We have all gone through this at some point in our lives, the house is a mess, being stuck in traffic is stressing us out, the kids are loud, the pets are ill and are behaving abnormally (throwing up on the carpet or doing their business indoors), our boss is in one of their moods and it’s causing the work environment to be unpleasant, work deadlines are piling up, and for the life of us, we are not able to make this headache and the pressure in our face and jaw go away. It makes checking the boxes off our tasks completed much more challenging. The frequency and duration of our headaches appear to be increasing by the day and there appears to be no quick solution. Or is there? Through the years we’ve observed and treated patients enough to understand that there are fast solutions for the majority of solutions.
How Headaches Come About
Resolving headaches in the long run can be challenging because there are a lot of moving parts to what is contributing to your symptoms (decrease activation of the small muscles that rotate and extend the head at the base of the head, tight upper trapezius muscles that can contribute to restricted motion and dysfunction of the C1 -C3 segments, and weakened serratus anterior muscles that can cause abnormal alignment of the shoulder blades leading to excessive pulling of the C1 and C3 segments due to a lengthening and spasming of overworked levator scapulae muscles; that’s a mouthful huh?!).
According to Bogduk (1995), the head and neck are linked together in the area of the brainstem known as the trigeminocervical nucleus.
It acts like an old school switchboard phone operator connecting two different areas to communicate, in this case the areas of nerve distribution from the trigeminal nerve can appear to be painful as seen above (the forehead, eye areas, cheeks, and jaw) when the area of irritability or dysfunction are the first three spinal neck levels, C1, C2, and C3.
So, what can be done to facilitate a quick resolution?
A Potentially Quick Solution
You probably know where we are going here, which is yes, spinal manipulations. However, you may be wondering why they are incorporated and the safety of the treatment.
Quickly and simply, they are incorporated into treatment for their ability to reduce pain and improve function by restoring normal tone of the muscles of the head, neck, and upper back, explaining why manipulations are incorporated into treatment for headaches. Dunning et al (2016) randomize controlled trial compared treatment of only thoracic and cervical spinal manipulations (high thrust movements with audible cracking that everyone so loves on YouTube) combined (Group 1) vs. mobilizations (movement of the joints in various ranges but no thrusting) and exercise (neck flexor activation, lower trapezius, and serratus anterior strengthening) combined (Group 2) and the results where noticeable. Throughout 6-8 visits in a 4 week span the manipulation group did better in every single category of headache intensity (3.4 points pain level decrease, compared to 2.4 points pain level decrease of Group 2), headache frequency, headache duration, function, decrease in medication usage (which was significant in the manipulation group and only slight in the mobilization/exercise group), and patient satisfaction at 1 week and 4 week follow-ups (high satisfaction in the manipulation group vs. the moderate safisfaction in the mobilization/exercise group). Frequency, duration, and the decrease in medication usage were still greater in the manipulation group 3 months after the start of treatments. A recent systematic review and meta-analysis by Bini Et al. (2022) corroborates support for incorporating manipulative therapy with the addition of exercises, which we have consistently supported as the key to avoiding the need for any type of treatment in the long run.
How Safe Are Neck Spinal Manipulations?
Large-scale studies in Australia and Canada have found that the risk of serious adverse events, such as vertebrobasilar stroke, is extremely low, estimated between 1 per 50,000 (.002%) and 1 per 5.85 million (.00000017%) manipulations. To put it into perspective, you’re way more likely to be seriously injured in a car crash, struck by lightning, or killed in a shark attack. More importantly, Cassidy’s study in 2008 showed that patients experiencing symptoms (such as neck pain and headache) of vertebral artery dissection (a precursor condition prior to having a stroke) are just as likely to visit their primary care doctor instead of a practitioner such as a chiropractor who typically perform manipulations (Cassidy’s study specifically looked at chiropractors). The association between stroke and cervical manipulations is likely due to patients seeking care for early symptoms of an impending stroke rather than the manipulation itself causing the event.
Suppose you’re still on the fence about how rare damage to the neck vasculature is with cervical manipulations. In that case, Herzog’s (2012) study looking at high velocity cervical thrust manipulations to human cadavers, comparing that to the amount of stress attained with passive range of motion of the cadavers’ necks into end range positions of rotation, and extension, showed the amount of stress to the vertebral artery (see the picture above with the black arrows pointing to the vertebral artery) was less for cervical manipulations at the upper, middle, and lower cervical segments. Both manipulation and passive range of motion to the necks of the cadavers to end ranges were also significantly lower than the force stress threshold required to damage the vertebral artery, by at least 30%.
That being said, there is still a minuscule risk, particularly for patients with specific contraindications or red flags (acute fracture, vascular disease, recent trauma). If your practitioner is informed about your past medical history and is being vigilant during the physical exam, any further risk is minimized.
The Takeaway
Upper cervical spinal manipulation is generally safe and effective for the majority of patients with cervicogenic headache, neck pain, and related conditions. Its benefits are maximized and the risks minimized when combined with thorough screening and adjunct treatments, such as dry needling and exercise (which is the subject of another blog). Often, you will attain relief within one session if the source of your headache is coming from the upper portion of your neck. By the way, if you want to reach a point where you no longer need to rely on cervical manipulations, strengthening your neck and shoulder blades with simple exercises will be necessary. If you have questions, would like to learn, or need this procedure performed on you, please do not hesitate to reach out. Stay well and be well, Mobile Spine Family!
Sources:
Bini, P., Hohenschurz-Schmidt, D., Masullo, V., Pitt, D., Draper-Rodi, J., 2022. The effectiveness of manual and exercise therapy on headache intensity and frequency among patients with cervicogenic headache: a systematic review and meta-analysis. Chiropr Man Therap 30.
Bogduk, N. (1995) ‘Anatomy and physiology of headache’, Pharmacology & Therapeutics, 49, pp. 435–445.
Cassidy, J.D., Boyle, E., Cote, P., He, H., Hogg-Johnson, S., Silver, F.L., Bondy, S.J., n.d. 2008. Risk of Vertebrobasilar Stroke and Chiropractic Care.
Dunning, J.R., Butts, R., Mourad, F., Young, I., Fernandez-de-las Peñas, C., Hagins, M., Stanislawski, T., Donley, J., Buck, D., Hooks, T.R., Cleland, J.A., 2016. Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: a multi-center randomized clinical trial. BMC Musculoskelet Disord 17.
Haldeman, S., Carey, P., Townsend, M., Papadopoulos, C., n.d. Arterial dissections following cervical manipulation: the chiropractic experience.
Herzog, W., Leonard, T.R., Symons, B., Tang, C., Wuest, S., 2012. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. Journal of Electromyography and Kinesiology 22, 740–746.
Magarey, M.E., Rebbeck, T., Coughlan, B., Grimmer, K., Rivett, D.A., Refshauge, K., 2004. Pre-manipulative testing of the cervical spine review, revision and new clinical guidelines. Manual Therapy 9, 95–108.
