Can Chronic fatigue syndrome and Myalgic encephalomyelitis be caused by cervical stenosis and cervical spine instability?

Ross Hauser, MD

Myalgic encephalomyelitis (muscle pain from nerve inflammation) or Chronic Fatigue Syndrome is/are very complex disorders. It is difficult to determine their true causes as the true cause can be extremely multifactorial. There are numerous hypotheses as to cause and treatments.  If you are reading this article it is more than likely that you have been on a long medical journey and you are very well educated in the ideas of yeast, molds, environmental illness, diet, hormones, thyroids and adrenals, and a runaway immune system that causes muscle pain. Sometimes this is diagnosed as Fibromyalgia.

You have been to many doctors, nutritional specialists, allergists, immunologists, endocrinologists, and other specialists. You may have even traveled to a few gurus. While you may have been helped, you still struggle. For people like you, even the smallest help in finding answers to your challenges of excessive fatigue and the many symptoms that usually accompany chronic fatigue syndrome is met with hopeful but guarded optimism.

Stories probably like yours

We get many emails about problems of the cervical spine and fatigue. They go something like this:

My problems have been going on for years. I have a lot of neck pain, I have pain going down my arms. My one elbow is particularly painful, I wear a large brace on it so I can squeeze an ice pack in there when it really hurts. I have my general practitioner, a chiropractor, an orthopedist, and a neurologist trying to help me. They are trying but nothing is helping. I also have a significant problem with fatigue. My general practitioner thinks it may be chronic fatigue syndrome based on other symptoms I am having, like feeling sick all the time. My surgeons think it may just be the stress and exhaustion of being in pain all the time. Either way, I am tired all day and find myself with the need to nap nearly every day.

Others we hear from have their diagnosis and simply want to know if treating their cervical spine problems will help their chronic fatigue. These emails are sometimes very short and matter of fact. Generally an indication of someone who has had a lot of previous medical care. They go something like this:

I have been diagnosed with chronic fatigue syndrome. I have severe migraines and headaches. I am looking for help.

-or-

I have been sick for years. I have been diagnosed with POTS, chronic headaches, chronic fatigue syndrome among other ailments. None of the treatments are working, I feel sick every day. Can you help?

-or-

I have chronic fatigue syndrome. Can you help me with craniocervical instability and Chiari malformation?

Before we begin this article and research findings, if you would like to contact our medical team with similar questions, please use our contact form page. We can help assess your candidacy for our treatments and answer your questions.

Can Chronic fatigue syndrome and Myalgic encephalomyelitis be caused by cervical stenosis and cervical spine instability?

In this article, we will present information and a case for cervical spine instability as a possible root cause of your health issues. It is not the grand unifying theory of Myalgic encephalomyelitis and Chronic Fatigue Syndrome (ME/CFS), but a concept of what may be happening in some patients.

We will show evidence that the pressure exerted by loose and floating vertebrae that pinch nerves and compresses arteries that pass through the cervical neck region may be an answer for you.

It is important to point out that not every sufferer of chronic fatigue syndrome will find that the origins of their problems are related to neck instability. The case we make is that some sufferers may. We are going to go straight to a research study to set the tone for this article that there may be a cervical neck connection to the onset and worsening conditions of chronic fatigue syndrome.

Intracranial hypertension and craniocervical obstructions from cervical spine instability

In an August 2020 paper published in the journal Frontiers in Neurology (1) researchers tested their hypothesis that hypermobility, signs of intracranial hypertension, and craniocervical obstructions may be more common in patients with ME/CFS and thereby explain many of these patient’s symptoms.

How they tested their hypothesis:

A cervical neck connection to the onset and worsening conditions of Chronic Fatigue Syndrome (ME/CFS)

While we practice regenerative medicine injection treatments to strengthen the cervical ligaments to bring stability to the neck, we are going to explore a surgical study from Johns Hopkins University School of Medicine. The point that we hope to show you is that if you treat cervical instability you may find relief from your chronic fatigue and muscle pain.

Writing in the Journal of Translational Medicine (2), the John Hopkins researchers described surgical outcomes for three patients here were their symptoms:

Two patients underwent Anterior cervical disc replacement surgery and the other a hybrid anterior cervical disc fusion and disc replacement in the third was associated with a marked improvement in myelopathic symptoms, resolution of lightheadedness and hemodynamic dysfunction (increased positive blood flow), improvement in activity levels, and improvement in global Myalgic encephalomyelitis or chronic fatigue syndrome.

Here is the conclusion of this case study from the surgeons:

“The prompt post-surgical restoration of more normal function suggests that cervical spine stenosis contributed to the pathogenesis of refractory ME/CFS and orthostatic symptoms. The improvements following surgery emphasize the importance of a careful search for myelopathic examination findings in those with ME/CFS, especially when individuals with severe impairment are not responding to treatment.”

Comment: Here a treatment (surgery) improved the conditions of chronic fatigue and muscle pain and the related symptoms of lightheadedness, symptoms associated with decreased blood flow, and energy output. This helped patients who had no help before. For those of you who want to explore a non-surgical option, we will explain below.

Why did these people respond so favorably? Alleviation of compression.

Are Vagus nerve inflammation and compression the cause of Chronic fatigue syndrome and Myalgic encephalomyelitis?

In this illustration compression at C1, C2, C3 can cause vagus nerve inflammation and contribute to the development of Chronic fatigue syndrome and Myalgic encephalomyelitis

In this illustration compression at C1, C2, C3 can cause vagus nerve inflammation and contribute to the development of Chronic fatigue syndrome and Myalgic encephalomyelitis

The Vagus nerve is part of a pair of nerves. You have the left side vagus nerve and the right side vagus nerve. Because the vagus nerves are so long, (vagus literally meaning wandering) they impact a large number of bodily functions and systems. When the vagus nerve is compressed by vertebrates as in cervical stenosis,  it can cause disruption in the body systems and many problems for the sufferer.

In the above research, the surgeons pointed out that the patients suffered from tremors, twitching, spasmodic tendency, absence of gag reflex. As noted these symptoms seemingly point to a connection between vagus nerve compression and Myalgic encephalomyelitis and Chronic Fatigue Syndrome (ME/CFS).

Vagus nerve involvement in Myalgic encephalomyelitis and Chronic Fatigue Syndrome (ME/CFS) has presented some interesting research and speculation as to what may be the origin or etiology of their problem for so many people. At the onset of this article, we discussed that these disorders are very complex disorders. It is difficult to determine the cause as a cause can be very multifactorial. BUT, sometimes you can connect some dots that may lead some to a realization that it is cervical spine instability causing these health issues.

Common symptoms shared by cervical neck instability patients and Myalgic encephalomyelitis and Chronic Fatigue Syndrome patients

Ross Hauser, MD discusses cervical instability and vagus nerve impairment in this discussion about cases with chronic idiopathic symptoms that include fevers, chronic fatigue, and hypersomnolence the desire to sleep all the time.

This is a summary transcript

Troubling temperatures – chronic fevers and “crippling fatigue”: People have fevers or they have the sensation of having a fever and nobody has figured out the cause. Another sensation that people tell us about is crippling fatigue.

“my worst symptom is an intense desire to sleep I have suffered with it for 8 years”

(1:30) A patient case: Desire to sleep, fatigue, fevers

The case that I have in front of me describes someone, who since 2012, has had an intense desire to take naps and sleep. It did not matter how much sleep this person had, they never felt refreshed and the interesting thing was that they intermittently also had very high fevers, in the 103 – 104 degree range for days at a time. Imagine if you went to the emergency room and you had a fever of 103-104, right away they would give you a diagnosis of something like encephalitis or all kinds of things. In this person’s case, their fever came from cranial cervical syndrome or atlantoaxial or upper cervical instability.

Testing for idiopathic hypersomnia and other sleep studies:

This particular person had multiple sleep studies and finally, they were diagnosed with idiopathic hypersomnia. Many of you probably have this diagnosis. It means that your doctors do not know why you are so tired and want to sleep all the time.

This person had functional brain tests where it was discovered that the blood supply and the nutrient supply to the brain were flowing too low. So if you think about what would cause moment-to-moment decreased flow of blood and nutrients to the brain, you would come up with the logical assessment that this person has something causing intracranial pressure, the build up of pressure inside their brain caused by some sort of blockage.  For some people, the blockage is caused by upper cervical spine instability.

For some people, the blockage is caused by upper cervical spine instability.

Here is an example. I had a teleconference with a person who had a Cine MRI scan to measure their cerebrospinal fluid flow.

(4:40) The fevers

Returning to the case I am discussing in this video. This person had fevers nobody could explain. When someone has fatigue and fevers no one can explain they are often diagnosed with multiple environmental chemical sensitivities, chronic fatigue syndrome, or Lyme disease.

(5:05) Inflammation

What these people’s doctors are trying to figure out is why this person has fevers. There must be an inflammation somewhere in the body. Another patient with whom I had a teleconference told me about an elevated C-reactive protein that was ten times normal. None of her doctors could figure out why. The fever/inflammation remained, even when she took strong doses of steroids. No one could figure out why. I told this patient to look up “The Cholinergic Anti-inflammatory Pathway.”

Note: In a 2003 paper in the journal Molecular Medicine, (3) doctors described the Cholinergic Anti-inflammatory Pathway as the interaction between the nervous and immune systems in response to an immune challenge and a unique function of the efferent vagus nerve. This pathway plays a critical role in controlling the inflammatory response.

We all know fever comes from inflammation that the body is trying to mount an immune reaction to. The vagus nerve, as noted in the above landmark paper, controls the inflammatory response. If the vagus nerve is compressed, distorted messages about inflammation and fever regulation needs can go to the brainstem. The brainstem may then send distorted or incorrect messages to the hypothalamus and the hypothalamus nuclei which are the temperature controls in the body.

An August 2022 paper in the Journal of pain research (15) had researchers give patients a drawing of the front and back of the head, neck, and shoulders and then asked the patients, to draw on this drawing where did they have pain. Where the patients indicated pain helped the researchers determine the type of headache the patient had with the goal of isolating out the cervicogenic headache – C2 pain pattern and further to assess whether there was an association between dizziness/imbalance.

The findings demonstrated that a C2 pattern (putative cervicogenic headache) as determined by pain drawing was common among patients with chronic fatigue. The pain pattern is that of the third image top, pain on one whole side of the face, not seen is that this pain goes through the neck and into the shoulders. Complaints of dizziness/imbalance were more prevalent in this group as compared to patients without a C2 pain pattern. Besides, self-reported pain was worse in patients who did present with the C2 pain pattern. The results thus imply that there might be a cervical spinal nerve involvement in patients with chronic fatigue who present with cervicogenic headache.

Cervical instability and craniocervical instability. Are common symptoms with Myalgic encephalomyelitis and Chronic Fatigue Syndrome, is this a clue to cervical instability being the problem and a road to proper treatment?

The person who comes to us for problems related to the cervical spine or craniocervical instability does not come in presenting one problem. They come in presenting many problems. We rarely get a patient who comes in with Myalgic encephalomyelitis or chronic fatigue syndrome as the primary concern. But fatigue is a dominating secondary concern. If you are reading this article you do not have to be convinced of the complexity of your case. We would, however, like to show more research that makes the case for cervical spine or craniocervical instability for symptoms related to patients with Myalgic encephalomyelitis or chronic fatigue syndrome.

This is a patient of ours, she explains her myriad of symptoms that included fatigue:

In the video, the patient, Katelin tells her story. Here is a summary of her video:

Cervical Vertigo and Myalgic encephalomyelitis and Chronic Fatigue Syndrome, is this a clue to cervical instability being the problem and a road to proper treatment? 87% Neck pain – 85% Fatigue seen in patients.

A 2013 study from Norwegian doctors published in the Scandinavian Journal of Pain (4) demonstrated that the patients in this study, with a primary diagnosis of chronic benign paroxysmal positional vertigo, that is dizziness with a change in head position, reported the following coexisting problems:

Visual disturbance, fatigue, and dizziness are well-known characteristics of patients with Myalgic encephalomyelitis and Chronic Fatigue Syndrome (ME/CFS). So what is the origin of the problem?  Is ME/CFS the cause of these symptoms or is it cervical spine/neck instability? For a more detailed discussion see our article: Can neck problems cause vertigo? Cervical Vertigo and Cervicogenic Dizziness

Cervical Spine / Neck instability, vision problems, Myalgic encephalomyelitis, and Chronic Fatigue Syndrome, is this a clue to cervical instability being the problem and a road to proper treatment?

At the onset of research into Chronic Fatigue Syndrome in the early 1990s (CFIDS – Chronic Fatigue Immune Dysfunction Syndrome) a connection between chronic fatigue and visual disturbances was immediately identified. In a 1992 study published in the journal Optometry and Vision Science (5): the official publication of the American Academy of Optometry, researchers wrote that:

In the 27+ years since there has been conflicting and confusing information in regard to using eye problems as a tool to verify Chronic Fatigue Syndrome or Myalgic encephalomyelitis. In 2000, researchers published a case-control masked study on 37 patients with Chronic Fatigue Syndrome to evaluate ocular signs, symptoms, and functional parameters. The research which appeared in the Annals of Ophthalmology (6) suggested “a significant association was between CFS and blurred vision at near (inability to make out fine details), foggy vision, shadowed vision, headaches, and photophobia (intolerance of light). Blurred vision, foggy vision, and headaches were associated with abnormal oculomotor function, and shadowed vision and photophobia were associated with tear deficiency.”

In their 2014 paper: “Characteristics of visual disturbances reported by subjects with neck pain,” Researchers at The University of Queensland wrote in the journal Manual Therapy (7) of the most difficult to treat and manage visual disturbances in their patients with neck pain.

The commonality is unavoidable. People who have these vision problems and a diagnosis of Chronic Fatigue Syndrome or Myalgic encephalomyelitis should be checked for cervical spine instability.

Cervical Spine / Neck instability – Headaches and Myalgic encephalomyelitis and Chronic Fatigue Syndrome, is this a clue to cervical instability being the problem and a road to proper treatment?

Many people with ME/CFS have headaches. These include classic migraine (aura) and accompanying visual disturbances to included flashes of lights and blackout areas in vision. Again, we want to point out that people with ME/CFS may have these problems as a result of their sensitivities to chemicals, environmental pollutants, and certain foods. We are not suggesting that migraine and headaches in ME/CFS have a singular cause in cervical spine neck instability. We are suggesting that it is a possibility in many.

In the medical journal, BMC Neurology (8) researchers at Georgetown University produced a detailed paper on migraines, headaches, and Chronic Fatigue Syndrome. This was part of the summation:

“Chronic Fatigue Syndrome subjects have a high prevalence of migraine headaches that may be overlooked and undertreated. The proportion of an aura was similar to other migraine groups. CFS (sufferers with migraine and aura) was associated with higher severity scores for neural problems such as numbness and dizziness, and alterations of the heartbeat. The lower pressure-induced pain thresholds and hyperalgesia (high sensitivity to pain) found in the CFS subgroup (migraines without aura) was suggestive of nociceptive hyperresponsiveness (tissue damage causing breathing problems set off by asthma or exposure to an irritant) and central sensitization (Sensitivity to pain).”

In this short paragraph, we have two types of CFS sufferers. The latter is the sufferer whose headaches and migraines were triggered by asthmatic or breathing problems. The former or first sufferer who has their migraines set off by events strongly linked to cervical neck instability.

In our 2014 research lead by Danielle R. Steilen-Matias, MMS, PA-C and published in The Open Orthopaedics Journal (9) our research team was able to demonstrate that when the neck ligaments are injured and cause cervical spine instability (excessive movement of the cervical vertebrae), in the upper cervical spine (C0-C2), this can cause a number of other symptoms including, but not limited to, nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches.

A brief note on vertebrobasilar insufficiency. Typically this describes a narrowing of the arteries that is usually treated with blood thinners and cholesterol medication. In this context, vertebrobasilar insufficiency is describing a situation where hypermobility of the neck vertebrae is causing a “squeezing,” of the arteries by pinching movement. In the Georgetown research, it is worth noting again: “CFS (sufferers with migraine and aura) was associated with higher severity scores for neural problems such as numbness and dizziness, and alterations of a heartbeat.”

Please refer to our article Vertebrobasilar insufficiency – Hunter Bow Syndrome – Cervical neck instability for more on this possible connection to problems in ME/CFS.

A July 2021 paper from doctors at the Addenbrooke’s Hospital, Cambridge, in the United Kingdom and published in the journal Fatigue (14) noted the “Clinical similarities between chronic fatigue syndrome and idiopathic intracranial hypertension, supported by measurements of intracranial pressure. . . and that this may suggest the problems of chronic fatigue syndrome and idiopathic intracranial hypertension are connected, with chronic fatigue syndrome representing a milder version of idiopathic intracranial hypertension.”

What the researchers identified  the primary structural problem as acquired obstruction to cranial venous outflow. “This obstruction.” they wrote, “can take different forms, may be intermittent and subtle, and even be mistaken for normal venous anatomy, yet would be the driving force behind a tendency towards increased intracranial pressure.”

The researchers are looking at intracranial pressure and its relationship to chronic fatigue syndrome nad what they found was: “chronic elevation of intracranial pressure stresses the dural membrane maintaining the integrity of the subarachnoid space, which can rupture at a weak point, allowing CSF to leak away and intracranial pressure to fall.” As the researchers point out, in some instances, a CSF leak will mitigate (reduce pressure), in others it will compound it, producing a disease spectrum ranging through idiopathic intracranial hypertension, chronic fatigue syndrome, fibromyalgia, and spontaneous intracranial hypotension.”

A link between idiopathic intracranial hypertension, fibromyalgia, and chronic fatigue syndrome? Is Ehlers-Danlos syndrome involved as well?

In December 2018 study in the Journal of Pain Research (10) found that idiopathic intracranial hypertension, fibromyalgia, and chronic fatigue syndrome shared many characteristic features.

Before we get to these research findings, let’s explore some explanatory notes. In our article Cervical Spine Instability, Vein blockage, fluid build up and intracranial hypertension, we note:

We see many patients who have a serious health challenge in having intracranial hypertension. In many of these people, intracranial hypertension was not initially thought of as a problem as their doctors instead tackled the symptoms that these people were facing. Symptoms included dizziness, headache, vision problems such as sensitivity to light where exaggerated pupillary hippus dilating and constricting which can cause problems with light sensitivity and the pupil fails to respond correctly to light sources. These people also faced symptoms and diagnosis of Tinnitus or ringing in the ears, neck pain, and tremors.

Now in this research, we get a confirmation of something else we were seeing in these patients. Excessive fatigue.

In this study the researchers made these observations:

Laryngeal Manifestations – voice and airway dysfunctions, Myalgic encephalomyelitis, and Chronic Fatigue Syndrome, is this a clue to cervical instability being the problem and a road to proper treatment?

Here is an April 2020 (11) study published in the Journal of the American Medical Association (JAMA) Otolaryngology, Head & Neck Surgery from researchers at Johns Hopkins University.

Results:

My note: What could be a shared cause? Upper cervical instability

Research on cervical instability non-surgical treatments

Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult to treat musculoskeletal disorders. We are going to refer to two of these studies as they relate to cervical instability and a myriad of related symptoms including the problems described in this article which may impact the Myalgic encephalomyelitis and Chronic Fatigue Syndrome diagnosed sufferer.

In this video, a demonstration of treatment is given

Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.

This video jumps to 1:05 where the actual treatment begins.

This patient is having C1-C2 areas treated. Ross Hauser, MD is giving the injections.

In our 2014 study mentioned earlier in this article, we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments.

This is what we wrote: “To date, there is no consensus on the diagnosis of cervical spine instability or on traditional treatments that relieve chronic neck instability issues like those mentioned above. In such cases, patients often seek out alternative treatments for pain and symptom relief. Prolotherapy is one such treatment that is intended for acute and chronic musculoskeletal injuries, including those causing chronic neck pain related to underlying joint instability and ligament laxity. While these symptom classifications should be obvious signs of a patient in distress, the cause of the problems are not so obvious. Further and unfortunately, there is often no correlation between the hypermobility or subluxation of the vertebrae, clinical signs or symptoms, or neurological signs or symptoms. Sometimes there are no symptoms at all which further broadens the already very wide spectrum of possible diagnoses for cervical instability.”

What we demonstrated in this study is that the cervical neck ligaments are the main stabilizing structures of the cervical facet joints in the cervical spine and have been implicated as a major source of chronic neck pain and possibly in the case of Myalgic encephalomyelitis and Chronic Fatigue Syndrome type symptoms, cervical instability. (9)

Prolotherapy, the curve of the neck and blood flow

In this image, the progression and degeneration of the cervical spine is demonstrated, from Lordotic curve to the Military curve to the Kyphotic curve to the "S" curve of severe osteoarthritis.

In this image, the progression and degeneration of the cervical spine are demonstrated, from the Lordotic curve to the Military curve to the Kyphotic curve to the “S” curve of severe osteoarthritis.

In February 2016 a paper appeared in the Medical Science Monitor: International Medical Journal of Experimental and Clinical Research. (12) Here medical university researchers in Turkey made these observations:

This is research with which we have seen empirical evidence in our over 27+ years of regenerative medicine practice. To fix the problems related to the cervical spine, you need to restore the natural curvature of the neck. This is part of our Caring Cervical Realignment Therapy (CCRT) developed by Ross Hauser, M.D. This program was the evolutionary product of decades of treating patients with neck disorders, including cervical instability and degenerative disc disease, to provide long-term solutions to cervical neck instability related symptoms. CCRT combines individualized protocols to objectively document spinal instability, strengthen weakened ligament tissue that connects vertebrae, and re-establish normal biomechanics and encourage the restoration of lordosis.

Research: Correct the problems of loss of lordosis: immediately increase cerebral blood flow

In the medical journal Brain Circulation (Jan-March 2019) (13), doctors wrote their analysis of case study patients who had cervical lordosis. They wrote that if you restored the natural curve to the neck, you could immediately increase cerebral blood flow as pressure is removed from the cerebral artery.

Here are the learning points of this research. They present a good summary of what we discussed in this article:

The challenges of Vertebrobasilar insufficiency are many. Fixing cervical neck instability is not something that can be treated simply or easily, it takes a comprehensive non-surgical program to get the patient’s instability stabilized and the symptoms abated. We believe that if you have been going from clinician to clinician, practitioner to practitioner, doctor to doctor, there is a good likelihood that you have problems of cervical neck instability coming from weakness and damage to the cervical ligaments. Our treatments of dextrose Prolotherapy and in some cases Platelet Rich Plasma Prolotherapy can be an answer.

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

We hope you found this article informative and it helped answer many of the questions you may have surrounding Chronic fatigue syndrome and Myalgic encephalomyelitis be caused by cervical stenosis and cervical spine instability. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

References

1 Bragée B, Michos A, Drum B, Fahlgren M, Szulkin R, Bertilson BC. Signs of Intracranial Hypertension, Hypermobility, and Craniocervical Obstructions in Patients With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Frontiers in Neurology. 2020 Aug 28;11:828. [Google Scholar]
2 Rowe PC, Marden CL, Heinlein S, Edwards CC. Improvement of severe myalgic encephalomyelitis/chronic fatigue syndrome symptoms following surgical treatment of cervical spinal stenosis. Journal of translational medicine. 2018 Dec;16(1):21. [Google Scholar]
3 Pavlov VA, Wang H, Czura CJ, Friedman SG, Tracey KJ. The cholinergic anti-inflammatory pathway: a missing link in neuroimmunomodulation. Molecular medicine. 2003 May;9(5):125-34. [Google Scholar]
4 Iglebekk W, Tjell C, Borenstein P. Pain and other symptoms in patients with chronic benign paroxysmal positional vertigo (BPPV). Scandinavian journal of pain. 2013 Oct 1;4(4):233-40. [Google Scholar]
5 Potaznick WA, Kozol NE. Ocular manifestations of chronic fatigue and immune dysfunction syndrome. Optometry and vision science: official publication of the American Academy of Optometry. 1992 Oct;69(10):811-4. [Google Scholar]
6 Mastropasqua L, Ciancaglini M, Carpineto P, Iezzi A, Racciatti D, Falconio G, Zuppardi E, Pizzigallo E. Ocular manifestations in chronic fatigue syndrome. Annals of ophthalmology. 2000 Sep 1;32(3):219-24. [Google Scholar]
7 Treleaven J, Takasaki H. Characteristics of visual disturbances reported by subjects with neck pain. Manual therapy. 2014 Jun 1;19(3):203-7. [Google Scholar]
8 Ravindran MK, Zheng Y, Timbol C, Merck SJ, Baraniuk JN. Migraine headaches in chronic fatigue syndrome (CFS): comparison of two prospective cross-sectional studies. BMC neurology. 2011 Dec;11(1):30. [Google Scholar]
9 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]
10 Hulens M, Rasschaert R, Vansant G, Stalmans I, Bruyninckx F, Dankaerts W. The link between idiopathic intracranial hypertension, fibromyalgia, and chronic fatigue syndrome: exploration of a shared pathophysiology. Journal of pain research. 2018;11:3129. [Google Scholar]
11 Piersiala K, Akst LM, Hillel AT, Best SR. Chronic Pain Syndromes and Their Laryngeal Manifestations [published online ahead of print, 2020 Apr 30]. JAMA Otolaryngol Head Neck Surg. 2020;e200530. doi:10.1001/jamaoto.2020.0530 [Google Scholar]
12 Bulut MD, Alpayci M, Şenköy E, Bora A, Yazmalar L, Yavuz A, Gülşen İ. Decreased vertebral artery hemodynamics in patients with loss of cervical lordosis. Medical science monitor: international medical journal of experimental and clinical research. 2016;22:495. [Google Scholar]
13 Katz EA, Katz SB, Fedorchuk CA, Lightstone DF, Banach CJ, Podoll JD. Increase in cerebral blood flow indicated by increased cerebral arterial area and pixel intensity on brain magnetic resonance angiogram following correction of cervical lordosis. Brain Circulation. 2019 Jan 1;5(1):19. [Google Scholar]
14 P. Higgins JN, Pickard JD. A paradigm for chronic fatigue syndrome: caught between idiopathic intracranial hypertension and spontaneous intracranial hypotension; caused by cranial venous outflow obstruction. Fatigue: biomedicine, health & behavior. 2021 Jul 3;9(3):139-47. [Google Scholar]
15 Bernhoff G, Huhmar HM, Rasmussen-Barr E, Bunketorp Käll L. The significance of pain drawing as a screening tool for cervicogenic headache and associated symptoms in chronic fatigue. Journal of Pain Research. 2022 Jan 1:2547-56. [Google Scholar]

This page was last updated January 14, 2021

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