Caring Medical - Where the world comes for ProlotherapySuboccipital headache Moving away from nerve blocks and getting results from ligament repair and treatment of muscle spasms

In this article, Ross Hauser, MD will discuss Prolotherapy treatment for Suboccipital headache.

If you are a sufferer of suboccipital headaches, you know exactly what they are, headaches at the base of the skull that can radiate to your forehead and present a vice like pressure on your skull. During the years of trying to find relief, you likely heard that you suffer from tension headaches and/or you have a pinched nerve in your neck causing these headaches. You may have been told that muscle spasms are the cause. As with any problem surrounding the neck, these problems may have been brought on by years of wear and tear and posture problems or by acute injury or accident.

Desperate for answers, doctors start the slow turn away from nerve blocks and towards cervical ligament repair and treating the muscle spasms of the suboccipital region

  • University researchers are helping to confirm that cervical sympathetic syndromes (pain and functional problems) caused by instability in the neck are real problems and related to weakness of neck ligaments and muscles. 
  • This acknowledgment is featured in research in the Journal of Physical Therapy Science, which states a suboccipital headache is caused by muscle fatigue.
  • In this research, a Korean university team isolated on muscle fatigue.(1)
  • In Caring Medical research we isolate on cervical ligament weakness. Muscles get fatigued because they are in spasm from trying to stabilize an unstable neck. An unstable neck gets that way because of ligament weakness and damage. A result of ligament weakness causing muscle spasms is suboccipital headache.

Treating muscle spasms with manipulation

Another study (December 2017) in the Journal of manipulative and physiological therapeutics brings together observations from previous studies and clinical outcomes to suggest that cervical spinal manipulations that help “unfreeze,” or move the neck about, would help eliminate pressure in the muscles and neck and thereby reduce or alleviate Suboccipital headache.(2)

As we have documented in our research and discussed in our articles on Over Manipulation Syndrome, when the ligaments are exposed to continued stress, they will slowly stretch. Repeated stretching such as from excessive high-velocity manipulations will cause them to elongate and deform. The stretched out cervical and capsular ligaments of the spine will cause instability of the spine. When this goes on for too long, the ligaments stretch to the point of no return, and are unable to hold the vertebrae in place. The vertebrae shift and start to cause pain and other symptoms of spinal instability.

You can see how this could lead to a pattern of even more manipulations, because the vertebrae are now shifting more frequently. But manipulations at this point will only make things worse. The attempt at realignment with manipulations will not hold, but will stretch the ligaments further, potentiating the symptoms of over-manipulation syndrome.

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Suboccipital muscle spasm and the path towards nerve blocks

When a patient comes in with headache and neck pain related to the base of the skull we see on examination the hallmark finding of tenderness in the suboccipital muscles.

The function of the suboccipital muscles is underrated, which is confusing because these four fine-tuning muscles are vital in stabilizing the position of the head by helping provide stability in the upper cervical region.

The four muscles are the:

  • rectus capitis posterior major (blue)
  • rectus capitis posterior minor (orange),
  • the obliquus capitis inferior (red)  and
  • obliquus capitis superior (green).

Two terms to quickly identify before we move on:

  • Flexion – this is the motion of the neck forward where your chin can touch your chest.
  • Extension is the opposite motion where you chin will point straight in the air.
  • The atlanto-occipital joint (the joint between the Atlas and Axis (C0-C1) is responsible for 50% of flexion and extension)
  • The atlantoaxial joint (the joint between the first and second cervical vertebrae C1-C2) is responsible for 50% of the neck’s rotation.

Because of its location, the obliquus capitis inferior plays an important role in the static and dynamic stability of the atlantoaxial joint (the joint between the first and second cervical vertebrae C1-C2), especially when there is upper cervical ligament laxity. When cervical neck instability is present the obliquus capitis inferior muscle pulls back the transverse process of the atlas (C0 vertebrae), pulling the atlas back or in extension.

When all four muscles contract on one side, they pull on the neck to that side. When they contract on both sides, they extend the head on the upper cervical spine; this extension is produced at both the atlanto-occipital and atlantoaxial joints. The forward head posture position causes the cervical spine to straighten or go into a kyphotic position, which puts more strain on the structures of the upper cervical spine to hold the top two vertebrae, thus the head goes into extension.

  • Over time, the upper cervical ligaments stretch too far, recruiting the suboccipital muscles to tighten.
  • Once fatigued, they also become a source of significant pain. Suboccipital muscle tension or headache is one the major symptoms of someone having upper cervical instability.

Damage of soft tissue and increase of tension in neck limits stationary contraction of deep cervical muscle, posing difficulty in sustaining upright neck posture. With this process, cervical pain and cervicogenic headache occur, and as pain occurs or aggravates from the motion of returning to normal posture.

The desperation of pain relief – patients opt for high dose nerve blocks

Here is a study from the Mayo Clinic that appeared in the August 24th, 2018 edition of the medical journal Headache.(3)

When all else fails in helping patients with headaches, doctors turn towards High-Volume Anesthetic Suboccipital Nerve Blocks. Let’s see what happened to the patients.

  • In this study, 10 patients suffering from chronic cluster headaches, headaches that could last from weeks to month to years were seen at a dedicated headache clinic over a 7-year time period. These patients were considered difficult to treat as seen in their 7 year medical history of treatment at a dedicated headache clinic.
  • These 10 patients had, at least on 2 occasions analysis received High-Volume Anesthetic Suboccipital Nerve Blocks of 9 mL 1% lidocaine and 1 mL triamcinolone 40 mg/mL injected on the side of the cluster headaches.


  • Nine of the ten patients received pain relief –
    • 1 and a half weeks the minimal relief, 2 patients made it to 44 weeks of pain relief, the 1 patient received no relief.
    • The cumulative average relief time record was about 10 weeks
  • Serial injections in some patients
    • Five patients were injected serially for 2-4 years (30 injections, 17 injections, 15 injections, 10 injections and 3 injections, respectively) with a consistent pain relief .
    • The person who had 30 injections had a typical relief of 6 weeks
    • The person who had 17 injections had a typical relief of 4 weeks
    • The person who had 15 injections had a typical relief of 12 weeks
    • The person who had 10 injections had a typical relief of 4 weeks
    • The person who had 3 injections had a typical relief of 31 weeks

The person who had the 30 injections developed avascular necrosis of the hip

The result of this study are clear, for the desperate patient, High-Volume Anesthetic Suboccipital Nerve Blocks can provide pain relief.  In our research we believe we can show similiar results without the threat of bone damage.

The treatment of over stretched cervical neck ligaments as an alternative to High-Volume Anesthetic Suboccipital Nerve Blocks

Back to the Korean study at the top of this article

According to the researchers, this study was conducted to compare and analyze influence of craniocervical flexion and suboccipitalis relaxation in cervicogenic headache patients of their cervical muscular fatigue, tone, and headache intensity.

In a discussion of their research, the Korean team cited:

  • Most of cervicogenic headache patients take forward neck posture
  • Damage of soft tissue and increase of tension in neck limits stationary contraction of deep cervical muscle, posing difficulty in sustaining upright neck posture.
  • With this process, cervical pain and cervicogenic headache occur and as pain occurs or aggravates from the motion of returning to normal posture.
  • Suboccipital muscles receive overactive tension due to Upper-Cross Syndrome (as identified by Dr Vladimir Janda).
    • Upper Cross Syndrome is characterized by rounded shoulders and forward position of the  shoulder blade. More obviously is the forward pointed chin.

Cervicogenic headache patient with forward neck posture has high muscular tone and fatigue in superficial muscles to keep unstable head from gravity, which easily induces postural disorder and pain. Consequently, effort to keep upright posture is necessary and exercise intervention is most crucial.1

Spasm and tension in the cervical muscle fixes

What we see in the medical literature is a clear understanding that these headaches are caused by spasm and tension in the suboccipital muscles and the upper trapezius muscles that extend from mid back to base of skull.

This was discussed in a study from Korean medical university doctors. In this research, the doctors found that the tone and stiffness of the suboccipital muscles and upper trapezius were higher in patients with cervicogenic headache than in healthy subjects. Here muscle tone refers to the degree of tension in relaxed skeletal muscle, and the most significant factor affecting the level of tone is muscle contraction (spasm) even in a resting state.(4)

Prolotherapy for Suboccipital headache

In 1993, Caring Medical and Rehabilitation Services opened its doors for the first time. Among our first patients were people who suffered from chronic headaches. Sixteen years later we were able to document our experience in treating patients with headaches:

In 2009 we published research in the journal Practical Pain Management (5) that showed weak or loose neck ligaments and/or tendons may act as headache triggers in some people.

  • In our study, patients received Prolotherapy injections with a 15% dextrose, 0.2% lidocaine solution (as demonstrated in the video) No other therapies were used. The patients were asked to reduce or stop other pain medications and therapies they were using as much as the pain would allow.

Our findings strongly suggest that Prolotherapy injections can play a role in decreasing intensity level, frequency, duration, number of associated symptoms and light sensitivity in patients with headache and migraine pain.

  • One-hundred percent of patients reported they were at least somewhat better after receiving Prolotherapy, with
    • 39% of these patients reporting 100% improvement.
    • 47% of patients stated the intensity of their pain was almost not noticeable after receiving treatment.
    • Notable improvements in the duration of time they suffered from headache pain was also experienced after treatment.
    • Seventy-three percent of patients reported a decreased sensitivity to light during a headache.
    • Symptoms associated with tension and migraine headaches decreased in 80% of the patients in this study.

It should be pointed out we did not report any cases of avascular necrosis of the hip from the treatments.

If you have questions about Prolotherapy for Suboccipital headache, get help and information from Caring Medical staff

Prolotherapy for Suboccipital headache


1 Yang DJ, Kang DH. Comparison of muscular fatigue and tone of neck according to craniocervical flexion exercise and suboccipital relaxation in cervicogenic headache patients. Journal of physical therapy science. 2017;29(5):869-73. [Google Scholar]

2 Malo-Urriés M, Tricás-Moreno JM, Estébanez-de-Miguel E, Hidalgo-García C, Carrasco-Uribarren A, Cabanillas-Barea S. Immediate Effects of Upper Cervical Translatoric Mobilization on Cervical Mobility and Pressure Pain Threshold in Patients With Cervicogenic Headache: A Randomized Controlled Trial. Journal of Manipulative & Physiological Therapeutics. 2017 Nov 1;40(9):649-58. [Google Scholar]

3 Rozen TD. High‐Volume Anesthetic Suboccipital Nerve Blocks for Treatment Refractory Chronic Cluster Headache With Long‐Term Efficacy Data: An Observational Case Series Study. Headache: The Journal of Head and Face Pain. 2018 Aug 24. [Google Scholar]

4. Park SK, Yang DJ, Kim JH, Heo JW, Uhm YH, Yoon JH. Analysis of mechanical properties of cervical muscles in patients with cervicogenic headache. Journal of physical therapy science. 2017;29(2):332-5. [Google Scholar]

5. Hauser RA, McCullough H. Dextrose Prolotherapy for recurring headache and migraine pain. Practical Pain Management. 2009:58-65. [Google Scholar]



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