This section is compiled by Frank M. Painter, D.C. Send all comments or additions to:
Frankp@chiro.org
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Headache Information Articles
Headache Classification System
This page differentiates between “primary” and “secondary” headaches, and then describes these primary headache types:
Cervicogenic, Tension-type, Migraine, and Cluster headaches.
Chronic Daily Headache in Adolescents: Prevalence, Impact, and Medication Overuse
Neurology 2006 (Jan 24); 66 (2): 193–197
Chronic daily headache (CDH) was common in a large nonreferred adolescent sample. Based on the International Classification of Headache Disorders, 2nd edition, criteria, chronic tension-type headache was the most common subtype;
Although this article does not discuss care options for chronic tension-type headache, conservative chiropractic care is the natural choice.
Upper Crossed Syndrome and Its Relationship to Cervicogenic Headache
J Manipulative Physiol Ther 2004 (Jul); 27 (6): 414—420
The principles of upper crossed syndrome and the use of exercise, chiropractic care, and myofascial release in the treatment of cervicogenic headache are discussed. A review of the literature indicates that analyzing muscle imbalance as well as vertebral subluxation may increase the effectiveness of chiropractic treatment for cervicogenic headache.
Upper Chiropractic Spinal Manipulation for Cervicogenic Headache in an 8-Year-Old
J Neuromusculoskeletal System 2002 (Fall); 10 (3): 98–103
A case of cervicogenic headache (CEH) in an 8-year-old boy that improved after chiropractic spinal manipulation is reported. A significant decrease in headache frequency as reported by the patient and parent was seen after the first treatment. After four treatments the headache frequency decreased to approximately one per month. The patient was followed for 2 months after termination of care and reported headache frequency of approximately two per month. There is evidence that spinal manipulation is effective in the treatment of CEH in adults.
Evidence Report: Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache (a.k.a. The Duke Headache Evidence Report)
This report found (1) Compared to amitriptyline use, chiropractic is shown to produce slightly lesser effects during the treatment period but markedly superior results afterward in the treatment of tension-type headache; (2) Compared to various soft tissue procedures, a course of manipulation treatments (diversified and/or toggle-recoil techniques, depending on the level of the palpated segmental dysfunction) is shown to produce sustained improvement in headache frequency and severity in the treatment of cervicogenic headache.
Headaches - Tension, Migraine and Cluster
American Chiropractic Association
A report released in 2001 by researchers at the Duke University Evidence-Based Practice Center in Durham, NC, found that spinal manipulation resulted in almost immediate improvement for those headaches that originate in the neck, and had significantly fewer side effects and longer-lasting relief of tension-type headache than a commonly prescribed medication.
Abstaining From Medicine May Cure Drug Rebound Headache
SAN FRANCISCO, CA -- March 23, 1998 -- Many people who suffer from chronic daily headaches would find relief simply by not taking daily headache medicine, according to a report in this month’s issue of the Western Journal of Medicine.
Three Articles Which Describe the Relationship Between the Upper Cervical Spine and Headaches and Chronic Head Pain
1. Atrophy of Suboccipital Muscles in Chronic Pain Patients
We have observed previously unreported muscle atrophy in the rectus capitis posterior minor (RCPMI) muscles of a group of chronic pain patients. We hypothesize that chronic pain, in this select group of patients, is a consequence of tramua that occurs to the C1 dorsal ramus during whiplash.
2. Magnetic Resonance Imaging of the Upper Cervical Spine
We are currently using MRI to investigate the functional integrity of the upper cervical spine. We started out looking for hypertonic muscles in a population of patients who were suffering from chronic head and neck pain. My first task was to collect MRI data and to identify suboccipital muscles within the MR images. So I brought together a physician and an anatomy professor to see if they could help me out. Their comments were classic. The anatomy professor said, "The reason you can't find those muscles is because they are not there." The physician immediately responded by saying, "No wonder these patients don't get any better." I had been using images that were collected from a chronic pain patient, and it was apparent that the rectus capitis posterior minor muscles were missing. When we looked at images from a control subject it was very easy to locate these muscles. At that point, the focus of our research switched from looking for hypertonic muscles to comparing muscle density between the control group and the chronic pain group.
3. Anatomic Relation Between the Rectus Capitis Posterior Minor Muscle and the Spinal Dura Mater
We observed that the PAO membrane was securely fixed to the surface of the dural tube by multitudinous fine connective tissue fibers. There was no real interlaminar space between these two structures and they appeared to function as a single entity. The influence of the RCPMI muscle on the dura mater was artificially produced in the hemisected specimen. Artificially functioning the muscle produced obvious movement of the spinal dura between the occiput and the atlas, and resultant fluid movement was observed to the level of the pons and cerebellum.
Upper Cervical Spine Information
This remarkable website, designed by a former Microsoft employee, clearly defines many aspects of the Upper Cervical Subluxation, and it's impact on health.
The ANATOMY of the ATLAS SUBLUXATION
An Open Study Comparing Manual Therapy With the Use of Cold Packs in the Treatment of Post-traumatic Headache
Cephalalgia 1990 Oct; 10(5): 241–50
It is concluded that the type of manual therapy used in this study seems to have a specific effect in reducing post-traumatic headache. The result supports the hypothesis of a cervical mechanism causing post-traumatic headache and suggests that post-traumatic dizziness, visual disturbances and ear symptoms could be part of a cervical syndrome.
A Holistic Approach to Severe Headache Symptoms in a Patient Unresponsive to Regional Manual Therapy
J Manipulative Physiol Ther 1996 (Mar); 19 (3): 202–207
This patient seemed to respond favorably to conservative care that included regions of spine not traditionally associated with headache pain. This suggests that some individuals may require a more comprehensive evaluation if regional care fails to promote a positive response within a few weeks. Controlled, randomized trials will assist in comparing effectiveness of various treatment interventions.
Subluxation and Neurology Articles
There are many other articles that explain the relationship between headaches and spinal subluxations o0n this page.
Cervicogenic Headache
Clinical Test of Musculoskeletal Dysfunction in the Diagnosis of Cervicogenic Headache
Manual Therapy 2006 (May); 11 (2): 91–166
The results indicated that when compared to the migraine with aura and control groups who scored similarly in the tests,
the cervicogenic headache group had less range of cervical flexion/extension (P=0.048) and significantly higher incidences of painful upper cervical joint dysfunction assessed by manual examination (all P<0.05) and muscle tightness (P<0.05). Sternocleidomastoid normalized EMG values were higher in the latter three stages of the cranio-cervical flexion test although they failed to reach significance. There were no between group differences for other measures. A discriminant analysis revealed that manual examination could discriminate the cervicogenic headache group from the other subjects (migraine with aura and control subjects combined) with an 80% sensitivity.
Cervicogenic Head and Neck Pain in the ENT Clinic
HNO 2005 (May 11)
It is discussed controversially whether cervicogenic pain in the head and/or neck is a pathogenic entity. The good results obtained with manual therapy in patients with head and neck pain contradict the refusal of the majority of the neurologists to accept the diagnosis "cervicogenic headache." Complaints about headache are frequently encountered in the general ENT clinic. The versatile picture of the cervicogenic headache is caused by the complex neural connections in the region of the upper cervical spine. The differential diagnosis of the cervicogenic headache is described.
Dose Response for Chiropractic Care of Chronic Cervicogenic Headache and Associated Neck Pain: A Randomized Pilot Study
J Manipulative Physiol Ther 2004 (Nov); 27 (9): 547—553
Patients were randomly allocated to 1, 3, or 4 visits per week for 3 weeks. All patients received high-velocity low-amplitude spinal manipulation. Doctor of Chiropractics could apply up to 2 physical modalities at each visit from among heat and soft tissue therapy. They could also recommend modification of daily activities and rehabilitative exercises. A large clinical trial on the relationship between pain relief and the number of chiropractic treatments is feasible. Findings give preliminary support for the benefit of larger doses, 9 to 12 treatments, of chiropractic care for the treatment of cervicogenic headache.
Upper Crossed Syndrome and Its Relationship to Cervicogenic Headache
J Manipulative Physiol Ther 2004 (Jul); 27 (6): 414—420
The principles of upper crossed syndrome and the use of exercise, chiropractic care, and myofascial release in the treatment of cervicogenic headache are discussed. A review of the literature indicates that analyzing muscle imbalance as well as vertebral subluxation may increase the effectiveness of chiropractic treatment for cervicogenic headache.
Chiropractic Spinal Manipulation for Cervicogenic Headache in an 8-Year-Old
J Neuromusculoskeletal System 2002 (Fall); 10 (3): 98–103
A case of cervicogenic headache (CEH) in an 8-year-old boy that improved after chiropractic spinal manipulation is reported. An 8-year-old boy presented with a complaint of daily headache. The duration of symptoms was over 3 years. The patient met the diagnostic criteria for CEH. Awkward head position reproduced head pain, as did palpation of the upper cervical region. Decreased range of motion of the neck was evident, as well as abnormal tenderness and primarily of the right upper cervical region. A significant decrease in headache frequency as reported by the patient and parent was seen after the first treatment. After four treatments the headache frequency decreased to approximately one per month.
Headache in Cervical Syndrome
Ther Umsch 1997 (Feb); 54 (2): 94–97
Headache is a common symptom in patients suffering from cervical spine disorders. The percentage of headaches in association with degenerative changes of the cervical spine ranges from 13 to 79% and that in association with indirect trauma of the cervical spine from 48 to 82%. Based on neuroanatomical and neurophysiological studies, the relationship of the upper cervical spine and the trigeminal nuclei has been demonstrated and serves as an explanation for perceived head pain in cervical spine disorders. As a source of pain, tension in the suboccipital muscles, irritation of the third occipital nerve, and degenerative changes of the C2/C3 joints have been discussed. Bogduk, in his studies, asserts a direct causative role of mechanical derangement of the cervical spine in the pathogenesis of cervicogenic headaches.
The Prevalence of Cervicogenic Headache in a Random Population Sample of 20-59 Year Olds
Spine 1995 (Sep 1); 20 (17): 1884–1888
A short questionnaire on headaches was mailed to 826 randomly selected residents of a midsized Danish town. A group of 57 individuals in the age range 20-59 years who reported having headache episodes on 5 or more days in the previous month were identified. Forty-five of the 57 were eventually interviewed and examined with respect to the IHS criteria for cervicogenic headache (the radiological criteria were omitted on ethical grounds). Of the 45 persons examined, eight fulfilled the diagnostic criteria for cervicogenic headache, equivalent to a prevalence in the headache group of 17.8%
Cervicogenic Headache: The True Pain in the Neck
Foundation for Chiropractic Education and Research
For decades, Doctors of Chiropractic have successfully treated headaches. Success was so quick and profound in some instances that chiropractors theorized that some headaches are caused by dysfunction in the neck and cervical spine. This theory was largely over-looked by the scientific community as they knew of no biological or physiological link. But the chiropractors were right! In 1995, a team of researchers at the University of Maryland in Baltimore were intricately dissecting cadavers and discovered the biological link—a connective tissue bridge from a muscle in the head to the membrane covering the brain and the spinal cord (the dura mater). (1)
Cervicogenic Headache:
Anatomic Basis and Pathophysiologic Mechanisms
Curr Pain Headache Rep 2001 (Aug); 5 (4): 382–386
Cervicogenic headache is pain perceived in the head but referred from a primary source in the cervical spine. The physiologic basis for this pain is convergence between trigeminal afferents and afferents from the upper three cervical spinal nerves.
Cervicogenic Headache:
Manual and Manipulative Therapies
Curr Pain Headache Rep 2001 (Aug); 5 (4): 369–375
This article reviews current literature on the role of manual medicine in the diagnosis and treatment of cervicogenic headache. Manual diagnostic procedures and treatment procedures are described for the cervical spine. Emphasis is placed on accurate diagnosis using a biomechanical model and precise localization of forces.
Cervicogenic Headache:
Diagnostic Evaluation and Treatment Strategies
Curr Pain Headache Rep 2001 (Aug); 5 (4): 361–368
The clinical presentation of cervicogenic headache suggests that there is an activation of the trigeminovascular neuroinflammatory cascade, which is thought to be one of the important pathophysiologic mechanisms of migraine. Another convergence of sensorimotor fibers has been described involving intercommunication between the spinal accessory nerve (CN XI), the upper cervical nerve roots, and ultimately the descending tract of the trigeminal nerve. This neural network may be the basis for the well- recognized patterns of referred pain from the trapezius and sternocleidomastoid muscles to the face and head.
Further Clinical Clarification of the Muscle Dysfunction in Cervical Headache
Cephalalgia 1999 (Apr); 19 (3): 179–185
From the perspective of physical characterization of cervical headache, it appears that response from passive stretch of muscle may not be a strong criterion for cervical headache but deep neck flexor performance may have potential to identify musculoskeletal involvement in headache. The finding may also provide positive directions for conservative treatment of cervical headache.
Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache
Duke University Evidence-based Practice Center
In 1996, the Agency for Health Care Policy and Research (AHCPR) was scheduled to produce a set of clinical practice guidelines on available treatment alternatives for headache. This headache project was based on the systematic evaluation of the literature by a multidisciplinary panel of experts. Due to largely political circumstances, however, their efforts never came to fruition. The work was never released as guidelines, but was instead transformed with modifications and budget cuts into a set of evidence reports on only migraine headache. Thanks to FCER funding, the evidence reports have now been updated on both cervicogenic and tension-type headaches. You may also download this as an
Adobe PDF file. You may also enjoy Dr. Anthony Rosner's recent article on this subject.
The Effect of Spinal Manipulation in the Treatment of Cervicogenic Headache
J Manipulative Physiol Ther 1997 (Jun); 20 (5): 326–330
The use of analgesics decreased by 36% in the manipulation group, but was unchanged in the soft-tissue group. The number of headache hours per day decreased by 69% in the manipulation group, compared with 37% in the soft-tissue group. Finally, headache intensity per episode decreased by 36% in the manipulation group, compared with 17% in the soft-tissue group. You might also enjoy this sidebar article
Chiropractic Effective for Cervicogenic Headache.
Cervicogenic Dysfunction in Muscle Contraction Headache and Migraine: A Descriptive Study
J Manipulative Physiol Ther 1992 (Sep); 15 (7): 418—429
A case of cervicogenic headache (CEH) in an 8-year-old boy that improved after chiropractic spinal manipulation is reported. Both muscle contraction/tension-type headache (MCH) and common migraine without aura (CM) subjects demonstrate high occurrences of: a) occipital and neck pain during headaches; b) tender points in the upper cervical region; c) greatly reduced or absent cervical curve; and d) X-ray evidence of joint dysfunction in the upper and lower cervical spine. These findings support the premise that the neck plays an important, but largely ignored role in the manifestation of adult benign headaches. A case-control study should be conducted to confirm the greater prevalence of cervicogenic dysfunction in headache as compared to nonheadache subjects.
Spinal Manipulation and Headaches of Cervical Origin
J Manipulative Physiol Ther 1989 (Dec); 12 (6): 455–468
This article reviews the published clinical studies of manipulation in the treatment of tension and migraine headaches. The topic of cervical headaches in general is reviewed and the current model of cervicogenic headache is critiqued. A representative case history is used to illustrate the thesis that the current model of cervicogenic headache may be too restrictive. The role of spinal manipulation as a trial of therapy in individual patients is also discussed. a retrospective diagnosis of cervical headache can often be confirmed by a successful outcome.
Upper Cervical Chiropractic Care for a Patient with Chronic Migraine Headaches with an Appendix Summarizing an Additional 100 Headache Cases
Journal of Vertebral Subluxation Research 2003 (Aug 3); 1–10
The onset of the symptoms following the patient’s fall on her head; the immediate reduction in symptoms correlating with the initiation of care; and the complete absence of all symptoms within three months of care; suggest a link between the patient’s concussion, the upper cervical subluxation, and her headaches. Further investigation into upper cervical trauma as a contributing factor to headaches should be pursued.
The Efficacy of Spinal Manipulation, Amitriptyline and the Combination of Both Therapies for the Prophylaxis of Migraine Headache
J Manipulative Physiol Ther 1998 (Oct); 21 (8): 511–519
There was no advantage to combining amitriptyline and spinal manipulation for the treatment of migraine headache.
Spinal manipulation seemed to be as effective as a well-established and efficacious treatment (amitriptyline), and on the basis of a benign side effects profile, it should be considered a treatment option for patients with frequent migraine headaches.
A Twelve Month Clinical Trial of Chiropractic Spinal Manipulative Therapy for Migraine
Australasia Chiropractic and Osteopathic Journal 1999 (Jul): 8 (2)
32 participants showed statistically significant (p < 0.05) improvement in migraine frequency, VAS, disability, and medication use, when compared to initial baseline levels. A further assessment of outcomes after a six month follow up (based on 24 participants), continued to show statistically significant improvement in migraine frequency (p < 0.005), VAS (p < 0.01), disability (p < 0.05), and medication use (p < 0.01), when compared to initial baseline levels. .
A Randomized Controlled Trial of Chiropractic Spinal Manipulative Therapy for Migraine
J Manipulative Physiol Ther 2000 (Feb); 23 (2): 91–95
The results of this study support previous results showing that some people report significant improvement in migraines after chiropractic SMT. A high percentage (>80%) of participants reported stress as a major factor for their migraines. It appears probable that chiropractic care has an effect on the physical conditions related to stress and that in these people the effects of the migraine are reduced.
Chiropractic Management of Migraine Without Aura: A Case Study
Australasia Chiropractic and Osteopathic Journal 1999 (Nov): 8 (3)
It now appears clear that chiropractic care may be used to assist patients with migraine. Research is currently being undertaken to investigate the potential mechanisms of chiropractic in the treatment of migraine. This research should also assess what (if any) prognostic signs can be identified to assist practitioners making a more informed decision on the treatment of choice for migraine.
Chronic Tension-type Headache
Trigger Points in the Suboccipital Muscles and Forward Head Posture in Tension-Type Headache
Headache: The Journal of Head and Face Pain 2006 (Mar); 46 (3): 454—460
Twenty chronic tension-type headache (CTTH) subjects and 20 matched controls without headache participated. Trigger points (TrPs) were identified by eliciting referred pain with palpation, and increased referred pain with muscle contraction. Side-view pictures of each subject were taken in sitting and standing positions, in order to assess forward head posture (FHP) by measuring the craniovertebral angle. Suboccipital active TrPs and FHP were associated with CTTH. CCTH subjects with active TrPs reported a greater headache intensity and frequency than those with latent TrPs. The degree of FHP correlated positively with headache duration, headache frequency, and the presence of suboccipital active TrPs.
Spinal Manipulation vs. Amytriptyline for the Treatment of Chronic Tension-type Headaches:
A Randomized Clinical Trial
J Manipulative Physiol Ther 1995 (Mar); 18 (3): 148–154
The results of this study show that spinal manipulative therapy is an effective treatment for tension headaches. Amitriptyline was slightly more effective in reducing pain by the end of the
treatment period, but was associated with more side effects. Four weeks after cessation of treatment however, patients who received spinal manipulation experienced a sustained therapeutic benefit in all major outcomes in contrast to the amitriptyline group, who reverted to baseline values.
Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache
Duke University Evidence-based Practice Center
In 1996, the Agency for Health Care Policy and Research (AHCPR) was scheduled to produce a set of clinical practice guidelines on available treatment alternatives for headache. This headache project was based on the systematic evaluation of the literature by a multidisciplinary panel of experts. Due to largely political circumstances, however, their efforts never came to fruition. The work was never released as guidelines, but was instead transformed with modifications and budget cuts into a set of evidence reports on only migraine headache. Thanks to FCER funding, the evidence reports have now been updated on both cervicogenic and tension-type headaches. You may also download this as an
Adobe PDF file. You may also enjoy
Dr. Anthony Rosner's recent article
on this subject.
Efficacy of Spinal Manipulation for Chronic Headache: A Systematic Review
J Manipulative Physiol Ther 2001 (Sep); 24 (7): 457–466
SMT appears to have a better effect than massage for cervicogenic headache. It also appears that SMT has an effect comparable to commonly used first-line prophylactic prescription medications for tension-type headache and migraine headache.
Impact of Migraine and Tension-type Headache on Life-style, Consulting Behaviour, and Medication Use: A Canadian Population Survey
Can J Neurol Sci 1993; 20 (2) May: 131–137
A large sample of Canadian adults was surveyed by telephone to determine the prevalence and characterization of headache, and the effects of headache on life-style, consulting behaviours and medication use. We reported prevalence and characterization in a previous issue; here, we detail the effects of headaches on sufferers. Sixteen and one-half percent of adult Canadians experience migraine and 29% tension-type headaches. In over 70% of headache sufferers interpersonal relationships are impaired. Regular activities are limited in 78% of migraine attacks and 38% of tension-type headaches. Despite this, only 64% of migraine and 45% of tension-type headache sufferers had ever sought medical attention, and of these only 32% returned for ongoing care. Fourteen percent of migraine and 8% of tension-type headache sufferers had used emergency departments. Most headache sufferers take medication, primarily over-the-counter varieties. Measures to reach the headache population are needed, as are safe effective treatment options that will encourage them to participate in their medical care.
Manipulation and Tension Headaches in the AMA Journal
Review Bove's 1998 JAMA article on tension headaches and chiropractic, and correspondence with the author. Responses from the academic and research community are also included.
Muscle/Joint Dysfunction
The Effect of Manipulation (Toggle Recoil Technique) for Headaches With Upper Cervical Joint Dysfunction: A Pilot Study
J Manipulative Physiol Ther 1994 (Jul); 17 (6): 369–375
Since the results of this pilot study were not adequately controlled they cannot be seen as proof supporting the clinical efficacy of manipulation for chronic headaches. However, as a group for duration, severity and frequency all measures were significant. These findings would suggest that further study of upper cervical manipulation for the treatment of chronic headaches with upper cervical joint dysfunction in a randomized, controlled clinical trial is needed.
Further Clinical Clarification of the Muscle Dysfunction in Cervical Headache
Cephalalgia 1999 (Apr); 19 (3): 179–185
From the perspective of physical characterization of cervical headache, it appears that response from passive stretch of muscle may not be a strong criterion for cervical headache but deep neck flexor performance may have potential to identify musculoskeletal involvement in headache. The finding may also provide positive directions for conservative treatment of cervical headache.
Clinical Study on Manipulative Treatment of Derangement of the Atlantoaxial Joint
J Tradit Chin Med 1999 (Dec); 19 (4): 273–278
The clinical diagnosis of derangement consists of: dizziness, headache, prominence and tenderness on one side of the affected vertebra, deviation of the dens for 1 mm-4 mm on the open-mouth X-ray film, abnormal movement of the atlantoaxial joint on head-rotated open-mouth X-ray film. An accurate and delicate adjustment is the most effective treatment.
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