Cervicogenic headaches: Migraines, tension headaches and cervical spine instability

Ross Hauser, MD

Patients with migraines and chronic headaches have a cervical neck instability problem

At Caring Medical, we have been seeing headache patients for a long time. In 2009, our research team led 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. Our 2009 paper was already based on 15 years of clinic observation. Here we are twelve years later confirming again what we see in our patients.

Many of the patients that we see have become headache experts over the years. By the time they come to us, they have been on a many-year medical journey and have learned to distinguish between the different types of headaches that they suffer from. They know that their Cervicogenic headache is not really a migraine or a tension-type headache nor is their migraine or tension headache a Cervicogenic headache. However, for many people, this is not a “one or the other” problem. They may have migraines, they may have tension headaches, they may have cervicogenic headaches all at the same time.

The one thing that this group of patients has learned in common is that in their case, they suffer from a cervical instability type headache. They know this because in addition to their headache they suffer from constant neck pain and neck pain or head pain when they turn to look up and down or left or right. So they do understand that their migraine is coming from their neck, their tension headache is coming from their neck, their cervicogenic headache is coming from their neck.

In this article, we will examine the research and treatments for these headaches that focus on neck stability and who these treatments may help.

“I have these headaches no one can figure out. Everything comes back normal”

Over the years we have been contacted by many people who tell us “I have these headaches no one can figure out.” Then they go on to describe something like this:

I am not getting any answers except medications.

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, the headache moves behind my eyes and sinus area. I am not getting any answers except medications.

I have been to several neurologists

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 headaches. A clear picture emerges for us when we take a medical history. What do we find in many of these patients?

It’s now years later I still have headaches, blurred vision, memory loss, concentration problems, head pressure, I can’t focus enough to read, I cannot look at any screen, I have no screen time, I am sensitive to light but the neurological said I’m good to go just let him know if I need a prescription filled.

As mentioned, some people respond very well to traditional drug-based medicine and stress management. These are not the people we see at our center.

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.

I have been diagnosed with chronic daily headaches, migraines, tension headaches, cluster headaches, occipital neuralgia, and Trigeminal neuralgia.

One of the great frustrations that people with headaches have is that it is easy for them to get a diagnosis and if they keep at it they will, more times than not, get an accurate diagnosis. The frustration of course is, and maybe the frustration you suffer from is that the “end of the line” has been reached. You are now only being offered prescriptions and counseling.

As mentioned at the start of this article, many patients that we see have become headache experts over the years as they diagnose and figure out their own cases and by their own trial and error figure out ways to help themselves.

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 a 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:

The management of common recurrent headaches

We are going to explore research that will give evidence that your chronic headache and migraine are 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 is:

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.

Number of chiropractic visits

For headache suffers from less than 3 months duration:

How do chiropractors treat by headache type?

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

BUT,

What are we to make of this?

In December 2020, (5) doctors at the Hospital for Special Surgery, Weill Cornell Medical College, and the Department of Neurology, at the Icahn School of Medicine at Mount Sinai, New York embarked on the “first study to provide detailed information on the patient management features associated with primary headache diagnosis by chiropractors. The majority of chiropractors in our study report utilizing ICHD (The International Classification of Headache Disorders) criteria for the diagnosis of primary headaches, a finding which may suggest that chiropractors are sometimes the first point of provider contact for patients seeking help in the management of primary headache disorders.

There are a number of factors that can challenge health care providers in delivering an accurate primary headache diagnosis. These include the co-occurrence of migraine with both cervicogenic headache and tension-type headache, variations in headache characteristics found within headache types, and the high prevalence of co-occurring neck pain associated with common recurrent headaches. With misdiagnosis resulting in suboptimal headache patient management, poor standards of headache diagnosis have raised concerns about the current level of headache education within primary health care curriculums.

Again, 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.

Chiropractic and acupuncture do they help?

An August 2021 study led by the California Institute of Behavioral Neurosciences & Psychology in the journal Cureus (6) offered this assessment of acupuncture and manual or chiropractic care.

“There are several non-pharmacologic treatment options suggested for tension-type headaches, such as cognitive behavioral therapy, relaxation, biofeedback, acupuncture, exercise, manual therapy, and even some home remedies.  . . Acupuncture was compared to routine care or sham (placebo acupuncture) intervention. Acupuncture was not found to be superior to physiotherapy, exercise, and massage therapy. . . Manual therapy has an efficacy that equals prophylactic medication (Angiotensin blockers, Antidepressants, Beta-blockers, NSAIDs, etc) and tricyclic antidepressants in treating tension-type headaches. The available data suggests that both acupuncture and manual therapy have beneficial effects on treating symptoms of tension-type headache. However, further clinical trials looking at long-term benefits and risks are needed.”

Sleep, fatigue, and neck stiffness

A September 2021 paper in the journal Evidence-based complementary and alternative medicine (7) explored alternative treatment techniques including acupuncture. What the researchers in this study found was that the patients enrolled in this research had:

The commonest non-headache pain co-symptoms were fatigue (71%) and neck stiffness (70%).

These problems people have are the things we see in many of our patients.  This is the very deep and interwind problems of fatigue cause lack of sleep, lack of sleep causing fatigue, pain-causing lack of sleep, lack of sleep causing pain.

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.

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

More instability

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:


Digital motion X-Ray C1 – C2

The digital motion x-ray is explained and demonstrated below

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

Let’s look at 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 (8) 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:

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

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. 

A Physiological Problem or a Forward Head Posture Problem?

Because you are reading this article, it will be assumed that you know what forward head posture is, it is likely that if you have been to a chiropractor or other health care provider and this problem may have been explained to you as a potential cause of your problem.

In December 2019, a randomized control trial’s results were published in the journal Medical Science Monitor (9) examined the impact of Forward Head Posture on patients with tension headaches. Here are the summary learning points:

To address this concern, the researchers “aimed to investigate the association between forward head posture and Tension-type headache and to evaluate the efficacy of various intervention methods on headache symptoms and other clinical variables in patients with Tension-type headache induced by forward head posture.

Three different treatments:

Interventions (treatments) were conducted 3 times per week for 4 weeks.

The researchers found that Biofeedback was more effective than Manual therapy and Stretching in the treatment of Tension-type headaches due to forward head posture. Such findings highlight the need to develop and promote a controlled exercise program to facilitate a return to normal daily activities in patients with Tension-type headaches due to forward head posture.

What the researchers are suggesting is that IF YOU CAN GET THE MUSCLES TO STOP SPASMING, forward head posture conditions and symptoms are lessened including headache. Another way to do this would be through addressing cervical ligament damage and the cervical instability it will cause. The common goal is to get the muscles out of spasm.

What are we seeing in this image?

On the left, ideal posture, no stress on the cervical neck muscles. On the right, forward head posture and stress and ultimately spasms in the neck muscles.

On the left, ideal posture, no stress on the cervical neck muscles. On the right, forward head posture and stress and ultimately spasms in the neck muscles.

Chiropractors found headaches have a neck instability component and the treatments offered were at best symptom management techniques. For many, they were not long-lasting treatments.

Above we discussed one study which compared biofeedback to manual therapy or chiropractic therapy. In this study, researchers at the Canadian Memorial Chiropractic College 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 this study, combination treatments were offered. Published in the European Spine Journal (10) the chiropractic team 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. More specifically, these are the recommendations:

The connection and problems of headache and neck pain in the workplace have 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. (11)

Short-term vs. long-term

This research was added to a 2019 study in the journal Medicine (12). Here researchers found short-term benefits but these benefits disappeared after eight weeks. Here are the summary learning points of this research:

Treatments:

Exercise can help you tolerate pain better

Again, the researchers point to symptom 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 this study from doctors at the University of São Paulo in Brazil,”(13), 50 women (age 18-55) diagnosed with migraine were randomized into 2 groups: a control group (25 patients) and a physiotherapy plus medication group (25 patients).

Conclusions: 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.

The 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.

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 mild residual head discomfort. (14)

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 (15) 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 a spasm of the cervical muscles. Patients with Unremitting head and neck pain may comprise a subgroup of Chronic Migraine, as well as 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:

The backup of cerebrospinal fluid in perimenopausal or in menopause. The cause of the pressure is the pressure headache.

A 2018 paper in the Journal of Women’s Health (16) titled: “A New Subtype of Chronic Daily Headache Presenting in Older Women,” found a new classification for perimenopausal or menopausal women suffering from headaches suspected of being caused by intracranial pressure. While this research suggests that obesity or weight may play a role, of the eight patients they examined, two were not overweight, reflecting 25% of the study group. Let’s look at the research:

The conclusion of this study: “This newly defined subtype of chronic daily headache appears to be caused by a state of elevated CSF pressure. It is hypothesized that a combination of an elevated BMI and the presence of cerebral venous insufficiency leads to this form of daily headache.” Elevated CSF pressure is also characteristic in cervical instability patients.

What are we seeing in this image?

The patient is in the head back, chin up extension. Because of cervical spine instability and cervical ligament laxity, extension turns into hyperextension. In hyperextension of the C1, the space between the C1-C2 is significantly narrowed. When space is narrowed, everything, including nerve roots that pass between them is squeezed. Compression of the nerve root can lead to occipital neuralgia and headache. When the body has a headache and the body senses it may be because of this nerve impingement, the muscles tighten to try to prevent the head from hyperextending backward.

The patient is in head back, chin up extension. Because of cervical spine instability and cervical ligament laxity, extension turns into hyperextension. In hyperextension of the C1, the space between the C1-C2 is significantly narrowed.

Prolotherapy and the neck element in headaches

Do weakened ligaments in the neck causes 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.

Study highlights:

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).

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

Clinically significant improvements were reported including:

Further reading: Cervical Spine Realignment and restoring loss of cervical lordosis

In our article Cervical Spine Realignment and restoring loss of cervical lordosis, Dr. Hauser presents the case that cervical spine, upper cervical spine, and lower cervical spine instability may be an unexplored cause of your neurologic-like, vascular-like and psychiatric-like conditions, and symptoms.

Further reading: Symptoms and conditions of Craniocervical Instability

In this article, Symptoms, and conditions of Craniocervical Instability, Dr. Hauser has put together a summary of some of the symptoms and conditions that we have seen in our patients either previously diagnosed or recently diagnosed with Craniocervical Instability, upper cervical spine instability, cervical spine instability, or simply problems related to neck pain.

For many of these people, symptoms, and conditions extended far beyond the neck pain, radiating pain of cervical radiculopathy, headaches, TMJ, and possibly dizziness usually associated with problems in the neck. These people’s symptoms and conditions extend into neurologic-type problems that may include digestion, irregular cardiovascular problems, hallucinogenic sensations, vision problems, hearing problems, swallowing problems, excessive sweating, and a myriad of others.

I want to point out that the symptoms and conditions you will see described below can be caused by many problems. This article demonstrates that craniocervical instability and cervical neck instability can be one of them.

Summary and contact us. Can we help you?

Sometimes a person has other factors, in addition to ligament weakness in the neck, associated with initiating the migraines, including food sensitivities, hormone deficiencies, and yeast infections. In these instances, Prolotherapy must be combined with other treatments, such as elimination of allergic foods from the diet, natural hormone supplementation, or yeast infection treatment, to obtain completely curative results.

If the migraine headaches occur at a particular part of a woman’s menstrual cycle, a hormonal abnormality is likely involved. The hormonal abnormality is usually due to a low progesterone level during the second half of the menstrual cycle. Giving natural progesterone during this part of the menstrual cycle will often relieve the problem.

If the migraine headaches occur when eating particular foods, during particular times of the year, or when exposed to certain scents, an allergic component to the migraines should be investigated. Migraine headaches are a common symptom of food allergies. Eliminating the suspect food from the diet will likely solve the migraine problem. In addition, there are times when a person’s protein/fat/carbohydrate ratio is off. Eating according to one’s individual Diet Type can be a helpful piece to the puzzle to alleviate migraine headaches.

Current traditional drugs for migraine headaches, such as ergotamine, Fiorinal, sumatriptan, zolmitriptan, and other medications, provide only temporary relief. The patient dependent on these drugs for headache relief lives in fear of the next migraine attack. Patients describe their migraine headaches as similar to having one-half of their head hit repeatedly with a baseball bat.

From an anatomical perspective, cervical instability is the culprit in the majority of non-hormone or diet-related headaches and migraines. Upon palpation along the base of the head, and through the neck, tenderness or pain indicates weakness at the ligament attachments, the pain sensors of the body. Often patients also tell us that they have a lot of “knots” in their neck all the time, and for years they just attributed it to stress. While stress can certainly be a contributing factor to healing, the structures are tight for a reason. The muscles in the neck are trying to keep a 10-pound head balanced on the small, upper cervical vertebra. Like balancing a bowling ball on an espresso cup without a little assistance. Normally, the ligaments provide the stability needed to turn the head, side to side, up or down, and safely return back to a neutral position. With cervical ligament damage, the muscles have to kick into high gear, without rest, in order to stabilize the head. The muscles and ligaments are screaming for relief in the form of a crushing headache. Thus, Prolotherapy to the cervical ligament attachments may provide long-term success against headaches and migraines.

We hope you found this article informative and it helped answer many of the questions you may have surrounding your problems of chronic headaches and migraines.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References

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This article was updated October 18, 2021

 

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