SomeResearchandClinicalEvidenceinsupportof

TreatingCervicogenic HeadachesbyMassageTherapy

Embriologically,“Theheadisformedfromthefirsttwocervicalsegments(exceptthemandible,whichisformedbythethird).Thefirstandsecondcervicalvertebraarealsoderivedfromthesetwosegments.Hence,onanatomicalgrounds,lesionsoftheoccipito-atlanto-axialjointsmaysetuppainfelttospreadtoanypartofthehead.”- JamesCyriax (1975).

Trigeminocervicalcomplex

C1C2C3

TheTrigeminocervicalComplex(TCC)“Thetrigeminocervicalcomplexandmigraine:currentconceptsandsynthesis.”[Bartsch T,Goadsby PJ.InstituteofNeurology,QueenSquare,LondonWC1N3BG,UK.]AbstractNeuronesinthetrigeminocervicalcomplexarethemajorrelayneuronesfornociceptiveafferentinputfromthemeningesandcervicalstructures;therefore,theyaretheneuralsubstratesofheadpain.Thisreviewhighlightstheimportanceoftwobasicmechanismsinheadachephysiology:convergenceofnociceptiveafferentsandsensitizationoftrigeminocervicalneurones.Thesephysiologicfindingshaveclinicalcorrelatessuchashypersensitivityandspreadandreferralofpainfrequentlyseeninpatientswithprimaryheadache,suchasmigraine.Specialreferenceismadetotheinfluenceofstructuresfromtheuppercervicalspineingeneratingandcontributingtomigraineheadaches.Thepathophysiologyandfunctionalrelevanceofthesebasicmechanismstoheadachesisdiscussedinthecontextofrecentexperimentalfindingswithregardtopainprocessing

Curr PainHeadacheRep. 2003Oct;7(5):371-6.

TheTrigeminocervicalComplex(TCC)“Migraineandtheneck:newinsightsfrombasicdata.”[Bartsch T.DepartmentofNeurology,UniversityofKiel,Schittenhelmstr.10,24105Kiel,Germany.t.bartsch@neurologie.uni-kiel.deAbstractTheclinicalpresentationofpaininpatientswithmigraineshowingspreadandreferralofpainthroughoutthetrigeminalandcervicalinnervationterritoriesaccompaniedbyhyperalgesia andallodyniaindicatesadynamictrigemino-cervicalinteraction.Thephysiologicmechanismsmaybeconvergenceoftrigemino-cervicalafferentsandcentralsensitizationoftrigemino-cervicalneuronsleadingtodynamicneuroplastic changesduringmigraine.Thisreviewhighlightstheclinicalphenotypeandmechanismsofhownociceptiveinputfromneckstructuresoftheuppercervicalspineareintegratedintothetrigemino-cervicalsystem. Thenociceptiveinputintothespinalcordalsoissubjecttoamodulationbysegmentalmechanismsinthespinalcordandbyinhibitoryprojectionsfrombrainstemstructuressuchastheperiaqueductalgray.Thefunctionalrelevanceofthesebasicmechanismsisdiscussedwithreferencetorecentstudiesusingneurostimulation ofafferentnervesaimingatpainmodulationinpatientswithmigraine.Curr PainHeadacheRep. 2005Jun;9(3):191-6

TheTrigeminocervicalComplex(TCC)“MASSAGINGOVERTHEGREATEROCCIPITALNERVEREDUCESTHEINTENSITYOFMIGRAINEATTACKS”– “Evidenceforinhibitorytrigemino-cervicalconvergencemechanisms”[Elcio Juliato Piovesan1,2,Fabrizio DiStani3,PedroAndréKowacs1,Rogério AndradeMulinari2,VictorHugoRadunz2,MarcoUtiumi2,EderBMuranka2,MarioLuiz Giublin1,Lineu CésarWerneck1,2]ABSTRACT - Activationofthetrigemino-cervicalsystemconstitutesoneofthefirststepsinthegenesisofmigraine.Theobjectiveofthisstudywastoconfirmthepresenceoftrigemino-cervicalconvergencemechanismsandtoestablishwhethersuchmechanismsmayalsobeofinhibitoryorigin.Wedescribeacaseofa39-years-oldwomansufferingfromepisodicmigrainewhoshowedasignificantimprovementinherfrontalheadacheduringmigraineattacksifthegreateroccipitalnerveterritorywasmassagedaftertheappearanceofstaticmechanicalallodynia(corticalsensitization).Wereviewtrigemino-cervicalconvergenceanddiffusenociceptiveinhibitorycontrol(DNIC)mechanismsandsuggestthattheconvergencemechanismsarenotonlyexcitatorybutalsoinhibitory.

Arq Neuropsiquiatr 2007;65(3-A):599-604

Trigeminocervicalcomplex

C1C2C3

“Theintermingledimpulsesthentraveluptothecortexofthebrain.Thecortexisunabletodistinguishthepreciseareafromwhichtheimpulsesarose,soinformationfromtheC1-C3neckstructuresareindiscerniblefromtrigeminalimpulses. Inotherwordsthereistheclassicneurologicconditionof‘referredpain.”(Rothbart 1996).Thetrigeminocervicalnucleusincorporatesthemarginalzone,thesubstantia gelatinosa andthenucleusproprius ofthegreymatterofthecervicalspinalcordandthehomologousdivisionsofthetrigeminalnucleus.Inboththecordandthetrigeminalnucleus,theseareasarethemaincentresinvolvedinthetransmissionofnociceptiveinformation,i.e.pain.Thereforethetrigeminocervicalnucleuscanbeviewedasthenociceptivenucleusfortheentireheadandneck. (Bogduk Grieves).

SympatheticNervousSysteminnervationoftheHead

Headandnecknerveplexuses.Mostofthesympatheticnervesupplytotheheadandneckisderivedfromthesuperiorcervicalganglionofthesympatheticchain...Postganglionicaxonsofsympatheticnervesformplexusesthatextendsuperiorlytotheheadandinferiorlytotheneck.Theplexusesgiveoffbranchestosupplysweatglandsintheskin,smoothmuscleinskeletalandskinbloodvessels,andthesmoothmuscleofthearrector pili.Axonsfromtheplexusesalsojoinbranchesofthetrigeminalnerves(cranialnerveV)tosupplytheskinoftheface,thesalivaryglands,theiris,andtheciliary musclesoftheeye.

FromAnatomyandPhysiology,SixthEdition,Seeley−Stephens−Tate, TheMcGraw−HillCompanies,2004

CervicalGanglion

SympatheticNervousSystemInnervationoftheHead

• Thesuperiorcervicalganglion(SCG)fromwhichtheSNSprovidesitssignalsfortissues,glandsandorgansintheheadandneckissituatedinfrontofC2-3.• Itisdeepinthesheathencirclingtheinternalcarotidarteryandinternaljugularvein.Andisanteriortothelonguscapitismuscle.

TheSCGprovidessympatheticinnervationto:

• Choroidplexusandthebloodvesselswithinthecranium(i.e.,smoothmuscle)

• Anterior2/3oftheduramater• Pinealgland• Eyes(bothfordilatingpupilandforthelens)• Vestibularsystem• Tympanimuscle• Lacrimalglands,nasalglands• Salivaryglands• Thyroidgland• Plus,smoothmuscleintheface,headandneck(bloodvessels,erectorpili,sweatglands…)

CervicogenicHeadachewww.painmanagementrounds.org;2004Volume1,Issue8;ByDAVIDM.BIONDI,DO

• “Cervicogenicheadache”coversawidevarietyofsymptomsorheadacheclassifications.

• Itincludespainandothersymptomsthatcomefromavarietyofsourcesintheneck:muscle,joint,ligament,vascular,andneurological.

• Theareaoffocusisonallofthetissuesandstructuresthatmakeupwhatwewouldcalltheuppercervicalspine(Occiput-C1-2-3),thetrigeminocervicalcomplexandthetrigeminalnerve(&andallthatitinnervates).

Cervicogenic Headache(cont.)“Thepathophysiologyandsourceofpaininthisconditionhavebeendebated…butitisbelievedtobereferredfromoneormoremuscular,neurogenic,osseous,articular,andvascularstructuresintheneck…Thetrigeminocervicalnucleusisanareaoftheuppercervicalspinalcordwheresensorynervefibersinthedescendingtractofthetrigeminalnerve(trigeminalnucleuscaudalis)arebelievedtointeractwithsensoryfibersfromtheuppercervicalroots.Thisfunctionalconvergenceofuppercervicalandtrigeminalsensorypathwaysallowsthebidirectionalreferralofpainfulsensationsbetweentheneckandtrigeminalsensoryreceptivefieldsofthefaceandhead.”

CervicogenicHeadache

• Thisclassificationallowsustoincludetensionheadaches,migraines,oranyclassofheadachesthatinvolvestheneck-shouldergirdleand/orhead&faceasamenabletomanualtherapies.

TABLE2:Clinicalcharacteristicsofcervicogenicheadache

•Unilateralheadorfacepainwithoutsideshift;thepainmayoccasionallybebilateral•Painlocalizedtotheoccipital,frontal,temporal,ororbitalregions•Moderate-to-severepainintensity•Intermittentattacksofpainlastinghourstodays,constantpainorconstantpainwithsuperimposedattacksofpain•Painisgenerallydeepandnon-throbbingincharacter;throbbingmayoccurwhenmigraineattacksaresuperimposed

continued…•Headpainistriggeredbyneckmovement,sustainedorawkwardneckpostures;digitalpressuretothesuboccipital,C2,C3,orC4regionsoroverthegreateroccipitalnerve;valsalva,cough,orsneezemightalsotriggerpain•Restrictedactiveandpassiveneckrangeofmotion;neckstiffness•Associatedsignsandsymptomscanbesimilartotypicalmigraineaccompanimentsincludingnausea,vomiting,photophobia,phonophobia,anddizziness;othersincludeipsilateralblurredvision,lacrimation,andconjunctivalinjectionoripsilateralneck,shoulder,orarmpain

www.painmanagementrounds.org;2004Volume1,Issue8;ByDAVIDM.BIONDI,DO

NeurologicalStructures• TrigeminocervicalComplex• Suboccipitalnerve(dorsalramusofC1)innervatestheoccipital-atlantojoint(O-C1)

• C2 spinalnervegivesrisetothegreateroccipitalnerve anditsdorsalrootganglioninnervatetheatlantoaxial (C1-2)andC2-3zygapophysealjoints.– C2neuralgiaistypicallydescribedasadeepordullpainthatusuallyradiatesfromtheoccipitaltoparietal,temporal,frontal,andperiorbital regions.

– Asharporshock-likepainisoftensuperimposedovertheconstantpain.

– Ipsilateraleyelacrimationandconjunctival injectionarecommonassociatedsigns.

– ArterialorvenouscompressionoftheC2spinalnerveoritsdorsalrootganglionhavebeensuggestedasacauseforC2neuralgiainsomecases.

GreaterOccipitalNerve(C2)

LesserOccipital

Nerve(C2-3)

ThirdOccipitalNerve(C3)

NeurologicalStructures• Thirdoccipitalnerve(dorsalramusC3)hasacloseanatomicproximitytoandinnervatestheC2-3zygapophysealjoint.– Thisjointandthethirdoccipitalnerveappearmostvulnerabletotraumafromacceleration-deceleration(“whiplash”)injuriesoftheneck

– PainfromtheC2-3zygapophysealjointisreferredtotheoccipitalregion,butisalsoreferredtothefronto-temporalandperiorbitalregions

Fig.5.Distributionofinnervation.-C2P,PosteriorramusofC2;-C2A,anteriorramusofC2;-C3AandC3P,anterior(A)andposterior(P)ramiofC3.

JawPinch-roll:forC2

EyebrowPinch-roll- C2-3facet;also,skinthickenedipsilaterally

From“CervicogenicHeadache”byRobertMaigne,MD

NeurologicalStructures“Sensoryafferentnervefibersfromuppercervicalregionshavebeenobservedtoenterthespinalcolumnbywayofthespinalaccessorynervebeforeenteringthedorsalspinalcord…Itisbelievedthatthecloseassociationbetweensensorimotorfibersofthespinalaccessorynerveandspinalsensorynervesallowsforafunctionalexchangeofsomatosensory,proprioceptive,andnociceptiveinformationfromthetrapezius,sternocleidomastoidandothercervicalmusclestoconvergeinthetrigeminocervicalnucleus,ultimatelyresultinginthereferralofpaintotrigeminalsensoryfieldsoftheheadandface.” whichmeans→

www.painmanagementrounds.org;2004Volume1,Issue8;ByDAVIDM.BIONDI,DO

ReferredPain– TrP’sTheinter-relationshipbetweentheuppercervicalsensorynerves,theirpassageintoandthroughthetrigeminocervicalcomplexandtheAccessoryNerve(CranialNerveXI)whichsuppliestheUpperTrapezius& Sternocleidomastoidmuscles,etc.goesalongwaytoexplaintheneurologicalconnectionsthatUnder-liestheMyofascialTriggerPoint(TrP)referralpatternsintotheheadandface.

Justincaseyouwantedmore….Thekeystructuresinvolvedinprimaryheadacheappeartobethelargeintracranialvesselsanddura matertheperipheralterminalsofthetrigeminalnervethatinnervatethesestructuresthecaudalportionofthetrigeminalnucleus,whichextendsintothedorsalhornsoftheuppercervicalspinalcordandreceivesinputfromthefirstandsecondcervicalnerveroots(thetrigeminocervical complex)thepainmodulatorysystemsinthebrainthatreceiveinputfromtrigeminalnociceptors.

Theinnervationofthelargeintracranialvesselsanddura materbythetrigeminalnerveisknownasthetrigeminovascular system.Autonomicsymptoms,suchaslacrimationandnasalcongestion,areprominentinthetrigeminalautonomiccephalalgias,includingclusterheadacheandparoxysmalhemicrania,andmayalsobeseeninmigraine.Theseautonomicsymptomsreflectactivationofcranialparasympatheticpathways,andfunctionalimagingstudiesindicatethatvascularchangesinmigraineandclusterheadache,whenpresent,aresimilarlydrivenbythesecranialautonomicsystems.Migraineandotherprimaryheadachetypesarenot"vascularheadaches";thesedisordersdonotreliablymanifestvascularchanges,andtreatmentoutcomescannotbepredictedbyvasculareffects.