the case with an upper respiratory infection, the ear feels full and the body feels off balance. A ringing in the ear can occur, along with vertigo (dizziness).

The symptoms of Cervicocranial syndromes

Chest pain
Migraine headaches
Clicking in the neck
Neck pain
Ear pain
Recurrent disturbed vision
Facial pain
Severe fatigue
Headache
Sinus congestion
Hoarseness
Thinking impairment
Light headedness
Tinnitus
Loss of voice
Vertigo
Memory problems
Symptoms often increase with neck motion

Cervico-orofacial syndromes

In September 2022, (1) researchers analyzed the neuroanatomical and neurophysiological (the structure and function of the nervous system) basis of cervicogenic pain in cervico-cranial pain syndromes. The researchers focused on cervico-orofacial syndromes. In reviewing previously published data, the researchers noted: “Despite abundant available experimental and clinical data, cervicogenic orofacial pain may be challenging to diagnose and treat. Crucial non-surgical therapeutic approach is the orthopedic manual therapy focused on correction of body posture, proper alignment of cervical vertebra and restoration of normal function of temporomandibular joint and occlusion.”

In many patients we see symptoms of TMJ are essentially the same as cervicocranial syndrome. It is our belief that the symptoms, such as dizziness, vertigo, etc., that physicians ascribe to TMJ. may in fact in many people are caused by cervicocranial syndrome / Barré-Lieou syndrome.

Barré-Liéou Syndrome

In September 2015, our researchers including Ross Hauser, MD and Danielle Steilen published our findings in the European Journal of Preventive Medicine on Cervical Instability as a Cause of Barré-Liéou Syndrome and Definitive Treatment with Prolotherapy: A Case Series.

This paper is summarized here:

Barré-Lieou syndrome was discovered by and named after Jean Alexandre Barre, M.D., a French neurologist, and Yong-Choen Lieou, a Chinese physician. Each discovered the syndrome independently and described a very wide range of symptoms thought to be due to a dysfunction of the group of nerves called the posterior cervical sympathetic nervous system, located near the vertebrae in the neck. Therefore, this condition is often better known as cervicocranial syndrome and posterior cervical sympathetic syndrome.

Barré-Liéou and Cervicocranial syndrome are due to cervical vertebral instability, which affects the function of the nerve cell aggregations located in the neck just in front of the vertebrae. Vertebral instability or misalignment occurs because the ligaments that support the neck become weakened or injured. This is what occurs in the commonly known whiplash injury. Not only do neck and headache pain occur with whiplash injury, but also the signs and symptoms of Barré-Lieou syndrome.

Barré-Liéou syndrome has symptoms related to underlying cervical instability. While classified as a rare disease, Barré-Liéou syndrome is likely underdiagnosed. Vertebral instability, occurring after neck ligament injury, affects the function of cervical sympathetic ganglia (nerve bundle).

Symptoms include neck pain and neck instability, migraines/headache, vertigo, tinnitus, dizziness, visual/auditory disturbances, and other symptoms of the head/neck region.

This condition also may develop in people who spend a good portion of their day hunched over while working. Any activity that precipitates the head forward position and puts the cervical vertebral ligaments in a stretched position will cause the ligaments to weaken over time. The ligament laxity causes an even more head forward position as the ligaments can no longer keep the cervical vertebrae in their proper posterior alignment. Neck pain results and the cycle repeats itself.

Treatment for Barré-Liéou syndrome is suboptimal and often involves long-term use of pain medications, chiropractic care, or surgical fusion.

Trazodone (anti-depressant) treatment for Barré-Lièou syndrome

In May 2021, doctors writing in the journal Drug discoveries & therapeutics (3) retrospectively examined the effectiveness of trazodone (TZD) for treating Barré-Lièou syndrome in 20 patients. The researchers found Trazodone could effectively and safely treat Barré-Lièou syndrome, and early diagnosis and treatment can contribute toward good clinical outcomes.

Prolotherapy offers a noninvasive treatment option to relieve symptoms while treating the underlying cause of the disorder—cervical instability.

In this case series, the results of patients from 2011 to 2013 who received prolotherapy for Barré-Liéou syndrome following longstanding symptoms after trauma are reported. All patients reported improvement of neck pain and associated symptoms and increased physical activity. Prolotherapy should be considered as a treatment for Barré-Liéou syndrome.

A 33-year-old man

A 33-year-old man from Ireland came to Caring Medical in September 2013 for an evaluation of his chronic neck pain and tinnitus that he suffered after a bicycle accident in 2008. The patient’s neck pain was bilateral and constant, which prevented him from sleeping well.

He took tramadol and diazepam as needed for neck pain. In addition to the pain and tinnitus, the patient reported crepitation (cracking and grinding) in his cervical spine and a history of vertigo and dizziness, but did not report any radiculopathy sensation of numbness, tingling loss of function along limbs. The patient had previously tried chiropractic care (including manipulations) and physical therapy without relief.

The patient was treated in the neck region with Prolotherapy including Platelet Rich Plasma.

After two treatments, the patient reported a 40% improvement. The patient said that the crepitation in his neck had decreased significantly and his main complaint was no longer pain, just neck weakness. He no longer needed to take tramadol or diazepam for pain.

A 43-year-old male came to our chronic pain clinic in August 2012 for treatment of his neck pain. The patient had been in a motor vehicle accident 20 years earlier.

Eight months after the accident, he began to suffer from neck pain that had intensified over time. At the initial appointment, the patient was experiencing burning pain that radiated from his neck down through his shoulders and arms to his fingers. These symptoms improved upon lying down but increased when he stood up. When his neck pain was intense, the patient experienced eye pain and cervical headaches.

The patient admitted that he self-manipulated his neck, which made him feel better temporarily. About a year prior to coming to our clinic, this patient had plain radiographs taken of his cervical spine, which showed disc degeneration at multiple levels. The orthopedic surgeon who ordered the radiographs did not think the discs were causing his pain, so the patient managed his pain with occasional acetaminophen.

The patient underwent a series of five prolotherapy treatments to his entire posterior cervical spine, including C1.

The standard course for prolotherapy involves treatment every 4 to 6 weeks until symptoms are resolved, but the patient received prolotherapy to his neck every 8 weeks due to his schedule. His last treatment was in March 2013.

With each treatment, the patient noticed a decrease in his symptoms until his headaches, eye and facial pain, and radiculopathy were completely relieved.

After his first treatment, the patient noticed a decrease in crepitation and radiculopathy symptoms.
By his third treatment, his headaches and neck pain had reduced significantly.
After his last appointment, the patient reported substantial decreases in his pain and associated symptoms.

During the time in between prolotherapy sessions, the patient wore a hard cervical collar during the day and a soft cervical collar at night. Since the patient worked at a restaurant, it was imperative for him to wear a hard collar during the day to prevent excess rotation or flexion of his neck as he moved around the kitchen, as well as to prevent self-manipulation. As his symptoms continued to resolve, the patient was able to discontinue use of the collars.

A 57-year-old female consulted Caring Medical for chronic neck pain and associated symptoms.

This patient suffered a motor vehicle accident at the age of 16 years old. Symptoms included severe headaches, jaw aches, neck and shoulder pain, brain fog, and eye pain. On average, her neck pain was 6 on a scale of 0 to 10 (0 meaning no pain and 10 being the worst pain possible) and frequency was 10 of 10 (100% of the time).

The patient brought a recent x-ray report to her first appointment that showed mild cervical degeneration without foraminal narrowing (stenosis). The patient reported that she could feel her head “shift” when she did not wear a cervical collar.

The patient was diagnosed with cervical instability and received four prolotherapy treatments at Caring Medical over an 11-month span to alleviate her pain and symptoms. Ideally, patients with this condition should receive treatment every 4 to 6 weeks. The patient’s neck, including C1, was treated at every visit.

It was recommended that the patient wear a hard cervical collar to prevent excessive motion of her cervical spine, especially C1-C2. Although the patient was not compliant with wearing a hard collar, she did wear a soft cervical collar which did help.

After her first treatment, the patient reported a reduction in her headaches and pain and stated that it felt as if her neck was becoming more stable. By her third visit, the patient estimated she was about 80% better. At her fourth and final treatment in July 2013, the patient could sleep on her side without her neck shifting and reported a 90% improvement in all other symptoms.

1 Šedý J, Rocabado M, Olate LE, Vlna M, Žižka R. Neural Basis of Etiopathogenesis and Treatment of Cervicogenic Orofacial Pain. Medicina. 2022 Sep 21;58(10):1324. [Google Scholar]

1 Ross A. Hauser, Danielle Steilen, Ingrid Schaefer Sprague. Cervical Instability as a Cause of Barré-Liéou Syndrome and Definitive Treatment with Prolotherapy: A Case Series. European Journal of Preventive Medicine. Volume 3, Issue 5 , September 2015, Pages:155-166 [Abstract]

3 Morinaga Y, Nii K, Hanada H, Takemura Y, Sakamoto K, Inoue R, Mitsutake T, Tsugawa J, Kurihara K, Tateishi Y, Higashi T. Clinical features of Barré-Lièou syndrome and efficacy of trazodone for its treatment: A retrospective single center study. Drug Discoveries & Therapeutics. 2021 Apr 30;15(2):108-11. [Google Scholar]

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