Symptoms and signs
There is general agreement that stress may precipitate headacheattacks and that the over-conscientious or perfectionistic individualis especially susceptible to develop this syndrome.Frequently, the patient complains of pain in the neck and suboc-cipital region, radiating up and over the whole of the posterior por-tion of the skull. Headaches and neckaches occur concurrently, aregenerally intermittent, and usually originate from the neck.
The syndrome is not only inuenced by position and activity, but
can happen as a result of certain positions and activities. Localizedsigns in the neck may include stiffness and muscle tension.
Many patients develop symptoms at the end of a stress-lled day.
However, it is interesting to note that the syndrome has also oc-curred the morning after the patient held his head in an unsuitableposition during sleep.
The patient’s complaints may be misleading because the areaof complaint may be different from the actual site of the irrita-tion. Therefore, the physical examination should include attemptsto reproduce the pain by palpation of the myofascia or by passivestretching.Palpation of the osseous structures of the cervicalspine will usually reveal vertebral derangement.Localized tender points in the occipitocervical junctionare revealed on palpatory examination. The atlanto-
occipitial joint may be remarkably xed, and deep pres
-sure palpation may reproduce occipitoparietal tingling.Investigation of this area should be conducted withthe patient relaxed, in a sitting position, and with the
head maintained in a forward exed position. Palpa
-tion of the occipitocervical junction will often reveal theepicenter of the pain.Neurological examination will reveal no positive
changes, but the deep tendon reexes are frequently
very active. The patient may appear tense and ap-prehensive; tachycardia and mild hypertension may bepresent.Even though a high proportion of cervical-occipitalheadaches have a mechanical basis, each patient mustbe examined individually. Other causes such as eyestrain, sinusitis, digestive disturbance and neurologicaldiseases must be excluded.
Functional x-rays, such as the three lateral viewstaken of the patient sitting upright (the Davis Series),
may assist the doctor in conrming his palpatory mobil
Range of motion is a function of the conning liga
-ments, but the range of motion is not only covered bythe ligaments. Other factors include weight bearing an
the tone of the muscles, which also inuence the move
-ments.When evaluating the lateral radiographs, evidence of
hypomobility or xation of the atlanto-occipital joint maybe seen, thus conrming clinical ndings.
Combined therapy in this type of syndrome includesthe use of manipulation, soft tissue technique, tractionand psychological support.The design of therapy should include combinations of modalities, to be used to reinforce each other in alleviat-ing the symptoms.Manipulative therapy is well suited to the patient’sneeds as one of the essential modalities for manag-ing the musculoskeletal component of cervical tensioncephalalgia.Musculoskeletal structure and function are governedby recognized mechanical principles in which weight
Figure 1. The sensory distribution of the greater and less
-er occipital nerves is in the posterior and lateral portion
of the scalp. The shaded area represents hyperesthesia or
anesthesia of the scalp which may occur from compress-ibility or irritation of these nerve roots.