1. Atrophy of Suboccipital Muscles in Chronic Pain Patients
We have observed previously unreported muscle atrophy in the rectus capitis posterior minor (RCPMI) muscles of a group of chronic pain patients. We hypothesize that chronic pain, in this select group of patients, is a consequence of tramua that occurs to the C1 dorsal ramus during whiplash.

2. Magnetic Resonance Imaging of the Upper Cervical Spine
We are currently using MRI to investigate the functional integrity of the upper cervical spine. We started out looking for hypertonic muscles in a population of patients who were suffering from chronic head and neck pain. My first task was to collect MRI data and to identify suboccipital muscles within the MR images. So I brought together a physician and an anatomy professor to see if they could help me out. Their comments were classic. The anatomy professor said, "The reason you can't find those muscles is because they are not there." The physician immediately responded by saying, "No wonder these patients don't get any better." I had been using images that were collected from a chronic pain patient, and it was apparent that the rectus capitis posterior minor muscles were missing. When we looked at images from a control subject it was very easy to locate these muscles. At that point, the focus of our research switched from looking for hypertonic muscles to comparing muscle density between the control group and the chronic pain group.

3. Anatomic Relation Between the Rectus Capitis Posterior Minor Muscle and the Spinal Dura Mater
We observed that the PAO membrane was securely fixed to the surface of the dural tube by multitudinous fine connective tissue fibers. There was no real interlaminar space between these two structures and they appeared to function as a single entity. The influence of the RCPMI muscle on the dura mater was artificially produced in the hemisected specimen. Artificially functioning the muscle produced obvious movement of the spinal dura between the occiput and the atlas, and resultant fluid movement was observed to the level of the pons and cerebellum.

4. Visualization of the Muscle-Dural Bridge in the Visible Human Female Data Set
SPINE Journal 1995; 20 (23): 2484–2486
It has been speculated that the function of the muscle dural bridge may be to prevent folding of the dura mater during hyperextension of the neck. Also, clinical evidence suggests that the muscle dural bridge may play an important role the pathogenesis of the cervicogenic headaches.

An Open Study Comparing Manual Therapy With the Use of Cold Packs in the Treatment of Post-traumatic Headache
Cephalalgia 1990 Oct; 10(5): 241–50
It is concluded that the type of manual therapy used in this study seems to have a specific effect in reducing post-traumatic headache. The result supports the hypothesis of a cervical mechanism causing post-traumatic headache and suggests that post-traumatic dizziness, visual disturbances and ear symptoms could be part of a cervical syndrome.


A Holistic Approach to Severe Headache Symptoms in a Patient Unresponsive to Regional Manual Therapy
J Manipulative Physiol Ther 1996 (Mar); 19 (3): 202–207
This patient seemed to respond favorably to conservative care that included regions of spine not traditionally associated with headache pain. This suggests that some individuals may require a more comprehensive evaluation if regional care fails to promote a positive response within a few weeks. Controlled, randomized trials will assist in comparing effectiveness of various treatment interventions.

Behavioral and Physical Treatments for Tension-type
and Cervicogenic Headache
Duke University Evidence-based Practice Center
In 1996, the Agency for Health Care Policy and Research (AHCPR) was scheduled to produce a set of clinical practice guidelines on available treatment alternatives for headache. This headache project was based on the systematic evaluation of the literature by a multidisciplinary panel of experts. Due to largely political circumstances, however, their efforts never came to fruition. The work was never released as guidelines, but was instead transformed with modifications and budget cuts into a set of evidence reports on only migraine headache. Thanks to FCER funding, the evidence reports have now been updated on both cervicogenic and tension-type headaches. You may also download this as an Adobe PDF file. You may also enjoy Dr. Anthony Rosner's recent article on this subject.


The Effect of Spinal Manipulation in the Treatment of Cervicogenic Headache
J Manipulative Physiol Ther 1997 (Jun); 20 (5): 326–330
The use of analgesics decreased by 36% in the manipulation group, but was unchanged in the soft-tissue group. The number of headache hours per day decreased by 69% in the manipulation group, compared with 37% in the soft-tissue group. Finally, headache intensity per episode decreased by 36% in the manipulation group, compared with 17% in the soft-tissue group. You might also enjoy this sidebar article Chiropractic Effective for Cervicogenic Headache.


Cervicogenic Dysfunction in Muscle Contraction Headache and Migraine:
A Descriptive Study
J Manipulative Physiol Ther 1992 (Sep); 15 (7): 418—429
A case of cervicogenic headache (CEH) in an 8-year-old boy that improved after chiropractic spinal manipulation is reported. Both muscle contraction/tension-type headache (MCH) and common migraine without aura (CM) subjects demonstrate high occurrences of: a) occipital and neck pain during headaches; b) tender points in the upper cervical region; c) greatly reduced or absent cervical curve; and d) X-ray evidence of joint dysfunction in the upper and lower cervical spine. These findings support the premise that the neck plays an important, but largely ignored role in the manifestation of adult benign headaches. A case-control study should be conducted to confirm the greater prevalence of cervicogenic dysfunction in headache as compared to nonheadache subjects.

Neurolysis of the Greater Occipital Nerve in Cervicogenic Headache
A Follow-up Study
Headache 1992 (Apr); 32 (4): 175–179
In our opinion, this operation should not be performed in patients with cervicogenic headache in general. The present study shows that other therapeutic approaches should be searched for in cervicogenic headache.


Spinal Manipulation and Headaches of Cervical Origin
J Manipulative Physiol Ther 1989 (Dec); 12 (6): 455–468
This article reviews the published clinical studies of manipulation in the treatment of tension and migraine headaches. The topic of cervical headaches in general is reviewed and the current model of cervicogenic headache is critiqued. A representative case history is used to illustrate the thesis that the current model of cervicogenic headache may be too restrictive. The role of spinal manipulation as a trial of therapy in individual patients is also discussed. a retrospective diagnosis of cervical headache can often be confirmed by a successful outcome.

A Randomized Controlled Trial of Chiropractic
Spinal Manipulative Therapy for Migraine
J Manipulative Physiol Ther 2000 (Feb); 23 (2): 91–95
The results of this study support previous results showing that some people report significant improvement in migraines after chiropractic SMT. A high percentage (>80%) of participants reported stress as a major factor for their migraines. It appears probable that chiropractic care has an effect on the physical conditions related to stress and that in these people the effects of the migraine are reduced.


Chiropractic Management of Migraine Without Aura: A Case Study
Australasia Chiropractic and Osteopathic Journal 1999 (Nov): 8 (3)
It now appears clear that chiropractic care may be used to assist patients with migraine. Research is currently being undertaken to investigate the potential mechanisms of chiropractic in the treatment of migraine. This research should also assess what (if any) prognostic signs can be identified to assist practitioners making a more informed decision on the treatment of choice for migraine.


A Twelve Month Clinical Trial of Chiropractic
Spinal Manipulative Therapy for Migraine
Australasia Chiropractic and Osteopathic Journal 1999 (Jul): 8 (2)
32 participants showed statistically significant (p < 0.05) improvement in migraine frequency, VAS, disability, and medication use, when compared to initial baseline levels. A further assessment of outcomes after a six month follow up (based on 24 participants), continued to show statistically significant improvement in migraine frequency (p < 0.005), VAS (p < 0.01), disability (p < 0.05), and medication use (p < 0.01), when compared to initial baseline levels. .


The Efficacy of Spinal Manipulation, Amitriptyline and the Combination of Both Therapies for the Prophylaxis of Migraine Headache
J Manipulative Physiol Ther 1998 (Oct); 21 (8): 511–519
There was no advantage to combining amitriptyline and spinal manipulation for the treatment of migraine headache. Spinal manipulation seemed to be as effective as a well-established and efficacious treatment (amitriptyline), and on the basis of a benign side effects profile, it should be considered a treatment option for patients with frequent migraine headaches.

Trigger Points in the Suboccipital Muscles and Forward Head Posture
in Tension-Type Headache
Headache: The Journal of Head and Face Pain 2006 (Mar); 46 (3): 454—460
Twenty chronic tension-type headache (CTTH) subjects and 20 matched controls without headache participated. Trigger points (TrPs) were identified by eliciting referred pain with palpation, and increased referred pain with muscle contraction. Side-view pictures of each subject were taken in sitting and standing positions, in order to assess forward head posture (FHP) by measuring the craniovertebral angle. Suboccipital active TrPs and FHP were associated with CTTH. CCTH subjects with active TrPs reported a greater headache intensity and frequency than those with latent TrPs. The degree of FHP correlated positively with headache duration, headache frequency, and the presence of suboccipital active TrPs.


Efficacy of Spinal Manipulation for Chronic Headache: A Systematic Review
J Manipulative Physiol Ther 2001 (Sep); 24 (7): 457–466
SMT appears to have a better effect than massage for cervicogenic headache. It also appears that SMT has an effect comparable to commonly used first-line prophylactic prescription medications for tension-type headache and migraine headache.


Spinal Manipulation vs. Amytriptyline for the Treatment of Chronic Tension-type Headaches: A Randomized Clinical Trial
J Manipulative Physiol Ther 1995 (Mar); 18 (3): 148–154
The results of this study show that spinal manipulative therapy is an effective treatment for tension headaches. Amitriptyline was slightly more effective in reducing pain by the end of the treatment period, but was associated with more side effects. Four weeks after cessation of treatment however, patients who received spinal manipulation experienced a sustained therapeutic benefit in all major outcomes in contrast to the amitriptyline group, who reverted to baseline values.


Behavioral and Physical Treatments for Tension-type
and Cervicogenic Headache
Duke University Evidence-based Practice Center
In 1996, the Agency for Health Care Policy and Research (AHCPR) was scheduled to produce a set of clinical practice guidelines on available treatment alternatives for headache. This headache project was based on the systematic evaluation of the literature by a multidisciplinary panel of experts. Due to largely political circumstances, however, their efforts never came to fruition. The work was never released as guidelines, but was instead transformed with modifications and budget cuts into a set of evidence reports on only migraine headache. Thanks to FCER funding, the evidence reports have now been updated on both cervicogenic and tension-type headaches. You may also download this as an Adobe PDF file. You may also enjoy Dr. Anthony Rosner's recent article on this subject.


Impact of Migraine and Tension-type Headache on Life-style, Consulting Behaviour, and Medication Use: A Canadian Population Survey
Can J Neurol Sci 1993; 20 (2) May: 131–137
A large sample of Canadian adults was surveyed by telephone to determine the prevalence and characterization of headache, and the effects of headache on life-style, consulting behaviours and medication use. We reported prevalence and characterization in a previous issue; here, we detail the effects of headaches on sufferers. Sixteen and one-half percent of adult Canadians experience migraine and 29% tension-type headaches. In over 70% of headache sufferers interpersonal relationships are impaired. Regular activities are limited in 78% of migraine attacks and 38% of tension-type headaches. Despite this, only 64% of migraine and 43% of tension-type headache sufferers had ever sought medical attention, and of these only 32% returned for ongoing care. Fourteen percent of migraine and 8% of tension-type headache sufferers had used emergency departments. Most headache sufferers take medication, primarily over-the-counter varieties. Measures to reach the headache population are needed, as are safe effective treatment options that will encourage them to participate in their medical care.


Manipulation and Tension Headaches in the AMA Journal
Review Bove's 1998 JAMA article on tension headaches and chiropractic, and correspondence with the author. Responses from the academic and research community are also included.