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Ross Hauser, MD

At Caring Medical, we have been seeing headache patients for a long time. In 2009, our research team, published 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 fourteen 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, and they may have cervicogenic headaches all at the same time.

Most know, from explanations from their doctors and their own symptoms that cervicogenic headaches start in the neck and on one side of their head. The headache triggers could be a sudden or strained neck movement accompanied by reduced range of neck motion. Cervicogenic headache is also an umbrella term to describe various types of headaches and this could lead to confusion as to whether the patient is actually suffering from migraine, tension headache, or other primary headache syndromes.

The one thing that many in this group of patients have in common, is that in their case, eventually or hopefully they will get the right help in understanding  they suffer from a cervical instability type headache. Patients do understand that their migraine is coming from their neck, their tension headache is coming from their neck, and 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 how these treatments may help.

Article outline

Part 1: Cervicogenic headaches: Problems of diagnosis.

• There can be hundreds of different kinds of headaches and hundreds of explanations for what causes these different headaches.
• “I have these headaches no one can figure out. All my tests come back normal.”
• How can a person tell if they have cervicogenic headaches?
  • I am not getting any answers except for medications.
  • I have been to several neurologists.
• It’s now years later I still have headaches, blurred vision, memory loss, concentration problems, head pressure. . .
• I have been diagnosed with chronic daily headaches, migraines, tension headaches, cluster headaches, occipital neuralgia, and Trigeminal neuralgia.
• 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.
• Radiofrequency Ablation.

Part 2: Treatment and management of Cervicogenic headaches with a focus on cervical spine ligament damage.

• Treatments that do not work, do not work because they do not address the problems of cervical spine instability from cervical ligament damage.
• The management of common recurrent headaches.
  • Chiropractic and acupuncture do they help?
• Alternative treatments for sleep, fatigue, and neck stiffness.
• Short-term vs. long-term migraine pain relief – research on physical therapy for tension-type headaches.
• Exercise can help you tolerate migraine pain better.
• The effectiveness of craniocervical exercises in migraine patients has not been verified.
• A Physiological Problem or a Forward Head Posture Problem?
• Headache researchers are understanding that patients with migraines and chronic headaches have a neck pain/instability problem and it is more common than thought.
• Here are the results which give evidence to the neck pain connection to headaches: ligaments and tendons in stabilizing the joint.
• “Emerging evidence of occipital nerve compression in unremitting head and neck pain.”
• The backup of cerebrospinal fluid in perimenopausal or in menopause. The cause of the pressure is the pressure headache.
• Here are the results which give evidence to the neck pain connection to headaches: ligaments and tendons in stabilizing the joint.

Part 3: Cervical ligament injury and headaches – Treatments

• Here are the results which give evidence to the neck pain connection to headaches: ligaments and tendons in stabilizing the joint.
• Cervical Spine Realignment and restoring loss of cervical lordosis

Cervicogenic headaches: There can be hundreds of different kinds of headaches and hundreds of explanations for what causes these different headaches.

We get many emails describing the confusion and uncertainty surrounding a diagnosis of what type of headaches the person is suffering from. Below are some examples. For the purpose of clarity and grammatic flow they have been edited.

I am undiagnosed

I am undiagnosed but physical therapist says cervicogenic dizziness and cervicogenic headaches.(One morning) I woke up and when I lifted my head I was immediately dizzy. MRI of brain and neck showed chronic cervical spine degeneration and military neck. I’ve had 5 whiplash injuries, years of chiropractic adjustments. Have been in PT since  and get some relief but not sustained.

There can be hundreds of different kinds and hundreds of explanations of what causes these different headaches, or we can say that they all have a common structural etiology: cervical instability. This injury accounts for the different variety of headaches from a structural or mechanical cause. In other words, almost all structural headaches are cervicogenic headaches. Cervical instability accounts for the following, seen in chronic headache patients:

• Muscle spasms, especially in the suboccipital muscles
• Neuralgias involving primarily the occipital and trigeminal nerves
• cervical subluxations
• Temporomandibular joint dysfunction

The resultant positive symptom-relief, yet temporary responses include:

• massage
• exercises
• physical therapy
• traction
• bite splints
• orthodontic work
• surgeries
• radiofrequency ablation
• acupuncture nerve blocks
• epidurals
• various medications
• Botulinum toxin injections

The above treatments address the results of cervical instability, not the ligament laxity itself.

Cervicogenic headaches: “I have these headaches no one can figure out. All my tests come 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 for 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 for medications.

I have been to several neurologists

I have been to several neurologists. They were 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, and 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. Please see our article Finding the missing cause of headaches, dizziness, and facial pain.

How can a person tell if they have cervicogenic headaches?

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?

• We find someone who is or had been constantly self-manipulating or cracking their neck.
• We find someone who has a long history of getting manipulation from chiropractors for neck pain.
• We find someone who suffers from constant muscle spasms in the neck.
• We find someone who had physical therapy with less than desired results.
• We find someone who, like the example stories above describe, has tests that come back normal, no one knows what is wrong with them, but their doctors and providers may have a clue that there is something wrong in their neck. But since a traditional MRI of the head and neck are not showing any problems, the patient has reached the point of “everything is coming back normal” maybe you need counseling.

Here is another screening process: How can a person tell if they have cervicogenic headaches? Consider the following questions:

1. Have I had neck pain before, during, or after the headache?
2. Do I often feel muscular tension in my neck?
3. Does cracking (manipulating) my neck by myself or someone else help relieve the headache?
4. Does taking pressure off my neck by laying down (supine) make the headache better?
5. Does having my head in the bent down position for long periods of time texting, reading, or working on the computer give me tension in my neck?
6. Does massage therapy on my neck help me feel better?
7. Does wearing a soft cervical collar help the muscles in my neck feel better and also my headaches?
8. Do I have tender points (trigger points) on the sides and back of my neck?
9. Am I a loose-jointed person?

If you answered yes to any or all of the above questions, you likely suffer from cervicogenic headaches.

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.

• “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 a 50% reduction in headache frequency after three months of treatment.

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.

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 diagnose and plan treatments for a patient we suspect 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.

Part 2: Treatment and management of Cervicogenic headaches with a focus on cervical spine ligament damage

I have had a headache for the last five years.

I have had a headache for the last five years. It does not go away. My doctors and I have narrowed it down to an issue with my cervical spine. My primary symptoms are: a tension headache which starts in my suboccipital and wraps around my head in a band pattern, headache behind the eyes, fatigue, brain fog, difficulty concentrating, blurred vision, neck pain, and mild balance issues. I’ve visited many doctors and had many treatments over the 5 years and I have seen very little relief of symptoms. . . I’m desperate for a firm diagnosis or new treatments. 

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:

• “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 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:

• 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 headaches, migraine, and cervicogenic headaches.

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 from 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 headache types?

• 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.”

BUT,

• “While some aspects of chiropractic headache management, including the acceptance and use of headache diagnostic criteria, appear 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?

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 who have underlying ligamentous cervical instability. If you are reading this article you may be one of these patients.

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.

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 (6) 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 evidence suggests that episodic tension-type headaches should be managed with low load endurance craniocervical and cervicoscapular exercises.
• Patients with chronic tension-type headaches may also benefit from low load endurance craniocervical and cervicoscapular exercises; relaxation training with stress coping therapy; or multimodal care that includes spinal mobilization, craniocervical exercises, and postural correction.
• For cervicogenic headaches, low load endurance craniocervical and cervicoscapular exercises; or manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine may also be helpful.”

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. (7)

Chiropractic and acupuncture do they help?

An August 2021 study led by the California Institute of Behavioral Neurosciences & Psychology in the journal Cureus (8) 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.”

Alternative treatments for sleep, fatigue, and neck stiffness

A September 2021 paper in the journal Evidence-based complementary and alternative medicine (9) explored alternative treatment techniques including acupuncture. What the researchers in this study found was that the patients enrolled in this research had:

• Continuous headache pain (64%);
• fixed pain location (74%);
• headache pain was aggravated by overwork (74%),
• headache pain was aggravated by stress (74%), or mental strain (70%);
• and relieved by sleeping (78%).

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.  These are the very deep and interwind problems of fatigue that cause lack of sleep, lack of sleep causing fatigue, pain-causing lack of sleep, and lack of sleep causing pain.

Short-term vs. long-term migraine pain relief – research on physical therapy for tension-type headaches

This research was added to a 2019 study in the journal Medicine (10). Here researchers found short-term benefits but these benefits disappeared after eight weeks. Here are the summary learning points of this research:

• There has been a lot of research on physical therapy for tension-type headaches. However, the effectiveness of physical therapy on the suboccipital region remains unclear.
• The objective of this study was to establish the effectiveness of physical therapy on the suboccipital area of patients with tension-type headaches.

Treatments:

• Suboccipital soft-tissue inhibition technique (massage, physical therapy) + occiput-atlas-axis global manipulation (chiropractic)  was more effective than Suboccipital soft-tissue inhibition technique alone in increasing craniocervical extension (head back, chin up) at four weeks post-treatment. There was no difference at 8 weeks post-treatment.
• The suboccipital soft-tissue inhibition technique was more effective than the Suboccipital soft-tissue inhibition technique + occiput-atlas-axis global manipulation in increasing cervical flexion at 4-week post-treatment
• Suboccipital soft-tissue inhibition technique + occiput-atlas-axis global manipulation was more effective than the Suboccipital soft-tissue inhibition technique in decreasing the intensity of pain at 4-week post-treatment but no difference at 8-week.
• Suboccipital soft-tissue inhibition technique + occiput-atlas-axis global manipulation was more effective than the Suboccipital soft-tissue inhibition technique in reducing the functional score of the headache disability inventory at 4-week post-treatment
•  These results may indicate that the Suboccipital soft-tissue inhibition technique + occiput-atlas-axis global manipulation combined therapy is more effective in the short term (4-week), with no major difference in the longer-term (8-week).

Exercise can help you tolerate migraine 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 spasms.

In this study from doctors at the University of São Paulo in Brazil,”(11), 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).

• Both groups received medication for migraine treatment.
• Additionally, physiotherapy plus medication patients received 8 sessions of physical therapy over 4 weeks, comprised mainly of manual therapy and stretching maneuvers lasting 50 minutes.
  • Results: Twenty-three patients experienced side effects from the medication.
  • Both groups reported a significantly reduced frequency of headaches; however, no differences were observed between groups (physiotherapy plus medication patients showed an additional 18% improvement at posttreatment and 12% improvement at follow-up compared with control patients).
  • The reduction observed in the physiotherapy plus medication patients were clinically relevant in posttreatment
  • For pain intensity, physiotherapy plus medication patients showed statistical evidence and clinical relevance with reduction posttreatment. In addition, they showed better self-perception of (pain management symptom alleviation) than control patients.
  • The cervical muscle pressure pain threshold increased significantly in the physiotherapy plus medication patients and decreased in the control patients, but statistical differences between groups were observed only in the temporal area. No differences were observed between groups regarding the cervical range of motion.

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 effectiveness of craniocervical exercises in migraine patients has not been verified

A randomized control trial in the journal BioMed Central Neurology (12) compared neck-specific strengthening exercise with a placebo sham ultrasound in patients with migraine. The reasoning behind this study was that migraine patients have musculoskeletal disorders and pain in the cervical spine. Further, despite the relationship between migraine headaches and the cervical spine as a possible source of this pain, the effectiveness of craniocervical exercises in these patients has not been verified.

The researchers aimed to verify the effectiveness of craniocervical muscle-strengthening exercise in reducing the frequency and intensity of headaches in migraine patients.

• For eight weeks, the volunteers in the intervention group (21 patients) performed a protocol of craniocervical muscle-strengthening exercise, while those in the sham ultrasound group (21 patients) received the application of disconnected therapeutic ultrasound in the upper trapezius and guidelines for home-stretching. The primary outcomes were lessened frequency and intensity of the headache. The secondary outcomes were questionnaires about migraine and neck disability, satisfaction with the treatment, cervical range of motion, the pressure pain threshold, craniocervical flexion test, cervical muscle strength and endurance test, and cervical muscle activity during the physical tests.

Results:

• No differences were observed for the changes observed in lessened frequency and intensity of the headache after eight weeks and at the 3-months follow up
• Neck-specific strengthening exercises were insufficient in reducing the frequency and intensity of headaches, improving the performance of the cervical muscles, or reducing migraine and neck pain-related disabilities.

Why increase the pain threshold? Why not get rid of headache pain?

Doctors examined the 4th phase of a migraine cycle – (13) 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 a stiff neck. Many patients also reported mild residual head discomfort.

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.

Radiofrequency Ablation

A February 2023 paper (14) led by the New York Institute of Technology, College of Osteopathic Medicine examined dysfunction of the cervical spine, specifically the C1, C2, and C3 area and its spinal nerves for its cause of secondary headache / cervicogenic headache. The authors note that “the usefulness of pharmaceutical medications and physical therapy is currently the subject of scant literature.  Interventional pain management techniques can be applied when conservative treatment is unsuccessful. This study looks at radiofrequency ablation (RFA) and epidural steroid injection (ESI) to identify their safety and efficacy in managing patients with cervicogenic headaches and neck pain.”

Examining previously published research, the authors found the effectiveness of efficacy of radiofrequency ablation (RFA) and epidural steroid injection (ESI) differ. “Both interventions are effective in the reduction of cervicogenic headache pain intensity. However, their complication rates and pain duration are considerably different. With epidural steroid injection (ESI), the headaches can still recur weekly, demanding the use of oral analgesics to deal with them. On the other hand, radiofrequency ablation (RFA) has a low complication rate.”

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 (15) examined the impact of Forward Head Posture on patients with tension headaches. Here are the summary learning points:

• Tension-type headache decreases the ability to concentrate and function during daily activities in affected patients.
• Most patients with Tension-type headaches exhibit forward head posture.
• Various interventions have been proposed to resolve tension-type headaches. However, research regarding the efficacy of these interventions remains lacking.

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:

• Participants were randomly allocated to 3 groups:
  • Biofeedback. Explanatory note: Biofeedback is seen as a way to reduce muscle tension. In simplest terms, this can be conveyed as stress management. Many of you reading this article may have been introduced to biofeedback and had some good results but the results may have been short-lived. The idea is to get the muscles to relax and stop spasming. HOWEVER, if you have had cervical spine instability identified as a primary cause of your headaches, the muscles will intuitively keep spasming because they are trying to hold your neck bones in place.
  • Manual therapy
  • and Stretching

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 by addressing cervical ligament damage and the cervical instability it will cause. The common goal is to get the muscles out of spasms.

A January 2023 paper (16) acknowledged that “disorders in the cervical muscles, such as myofascial trigger points and tightness, are common factors in patients with cervicogenic headache. This research examined the “effectiveness of ultrasound-guided interfascial blocks of the trapezius muscle in patients with cervicogenic headache who showed tenderness in the upper cervical muscle groups.”

• 23 patients had bupivacaine (Local anesthetics) was injected between the muscle fascia.
• Numeric rating scale (NRS 0 – 10 rating), neck disability index (NDI), pain frequency, and analgesic consumption in the pre-treatment and post-treatment period were evaluated.
• The Numeric rating scale scores at 10 min, 1 week, 2 weeks, and 4 weeks after treatment were significantly better than the pre-treatment NRS score.
• The Neck disability index (NDI) scores at 1, 2, and 4 weeks after treatment were significantly better than the pre-treatment NDI score.
• The pain frequency at 1 and 2 weeks after treatment was significantly lower than that recorded in the pre-treatment period.
• Statistically significant reductions were observed in analgesic consumption at 1, 2, and 4 weeks after treatment, in comparison with consumption in the pre-treatment period.

The researchers concluded that “ultrasound-guided interfascial block of the trapezius muscle is effective for the treatment of cervicogenic headache caused by muscle disorders.”

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.

I’ve struggled with cervicogenic headaches for the last few years. I am seeing a neurologist who has prescribed welbutrin/anti-anxiety and cyclobenzaprine/muscle relaxers. I’ve had MRIs done to confirm it’s not a brain issue. I’ve seen massage therapists and chiropractors. All of these solutions offer effective relief, but only short term.  I started to I’ve noticed the issue is less of the headaches and more of the tight neck muscles, levator scapula, trapezius, occipitals, that are creating the issue. I’ve also noticed intense brain fog and lethargy that is almost unexplainable. 

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, of keeping the cervical spine stable.
• Ligament injury can cause headaches by multiple mechanisms. The most common mechanism of headache is muscle spasms. The muscle spasms 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 an underlying cervical ligament injury.
• Cervical ligament injury can also cause activation of nerves and ligaments that can refer to pain in the forehead and other parts of the head give headaches

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 (17) 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 of 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 migraines 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 a lower level of physical activity and psychological well-being, a 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 a 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. 

“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 (18) 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.

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 (19) 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:

• Eight patients were included in the presented case series.
• The average age of the patient at the onset of this distinct headache condition was 57 years old.
• All patients were either perimenopausal or in menopause when the headaches started.
• The pain experienced on both sides of the head starts daily from the onset and is typically at its most severe intensity the first thing in the morning before arising or when in the supine position (laying down).
• Immediate worsening in Trendelenburg appears to be an almost diagnostic test for the syndrome and occurred in all patients.
  • Explanation: Some of you may be familiar with the Trendelenburg position test. You are head down and feet up so the “blood rushed to your head.” As noted in one paper (20): “The Trendelenburg position causes a rapid increase in intracranial CSF pressure. In a patient with a known CSF leak who over time had less improvement in the supine position, being placed in Trendelenburg rapidly alleviated her daily headache. This suggested that the Trendelenburg position might be a good screening tool for low CSF pressure syndromes.”
• The majority of the patients had a history of episodic migraine, but the migraines were either very well controlled or had ceased by the time the new headache arose. The bulk of the patients (6/8) were either overweight or obese, although two patients were of normal body mass index (BMI). Neuroimaging showed no abnormalities. All patients responded to cerebrospinal fluid (CSF) pressure-/volume-lowering medications (acetazolamide or spironolactone), but only one patient was able to completely taper off treatment without headache recurrence.

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.

 

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

In this video, Ross Hauser, MD offers a brief introduction to the causes and the diagnosis of occipital neuralgia and migraines and is 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 the 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 an 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. See our research paper: Prolotherapy for Headache and Migraine Pain

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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.

In my article Ross Hauser, MD. Reviews of Diagnostic Imaging Technology for Cervical Spine Instability, I discuss DMX and compare it to standard digital imaging in varying cervical spine instability issues that may be implicated in migraines and tension headaches.

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.

• 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 levels 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 of patients

Sensitivity to light is a common complaint associated with tension or migraine headaches. Study participants reported 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 the 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 benefits.

Clinically significant improvements were reported including:

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

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.

The role of Lordosis in worsen symptoms of headaches is a somewhat controversial subject. The controversy surrounds understanding the total understanding of the extent lordosis plays in headaches.

A March 2023 paper in the Medical science monitor (18) made these observations surrounding the loss of cervical lordosis and cervicogenic headache. Both problems “have similar tissue abnormalities, including weakness and atrophy in the neck muscles. Cervicogenic headache is mainly unilateral and is perceived in the occipito-temporo-frontal regions.” However, it is not clear whether loss of cervical lordosis is a sign of headache with cervical origin. The researchers aimed to assess and compare headache characteristics in patients with and without loss of cervical lordosis.

Two groups of patients,

• 38 chronic neck pain patients with cervical lordosis, 28 Female about age 33 years old and
• 38 chronic neck pain patients without cervical lordosis, 29 Female about age 33 years old.

Patients with loss of cervical lordosis have longer duration of headache attack than those without. Loss of cervical lordosis may be a specific finding associated with longer cervicogenic headache attacks.

Further reading: Symptoms and conditions of Craniocervical Instability

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This article was updated March 25, 2023

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