injury to the cervical spine as a cause of headache
LESTER S. BLUMENTHAL, MD
La Jolla, California
Recent neurochemical, vascular, and hematologic research 1-4 has given us a better understanding of what occurs preceding or during a headache attack. However, we still do not know what triggers certain kinds of attacks, and except for methysergide and the antidepressants, these new developments have not substantially improved the treatment measures we can offer headache patients.
Every patient with headache should be thoroughly investigated by history and physical, neurologic, and laboratory methods for the cause of his complaint. This investigation should include a detailed musculoskeletal search for cervical spine injury. The possibility that such an injury may cause headaches other than posttraumatic is usually neglected, perhaps because too many claims have been made for the benefits to be derived from manipulation and because physicians do not wish to be regarded as osteopaths or chiropractors. Examination and treatment of the spine is usually left in the hands of these groups, orthopedists, or neurosurgeons. However, experience now indicates that cluster, migraine, and the many forms of tension headache5, as well as postconcussion and "whiplash" headache, may also be consequences of traumatic cervical spine injury.
This article documents the significant role that the cervical spine, its associated muscles, ligaments, and tendons, and other soft structures about the head, neck, and shoulder girdle play in the etiology of many headaches and offers a method of treating malalignment or subluxation.
Figure 1.
Headache and pain in the head and face originate in weak fibro-osseous
attachments of tendons to the occipital bone (A, B, C, D) as weak fibers
relax under normal tension and allow tension-overstimulation of sensory
nerves of the cervical spine.
Such pain is almost always referable to a specific location, a valuable
aid in diagnosis.
LI, interspinous ligament; LN, nuchal ligament.
Adapted from Hackett.7
Anatomy and Pathophysiology
Although there is no nerve radiating from the back of the neck to the temples or frontal area, pain is referred from one area to the other. A review of embryology indicates one way this can take place: the head is formed from the first and second embryonic cervical segments (the mandible from the third).
Thus, anatomically, lesions of the upper cervical joints may be expected to give rise to pain spreading to any part of the head.
Extrasegmental reference also occurs, mediated by the dura mater, from the cervical area down to the scapula and up to the temple, forehead, bridge of the nose, behind the eyes, or into the face.6 Reference patterns from ligaments, tendons, and fibro-osseous junctions 7 (figure 1) and from various muscles about the head, neck, and shoulder girdle 8 have been recorded. Those interested may wish to review the original work on dermatomal, myotomal, and sclerotomal reference patterns throughout the body. 9
According to Hackett,7 traumatic skeletal pain is most exquisite at the points of attachment of tendons and ligaments to bone. During the healing process, which requires three to four weeks, bone and fibrous tissue proliferate at these fibro-osseous junctions. Another three to four weeks is needed for maturing and strengthening of the fibro-osseous bond. Interference with normal healing due to motion at the site of injury, or to a deficient healing capacity results in a weak attachment, designated as ligament relaxation. If spontaneous repair has not occurred 1 1/2 to 2 months after injury, it is not likely to occur later.
The Injury
A typical cause of cervical spinal injury is the accident in which a slowed or stopped car is struck from the rear and the passenger, in the right front seat immediately or shortly thereafter experiences headache and pain or numbness radiating from the neck to one shoulder or arm. There is limited motion of the head and unilateral spasm of the trapezius or other posterior cervical muscles. Since it is impossible to voluntarily contract these muscles without also contracting the anterolateral neck muscles, this symptom cannot be attributed to neurosis or malingering, as is commonly done. Jackson10 has further detailed these effects.
The passenger also experiences any of a number of symptoms well described as the Barre-Lieou syndrome.11 These include pain reaching almost any part of the head and neck, visual blurring with ciliary spasm, mydriasis, dizziness, loss of balance, tinnitus, lacrimation, salivation, rhinorrhea, dysphagia, nausea, vomiting, forgetfulness, nervousness, and swelling and stiffness of the fingers.
 |
Figure 2. Trigger points (o) that often elicit muscle spasm and pain in patients with headache. a. Prone patient. b. Supine patient. Points at scalenus, sternomastoid, and trapezius insertions. Adapted from Kayfetz DO, Blumenthal LS, Hackett GS, et al: Whiplash injury and other ligamentous headache-its management with prolotherapy. Headache 3:21,1963. |
Examination of the Patient
Physical examination may reveal that the patient carries one shoulder lower than the other and holds his head rigid. The examiner should determine the degree of limitation in the range of active and passive motion of the head on the neck in all directions and record the amount of pain produced by attempting to extend each motion. Compression of the head downward on the neck often increases the pain; manual traction of the head upward from the neck may relieve it. Pain may also be increased by isometric pressure at the occiput, whereas pressure at the curve of the neck may decrease it.
Palpation often reveals muscle spasm of one or more of the supporting posterior neck muscles; small, tender areas of spasm in other muscles (trigger points, figure 2); or exquisite tenderness at the origin or insertion of the muscles to the occiput, cervical spine, or shoulder girdle. Coincidentally there often is limitation of motion and malalignment of the dorsal lumbar spine or lumbosacral or sacroiliac joints.
Neurologic and general systemic evaluations are usually normal. There may be non-specific changes in the reflexes and atrophy of muscles about the shoulder girdle or the arm. X-ray examination may show narrowed intervertebral disk spaces and hypertrophic arthritic changes about the Luschka interbody joints representing previous injury or pathologic process.
With an acute injury, there is usually loss or reversal of the normal lordotic curve or increased laxity of supporting ligaments, or both. The range of motion is so restricted--either by spontaneous spasm, by attempting to hold the head rigidly on the neck, or by prolonged use of a cervical collar--that a cycle of spasm, reflex pain, weakness, and atrophy of the tissues is set up.
Treatment of Cervical Spine Problems
Therapy must aim to: (1) remove the tender trigger areas which serve as foci of referred pain and spasm, (2) correct malalignments, subluxations, and restricted range of motion to as near normal as possible, and (3) strengthen the local supporting ligaments and tendons to prevent further malalignment and subluxation.
Several methods of therapy have been advocated. Cyriax,6 Jackson,10 and others have recommended cervical traction, while Mennell12 has suggested manipulation. Hackett7 has stressed prolotherapy injections to the ligamentous and tendenous attachments to the bones. Travrell8 has recommended coolant sprays, stretching, and local anesthetic injection of trigger areas in the involved muscles. Acupuncture has recently been advocated as treatment for all possible pain syndromes, including headache and those of the cervical spine.
My program to accomplish the above goals, borrowed from the ideas of many of the authors cited and from principles personally communicated to me by Ongley,13 is as follows.
1. After a complete history and physical, x-ray, and laboratory examinations, the conclusions are discussed thoroughly with the patient.
2. A negative history of allergic reactions to lidocaine (Xylocaine) hydrochloride or other medications to be used is ascertained.
3. The patient is positioned. In most cases, treatment can be administered while the patient sits facing the examining table, with arms folded on the edge of the table and forehead leaning on them to expose the cervical spinous processes. An occasional patient, because of needle-shyness or history of syncope after injections, is treated while lying prone, with a pillow positioned under the abdomen and chest to allow the head to drop over the edge of the pillow and rest on the folded hands.
4. Experience has shown that it is much easier to restore malalignments and subluxations and to increase range of motion if the supporting structures at the neck are thoroughly relaxed. I therefore inject small amounts of 0.5 % lidocaine into the attachments of the muscles and ligaments to the spinous processes, posterior laminae, and transverse processes of the cervical spines, using a 10-cc Luer-Lok syringe with a 21-gauge 2-inch needle. In some patients this must be done only at the fifth, sixth, and seventh cervical levels, but in others we must inject up to the second and third cervical levels and down to the first and second thoracic spines. The use of this technique should be observed a number of times before it is attempted.
With the thumb and forefinger I grasp the spinous processes to feel the level at which I am working. The needle is injected into the skin just above the fifth spinous process. The skin is quite lax in this region and can be moved upward over the deeper tissues, carrying the point of the needle with it. The needle is then injected tangentially through the supraspinous ligament to the posterior spine of C-2. The click of the needle against the bone is noted and I aspirate before each injection to make sure the needle is not in a blood vessel. Approximately 1 cc of 0.5 % lidocaine is injected at the fibro-osseous junction. I then manipulate the point of the needle laterally and inject it deeper to contact first the right and then the left posterior lamina, with the above precautions. Injection is again made against bone.
The needle is then manipulated into the interspinous ligament and again an injection is made against bone to the superior surface of the subjacent spinous process. Next, the needle is withdrawn almost through the skin and reinserted at the third vertebra.
The entire procedure is repeated at each level. At the level of the fifth vertebra, I am able to inject the undersurface of the fourth spinous process and the superior surface of the fifth spinous process. The needle is then redirected tangentially downward to the top of the sixth spinous process and all of the above maneuvers are repeated at the sixth and seventh levels and at the top of the first thoracic vertebra. A total of approximately 20 cc of 0.5 % lidocaine is used for the complete procedure.
Range of motion is then tested, and if marked tightening is felt or observed in the muscles attaching to the occiput, the transverse processes of the lower cervical vertebrae, or the scapular borders, surfaces, or spine, these areas are also injected.
5. When the anesthetic has taken effect, complete range-of-motion exercises and adjustment and manipulation of the cervical spine are carried out. In patients with long-standing complaints, particularly in the elderly, several such treatments may be needed before optimal range of motion is obtained; in some, full range may never be recovered. However, even a modest increase means that malalignments, subluxations, and possibly adhesions have been corrected and the cycle of pain, spasm, contracture, and reference symptoms is broken.
6. The patient is allowed to rest until the immediate effects of the lidocaine have disappeared and is then thoroughly instructed in how to carry out range-of-motion exercises at home. Analgesics, anti-inflammatory agents, and ice packs are prescribed as needed.
7. After two days, the patient returns for the first of a series of four to six weekly visits, during each of which the entire program is repeated. However, only a few minims of anesthetic are injected into each site, the solution now consisting of 6 cc of 0.5% lidocaine and 4 cc of the following special dextrose anesthetic-proliferative solution: 55cc dextrose (50% USP), 25 cc glycerin (USP), 2.8 cc phenol (89%), and enough sterile water to make 100 cc. The solution must be sterilized at 15 lb pressure for 15 minutes, removed from the autoclave as soon as possible to prevent caramelization, and stored in sterile rubber-capped bottles in a dark place.
Case Reports
The following three cases helped to focus my attention on the relationship of the cervical spine to headache.
Case 1. An 18-year-old woman with typical migraine headache denied any history of accident or injury. Because examination revealed evidence of cervical strain, a complete regimen of treatment for the cervical spine was initiated. She responded well and soon was headache-free. Several months later she reported that she had just remembered being involved in a minor rear-end automobile accident at age 16.
Case 2. A 62-year-old woman had recurrence of symptoms typical of migraine headache. She had had such headaches all her life but they had disappeared during menopause. Examination revealed strain of the cervical spine, but she denied sustaining any accidents, injuries, or falls. She responded well to treatment of the cervical spine. Months later she recalled that several weeks before the attacks had recurred, she had fallen and twisted her neck.
Case 3. A 57-year old man had had symptoms typical of one-sided cluster headache for ten years, for which he was taking large dosages of Cafergot and steroids. He complained about pain in the neck, shoulder and arm, and reexamination showed evidence of cervical strain. After a series of cervical spinal treatments, the symptoms disappeared, as did the long-standing cluster headache. History review showed that the headaches had begun after a fishing episode in which he had wrestled several hours trying to land a large marlin. While he did not have symptoms referable to the neck, shoulder, and arm at that time, he apparently had sustained injury to the cervical spine.
Summary
The possible etiologic role of injury to the cervical spine in headache syndromes has been largely ignored. However, many types of headache other than those following trauma or whiplash can be traced to such injury. If history and physical examination provide no explanation for chronic headache, a careful search should be made for disorders of the cervical spine. Stretching or tearing of the supporting ligaments or tendons at the fibro-osseous junction may have occurred, followed by malalignment of the articular facets, muscular spasm and atrophy, and reflex vasomotor and autonomic interference. The resulting cycle may cause headache and associated symptoms for many years.
A surprising number of intractable chronic headaches respond to a complete regimen of treatment to alleviate muscle spasm, to relax and break up scar tissue and adhesions, and to realign the facets.
REFERENCES
Originally published in POSTGRADUATE MEDICINE ·
September 1974 · Vol. 56 · No. 3