Cervicogenic headaches: Migraines, tension headaches and cervical spine instability

Ross Hauser, MD, Caring Medical, Fort Myers, Florida

At Caring Medical, we have been seeing headache patients for a long time. In 2009, our research team lead by Ross Hauser, MD., published our findings and recommendations for the treatment of chronic headaches and migraines in patients where clear cervical neck instability was suspected. This was based on already 15 years of clinic observation.

“I have these headaches no one can figure out”

A person may contact our office with an email or a phone call which they describe something like this:

I get these bad headaches, they started about a year ago. No one can figure out what is causing them. I have had brain scans, sinus scans, I had my teeth checked. I have been sent to ENTs who have requested lots of different blood workups. Everything comes back normal. My headaches start at the back of my head, eventually, it moves behind my eyes and sinus area. I am not getting any answers except medications.

I have been to several neurologists. They were are at a loss. Each one recommended treatments that I had already tried with the previous doctors that did not help me. Pain medications, physical therapy, mostly. Then I started to develop terrible neck pain as well. When I had the neck pain checked out the pain doctor told me I had cervical disc degenerative disease. I had cortisone and nerve blocks for my neck and my headaches went away. I was told that the relief would likely be temporary and it was. My neck pain and headaches are back. At least now I know that my headaches are Cervicogenic headaches.

For many people, physical therapy, medications, nerve blocks, can be helpful and provide long-term relief for their headaches. These are not the people we see in our office. We see the people who these treatments did not help.

Cervicogenic headaches – Migraines, tension headaches, and cervical neck instability

Above we gave two examples of the type of patient we can see who is confused about the cause and onset of their back of the head headaches. When someone comes into our clinic and we suspect Cervicogenic headaches we look for:

  • Someone who is constantly self-manipulating or cracking their neck.
  • Someone who gets manipulation from chiropractors for neck pain.
  • Someone who suffers from constant muscle spasms in the neck.
  • Someone who had physical therapy with less than desired results.
  • Then we examine them with Digital Motion X-Ray or DMX, this is explained below.

In our research, we discussed at the beginning of this article, published in the journal Practical Pain Management, (1) we described the problems of patients with headaches that were not being helped by traditional drug-based medicine and stress management. Not much has changed in the last ten plus years.

  • “While medicine carries 150 diagnostic headache categories, the vast majority of recurring headaches are classified as either migraine or tension. The most common headache types among adults and adolescents are tension headaches, chronic daily headaches or chronic non-progressive headaches. These muscle contraction headaches cause mild to moderate pain and come and go over a prolonged period of time.
  • Migraine headache pain is often moderate to severe and described as a pounding, throbbing pain lasting from four hours to three days, and usually occur one to four times per month. Migraines are associated with symptoms such as light sensitivity, noise or odor sensitivity, nausea or vomiting, loss of appetite, and stomach upset or abdominal pain.
  • Typical medical treatments for tension or migraine headaches involve the use of medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), triptans or muscle relaxants. Despite the advances in migraine-specific drugs, only 50% of patients with migraine headaches attain more than 50% reduction of headache frequency after three months of treatment.

Treatments that do not work, do not work because they do not address the problems of cervical spine instability from cervical ligament damage.

Among some of the reasons that patients do not get headache or migraine relief is that pharmaceutical-based management of the patient’s headaches does not address the problem of headaches coming from neck pain caused by weakened or damaged cervical ligaments.

In our 2014 research led by Danielle R. Steilen-Matias, MMS, PA-C, and published in The Open Orthopaedics Journal (2) our research team was able to demonstrate that when the neck ligaments are injured, they become elongated and loose, which causes 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.

Our research was cited in an April 2018 study in the International Journal of Environmental Research and Public Health.(3) Here researchers wrote:

  • “Understanding of the precise mechanisms of the relationship between Cervical Spondylosis and migraine risk remains limited. Cervical vertebral degenerative processes can compromise the capsular ligaments of facet joints, thereby contributing to the hypermobility of upper cervical vertebrae. Such cervical instability causes the dysregulation of the vertebrobasilar arteries, which leads to migraines.”

The management of common recurrent headaches

We are going to explore research that will give evidence that your chronic headache and migraine is not being resolved because no one is talking to you about ligaments, perhaps except those health care providers who cannot offer injection treatment or cannot prescribe pharmaceutical management: chiropractors. We will also discuss physical therapy below.

Above we wrote that someone who is suspected of having cervical neck instability as the cause of their headaches are:

  • Someone who is constantly self-manipulating or cracking their neck.
  • Someone who gets manipulation from chiropractors for neck pain.
  • Someone who suffers from constant muscle spasms in the neck.

An October 2018 study published in the journal BioMed Central Neurology, (4) describes the challenges faced by patients and chiropractors in helping patients with a tension headache, migraine, and cervicogenic headache.

Here are the learning points from that research.

  • The use of chiropractors for headache management appears to be significant. In a recent national US study, manipulative-based physical therapies were reported to be the most frequently used complementary and alternative treatments for migraine and headache patients.
  • In North America, a general population study reported between 25.7–36.2% of migraine headache patients had sought help from chiropractors at some time.
  • While the use of chiropractors for the management of headache disorders appears to be significant, little is understood about how this provider group manages this substantial patient population.

Number of chiropractic visits

For headache suffers with less than 3 months duration:

  • between 28 and 29.6% of participants reported providing less than 5 treatments,
  • between 54.2–55.5% provided between 5 and 10 visits and
  • between 14.9–16.5% reported providing more than 10 visits across all 3 headache types.

How do chiropractors treat by headache type?

  • The most frequent therapeutic approach by participants for migraine management was advice on
    • headache triggers (94.1%),
    • stress management (89.4%)
    • and non-thrust spinal mobilization (88.4%).
  • The most frequent therapeutic approach by participants for tension headache management was:
    • advice on headache triggers (90.9%),
    • stress management (90.1%)
    • and soft tissue therapies (massage, myofascial, stretching or trigger point therapy) to the neck/shoulder area (88.1%).
  • The most frequent therapeutic approach by participants for cervicogenic headache management was:
    • prescription exercises for the neck/shoulders (91.7%),
    • spinal manipulation (90.6%)
    • and soft tissue therapies (massage, myofascial, stretching or trigger point therapy) to the neck/shoulder area (88.3%)

Why are so many visiting the chiropractor? The researchers suggest:

  • “This substantial level of headache caseload within chiropractic clinical settings raises questions about the factors that influence the preference and use of chiropractors for the management of headaches compared to the use of other headache providers and treatments. Previous evidence suggests that patient dissatisfaction with preventative headache drug treatments are likely to be an important predictor for headache patient use of manual therapy providers.”


  • “While some aspects of chiropractic headache management, including the acceptance and use of headache diagnostic criteria, appears to be consistent with good clinical practice, other aspects of chiropractic headache management raise questions worthy of further research inquiry.”

What are we to make of this?

Chiropractors understand that there is a neck component to headache management, they may not have all the tools they need in their treatments to offer satisfactory relief for some patients. If you are reading this article you are likely one of these patients. We are pleased to be able to combine our treatments with chiropractic under the guidance of Ross Hauser, MD, and Brian R. Hutcheson, D.C.

In this video, Ross Hauser, MD explains and demonstrates the use of Digital Motion X-ray (DMX) to help identify cervical neck and spine instability in the C1-C2 region in a patient with severe migraines.

The summary transcript of this video, with explanatory notes, is below the video.

One of the more common conditions we see at Caring Medical is severe migraine headaches. I am going to demonstrate how we diagnosis and plan treatments for a patient we suspect of upper cervical spine instability as the cause of migraine headaches. In this video Digital Motion X-ray DMX is utilized to demonstrate the clues and signs of cervical spine instability, especially that surrounding the Dens or the C2 vertebrae.

  • The patient in this video is a physician who flew in from Europe to visit us here in Ft. Myers, Florida. He suffered a whiplash injury from snowboarding and windsurfing in 2011.
  • The patient has migraine headaches every day, horrible pain behind the eyes, terrible neck pain, he has clicking, grinding, and crunching in his neck.

At the 1:00 mark of the video, the Digital Motion X-ray DMX of the patient’s cervical spine instability is demonstrated.

  • As seen in the video, the DMX shows tilting of the C1 vertebrae. It is tilted through the full range of motion and this is one of the first signs that we see that a person has upper cervical instability.
  • In the DMX open mouth view (AT 1:18) the video we’re looking for several things the first thing is the symmetry of the C2 vertebrae this is where the Dens and the spinous process, the bony protrusion at the back of the vertebrae,  should be aligned with the Dens. In this particular patient, the C2 is shifted to the left. This misalignment, caused by cervical spine instability, is the reason that the person has migraine headaches primarily on their left side. That shift can be corrected with Prolotherapy. (Prolotherapy is a series of injections of simple dextrose. Below we will discuss the treatment further as well as provide medical research findings supporting its use in selected patients).

More instability

  • (At 1:40 of the video_ We also see in the C1-C2 facet joint that there is a misalignment, there is an overhang of one vertebra over the other. We also examine changes in the periodontoid space. In this patient the periodontoid space is more narrow on one side than the other, demonstrating misalignment.

This patient had 4 Prolotherapy treatments, his headaches are at a minimum. He will need a few more treatments to stabilize his cervical spine and further reduce eliminate his migraines.


Ross Hauser, MD. Cause of occipital neuralgia and migraines seen on DMX and resolved with Prolotherapy

In this video, Ross Hauser, MD offers a brief introduction to causes and the diagnosis of occipital neuralgia and migraines and treated with the aid of DMX (Digital Motion X-Ray and simple dextrose Prolotherapy cervical spine injections.

Summary highlights of the video:

  • One of the most common conditions that we see here at Caring Medical is migraine headaches. Another common condition is occipital neuralgia.
  • Much of the confusion surrounding the diagnosis of these two conditions is that a root cause, upper cervical spine instability (at C1-C2) is common to both problems and rarely looked for initially.
  • Focus on the Facet joint at C1-C2. On the back of this joint is the C2 nerve root. If the patient has upper cervical instability at C1-C2, the C1 vertebrae can hit, damage and compress the C2 nerve root. The occipital nerve is an offshoot of the C2 nerve. The cause of occipital neuralgia and the trigger of the structural cause of migraine headaches is the instability of the C1 – C2 facet joint.
  • The way we documented upper cervical instability in our offices is by digital motion x-ray or DMX. A brief demonstration is shown of teh digital motion X-ray of one of our patients who had their occipital neuralgia successfully treated with dextrose Prolotherapy cervical spine injections.
  • To see the C1-C2 facet joint – the x-ray is taken from the front of the face and with an open mouth. Then what we are looking for is a misalignment, is there and overhang of the C1-C2 vertebrae when the person bends their head to the side.
  • At 2:08 of the video, the x-ray takes a film of the patient’s neck in motion, demonstrating the C1-C2 overhang or misalignment. So the structural cause of migraine headaches is actually the looseness of the facet joint at C1 C2.
  • Prolotherapy cervical spine injections address this looseness by strengthening the connective tissue structures that are designed to prevent this looseness. These are the cervical spine ligaments of the neck.  Normally it takes anywhere from 4 to 5 treatment sessions to resolve this instability and thereby the symptoms.

Digital motion X-Ray C1 – C2

The digital motion x-ray is explained and demonstrated below

  • Digital Motion X-ray is a great tool to show instability at the C1-C2 Facet Joints
  • The amount of misalignment or “overhang” between the C1-C2 demonstrates the degree of instability in the upper cervical spine.
  • This is treated with Prolotherapy injections to the posterior ligaments that can cause instability.
  • At 0:40 of this video, a repeat DMX is shown to demonstrate the correction of this problem.

Headache researchers are understanding that patients with migraines and chronic headache have a neck pain/instability problem and it is more common than thought

Let’s look at five recent research studies.

Researchers representing Lund University in Sweden and the University of Copenhagen in Denmark published a December 2017 study in The Journal of Headache and Pain (5) showing that the prevalence of migraines with co-existing tension-type headache and neck pain is high in the general population.

They also acknowledge the problem that there is very little literature on the characteristics of these combined conditions.

The aim of their study was to investigate:

  • the prevalence of migraine with co-existing tension-type headache and neck pain
  • the level of physical activity, psychological well-being, perceived stress and self-rated health in persons with migraine and co-existing tension-type headache and neck pain compared to healthy controls,
  • the perceived ability of persons with migraine and co-existing tension-type headache and neck pain to perform physical activity, and
  • which among the three conditions (migraine, tension-type headache or neck pain) is rated as the most burdensome condition.

Here are the results which give evidence to the neck pain connection to headaches:

  • Out of 148 persons with migraine
    • 100 (67%) suffered from co-existing tension-type headache and neck pain.
    • Only 11% suffered from migraine only. (Only 1 in 9 migraines did not have a neck component).
  • Persons with migraine and co-existing tension-type headache and neck pain had lower level of physical activity and psychological well-being, higher level of perceived stress, and poorer self-rated health compared to healthy controls.
  • They reported reduced ability to perform physical activity owing to migraine (high degree), tension-type headache (moderate degree) and neck pain (low degree). The most burdensome condition was migraine, followed by tension-type headache and neck pain.

The researchers were able to conclude that migraine with co-existing tension-type headache and neck pain was highly prevalent and that persons with migraine and co-existing tension-type headache and neck pain may require more individually tailored interventions to increase the level of physical activity, and to improve psychological well-being, perceived stress, and self-rated health.

Now let’s examine the second study from a diverse team of Canadian researchers from medical universities and hospitals throughout Canada. Here doctors writing in the European Spine Journal explored treatments for managing patients who suffered from chronic tension-type headaches with constant neck pain and muscle spasm. The muscle spasms should have been a clue that the headaches were being caused by cervical neck instability. Muscles spasm in unstable joints because they are being overworked trying to help or replace the function of damaged ligaments and tendons in stabilizing the joint. 

Chiropractors found headaches have a neck instability component and the treatments offered were symptom management techniques

This is shown by researchers at the Canadian Memorial Chiropractic College who wrote of the effectiveness or non-effectiveness of non-invasive and non-pharmacological interventions for the management of patients with headaches associated with neck pain. In the European Spine Journal (6) they suggested that treatments should include exercise (to help stabilize), relaxation training with stress coping therapy (to reduce spasm) and perhaps manual therapy (chiropractic) to help get the neck back in its natural position.

  • Quick summary: The research found that headaches had a neck instability component and the treatments offered were symptom management techniques, not curative techniques.

The connection and problems of headache and neck pain in the workplace has also found recommendations from the University of Turin doctors for relaxation techniques to help manage muscle spasms and tension. The doctors noted a muscle relaxation program could significantly reduce the high rate of work disability.(7)

Again, the researchers point to system suppression, at least in these papers attempts are made to get away from pharmaceutical management of chronic headaches and do seek to find the problems of headaches routed in neck pain and instability, and muscle spasm.

In the fourth study from doctors at the University of São Paulo in Brazil, researchers concluded: “We cannot assume that physical therapy promotes additional improvement in migraine treatment; however, it can increase the cervical pressure pain threshold, anticipate clinically relevant changes, and enhance patient satisfaction.”(8)

  • Quick summary:  Why increase the pain threshold? Why not get rid of headache pain?

Lastly, the fifth paper doctors examined the 4th phase of a migraine cycle – The migraine postdrome – that is the physical aftermath after the migraine episode has dissipated. In this study of 120 patients, 81% reported at least one non-headache symptom in the postdrome.

Postdrome symptoms, in order of frequency, included feeling tired/weary and having difficulty concentrating and stiff neck. Many patients also reported a mild residual head discomfort.(9)

One notable characteristic of the patients was noted by the doctors:

There is a striking underestimation of the frequency of neck stiffness and sensitivity to light and noise.

“Emerging evidence of occipital nerve compression in unremitting head and neck pain”

That is the title of recent research that appears in the July 2019 issue of The Journal of Headache and Pain (10) It comes from researchers at the University of Texas and Harvard Medical School

The cause of Unremitting head and neck pain in some patients may be compression of the lesser and greater occipital nerves by the posterior cervical muscles and their fascial attachments at the occipital ridge (where the base of the skull meets the spine) with subsequent local perineural inflammation (nerve inflammation). The resulting pain is typically in the sub-occipital and occipital location, and, via anatomic connections between extracranial and intracranial nerves, may radiate frontally to trigeminal-innervated areas of the head. Migraine-like features of photophobia (light sensitivity) and nausea may occur with frontal radiation.

Occipital allodynia (a super sensitivity to pain) is common, as is spasm of the cervical muscles. Patients with Unremitting head and neck pain may comprise a subgroup of Chronic Migraine, as well as of Chronic Tension-Type Headache, New Daily Persistent Headache, and Cervicogenic Headache.

Centrally acting membrane-stabilizing agents (local anesthetics), which are often ineffective for Chronic Migraine, are similarly generally ineffective for Unremitting head and neck pain.”

The researchers suggest extracranially-directed treatments such as occipital nerve blocks, cervical trigger point injections, botulinum toxin, and monoclonal antibodies may provide more substantial relief for unremitting head and neck pain; additionally, decompression of the occipital nerves from muscular and fascial compression is effective for some patients and may result in enduring pain relief.

A brief explanation of cervical ligament injury and headaches

In this video, Ross Hauser, MD, explains the mechanisms of cervical ligament injury and headaches.

Transcript summary:

  • Chronic headaches are caused by ligament injury. Because of our modern lifestyle, we’re all hunched over computers and smartphones, when we are hunched over we are getting the slow stretching of the cervical ligaments that connect the bones in the cervical spine. Whiplash injury also causes ligament injury. When these ligaments are injured they can no longer do their intended job, keep the cervical spine stable.
  • Ligament injury can cause headaches by multiple mechanisms. The most common mechanism of headache is muscle spasm. The muscle spasms to try to limit the extra motion of bones so the vertebrae won’t compress nerves or pinch nerves or block cerebral spinal fluid. The person with chronic muscle tension headaches actually has underlying cervical ligament injury.
  • Cervical ligament injury can also cause activation of nerves and ligaments that can refer pain into the forehead and other parts of the head to give headaches

Prolotherapy and the neck element in headaches

Do weakened ligaments in the neck cause an unnatural head posture which can cause headaches? Can strengthening these neck ligaments resolve the problem of chronic headaches and migraines by resolving the problem of cervical instability?

We are going to return to our research published in the journal Practical Pain Management, (1)

Prolotherapy is based on the theory that the cause of most chronic musculoskeletal pain is ligament and/or tendon weakness (or laxity). This retrospective pilot study was undertaken to evaluate the effectiveness of dextrose prolotherapy on tension and migraine headache pain and its associated symptoms.

Typical areas treated during Prolotherapy sessions for chronic headaches and neck pain are the base of the skull, cervical vertebral ligaments, posterior-lateral clavicle, where the trapezius muscle attaches, as well as the attachments of the levator scapulae muscles. Because there is an anesthetic in the solution, generally the neck or headache pain is immediately relieved. This again, confirms the diagnosis both for the patient and the physician.

  • Prolotherapy, by strengthening cervical ligaments and tendons, treats very common trigger and pain locations of the posterior neck that can cause headaches.
  • Prolotherapy will likely become an increasingly useful treatment for aging patients who experience an increase in cervical pain as a trigger for tension and migraine headache pain.

Study highlights:

  • 15 patients
    • Of the 15 patients, five reported daily tension or migraine headaches.
    • Another five participants experienced three to six tension or migraine headaches per week.
    • Taken together, 66% of study participants had tension or migraine headaches multiple times each week.
    • All study participants experienced headaches at least monthly prior to treatment with Prolotherapy
  • After Prolotherapy treatments to the cervical spine, 60% reported the frequency of their headaches as less than once per month
    • Only one patient continued to have daily headaches, although all respondents reported a decrease in the level of pain overall.
  • Intensity Level and Length of Headaches
    • Patients were asked to rate the intensity level of their headaches prior to receiving Prolotherapy and after their last Prolotherapy treatment, using a scale of 1 to 10 (1 being non-noticeable and 10 being severe).
      • Prior to treatment, 67% reported a pain level of 10 out of 10.
      • The remaining 33% of study participants rated their pain between 8 and 9 out of 10.
      • All of the participants reported that their pain was at least 8 out of 10 on the pain scale prior to Prolotherapy treatment.
    • Following treatment, significant decreases in intensity level were noted for 100% of the patients.
    • Forty-seven percent were able to state that the intensity level following treatment was at level 1.

Light sensitivity in the study patients

Sensitivity to light is a common complaint associated with tension or migraine headaches. Study participants reported on light sensitivity both prior to and following completion of the
Prolotherapy treatments, rating them on a scale of 1 to 10 (with 10 being the most severe).

  • Sixty-seven percent reported a 10 out of 10 light sensitivity prior to treatment.
  • After Prolotherapy, 67% reported sensitivity levels of 1, indicating very little sensitivity to light during a headache.
  • Improvement continued for most patients, with 73% reporting reduced sensitivity that had at least somewhat continued well after final treatment. (On average, 22 months after their last Prolotherapy treatment.)

Our study followed patients, on average, 22 months after their last Prolotherapy treatment and all 100% still had benefit.

Clinically significant improvements were reported including:

  • decreased headache intensity level,
  • frequency,
  • duration,
  • number of associated symptoms and light sensitivity in patients with tension and migraine headache pain.

If this article has helped you understand the problems of chronic headaches and migraines and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists

1 Hauser RA, McCullough H. Dextrose Prolotherapy for recurring headache and migraine pain. Practical Pain Management. 2009:58-65. [Google Scholar]
2 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]
3 Lin WS, Huang TF, Chuang TY, Lin CL, Kao CH. Association between cervical spondylosis and migraine: a nationwide retrospective cohort study. International journal of environmental research and public health. 2018 Apr;15(4):587. [Google Scholar]
4 Moore C, Leaver A, Sibbritt D, Adams J. The management of common recurrent headaches by chiropractors: a descriptive analysis of a nationally representative survey. BMC Neurol. 2018;18(1):171. Published 2018 Oct 17. doi:10.1186/s12883-018-1173-6 [Google Scholar]
5 Krøll LS, Hammarlund CS, Westergaard ML, Nielsen T, Sloth LB, Jensen RH, Gard G. Level of physical activity, well-being, stress and self-rated health in persons with migraine and co-existing tension-type headache and neck pain. The journal of headache and pain. 2017 Dec 1;18(1):46. [Google Scholar]
6 Varatharajan S, Ferguson B, Chrobak K, Shergill Y, Côté P, Wong JJ, Yu H, Shearer HM, Southerst D, Sutton D, Randhawa K. Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. European Spine Journal. 2016 Jul 1;25(7):1971-99. [Google Scholar]
7 Rota E, Evangelista A, Ceccarelli M, Ferrero L, Milani C, Ugolini A, Mongini F. Efficacy of a workplace relaxation exercise program on muscle tenderness in a working community with headache and neck pain: a longitudinal, controlled study. Eur J Phys Rehabil Med. 2016 Jan 8.PubMed PMID: 26745361.  [Google Scholar]
8. Bevilaqua-Grossi D, Gonçalves MC, Carvalho GF, Florencio LL, Dach F, Speciali JG, Bigal ME, Chaves TC. Additional Effects of a Physical Therapy Protocol on Headache Frequency, Pressure Pain Threshold, and Improvement Perception in Patients With Migraine and Associated Neck Pain: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2015 Dec 21. [Google Scholar]
9. Giffin NJ, Lipton RB, Silberstein SD, Olesen J, Goadsby PJ. The migraine postdrome: An electronic diary study. Neurology. 2016;87(3):309-313 [Google Scholar]
10. Blake P, Burstein R. Emerging evidence of occipital nerve compression in unremitting head and neck pain. The journal of headache and pain. 2019 Dec;20(1):76. [Google Scholar]


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