Professional Papers _______________________________________________________

Conservative management of cervical tension cephalalgia

Franklin Schoenoltz, DC, DABCO Arcadia, California

ACA Journal of Chiropractic /June 1979

Doctors of Chiropractic have long recognized the therapeutic value of ma-nipulative therapy in the management of cervical tension cephalalgia. From aclinical standpoint, the role of manipulation in headache has been somewhatcontroversial. An attempt is made to present a clinical approach to a neuro-musculoskeletal disorder which responds favorable to chiropractic manipula-tive procedures.

Dr Franklin Schoenholtz is a diplomate of the American Board of Chiropractic Orthopedists,and maintains a private practice at 226-228 EastFoothill Blvd, Arcadia, California 91006. He taught

Diversied Technique and Undergraduate Ortho

-pedics at the Los Angeles College of Chiropracticfrom 1964-1976. Presently, Dr Schoenholtz is thesecretary-treasurer of the Board of Regents atLACC. He has authored numerous articles on themanipulative management of various musculosk-

eletal conditions. The most recent, “ConservativeManagement of Temporomandibular Joint Dys

-function,” appeared in the August 1978 issue of the ACA Journal.

Introduction

The causes of headache are legion. It is one of the mostcommon and confusing symptoms faced in private practice.It is conceivable that as this entity is understood, the mecha-nisms that determine its various causes will be able to be

classied.

We will address ourselves to the most common headache,known by several terms such as tension headache, cervi-cal tension cephalalgia, suboccipital cephalalgia, etc. We willexclude intracranial headaches or those which are secondary togeneralized disease.

Pathophysiology

The functional importance of the musculoskeletal structurerequires that particular attention be directed to the myofascialtissue as well as the articular components. In disorders of the

myofascia, the pain and suboccipital muscle spasm must rst

be brought to terms.The nerves in this region lie in close proximity to the verte-bral artery, at its point of angulation, prior to entering the skullthrough the foramen magnum.These nerves are vulnerable to irritation from themyofascial attachment of the cervical muscles tothe base of the skull, muscles through which they

transverse. Neural discharges or rings from ex

-tracranial tissues may result from abnormal psycho-logical reactions mediated via muscular contraction.Because of the combination of the irritation of C-1and C-2, which are primarily sensory, and suboc-cipital muscle spasm, patients may complain of painat the upper neck region accompanied by tingling inthe occipitoparietal region (Figure 1).

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 inuenced 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.

Examination

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 reexes 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.

Radiological examination

Functional x-rays, such as the three lateral viewstaken of the patient sitting upright (the Davis Series),

may assist the doctor in conrming his palpatory mobil

-ity tests.

Range of motion is a function of the conning 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 inuence the move

-ments.When evaluating the lateral radiographs, evidence of

hypomobility or xation of the atlanto-occipital joint maybe seen, thus conrming clinical ndings.

Treatment

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.

Figure 2. Intermittent motorized head halter tractionshould be arranged so that the pull will be in a 30°

forward-exed position with a cold pack placed under

the patient’s neck.Figure 3. Movement of the cervical spine be-

comes combined extension and lateral exion as

the head is bent to one side.

bearing forces and factors of stress and strain have a most impor-tant role.

To achieve the maximum benet from any form of therapy, the

doctor should use discretionary latitude in choice of treatment. Variations in treatment must be made in response to the patient’sreaction, which may change from visit to visit.

Intermittent motorized traction

When the muscle spasm is primarily in the posterior cervicalregion, head-halter cervical traction may be helpful. The traction

should be arranged so that the pull will be in a 30° forward-exion

position, allowing the posterior joints to open. Intermittent motor-ized traction gently stretches the posterior cervical musculature,thus improving mobility. It has been this author’s experience thata coldpack placed under the patient’s neck while traction is being

applied is of great benet because of its decongestive physiologi

-cal action and anesthetic effect (Figure 2).

Manual traction maneuver

As a precursor to manipulation, a manual traction maneuvermay be employed which stretches the posterior cervical spasmand mobilizes the upper cervical spinal joints.Te doctor stands at the left of the patient while the patient isin a supine position. The doctor places his left forearm under the

cervical spine, his hand at on the table and, using his right hand,

he pushes down on the forehead; the right hand remainsimmobile in order to exercise counterpressure (Figure 3).The doctor then cups his left hand against the tableand slowly raises his elbow (and to some lesser degree,his wrist), bending the patient’s head to one side in com-

bined extension and lateral exion. Maintain this position

for a moment, and then release. The procedure shouldbe repeated several times, since it often reduces pain bystretching and relaxing rigid muscles.Invariably, the source of the muscle irritation can betraced to the articulation connected with the muscle. Itthen becomes necessary to correct the cause of the articu-lar lesions.

Manipulative technique

Manipulation, well-selected and correctly performed,often constitutes and appropriate therapeutic solution.

It should be very specic. The effort should be directed

toward the articular derangement at the site of musclecontracture.The doctor stands at the patient’s head while the patientis supine; with his left hand, the doctor supports the headof the patient placed in left rotation (reverse techniquefor the opposite side). The lateral edge of the axis should

make contact with the radial border of the right index n

-ger. Rotate and extend the cervical spine to its maximum,