Edward Lichten, M.D.,PC
555 S. Old Woodward Avenue Suite 700
Birmingham, MI 48009 

Email: drlichten



Lecturer #8:

Consultant: Mitchell Elkiss, D.O.
Department of Neurology, Providence Hospital
Associate Director, Gertrude Levin Pain Clinic, Wayne State University

Novi Headache Symposium 1994


  • Accupuncture
  • Manipulation

In dealing with headaches an osteopathic approach is particularly helpful. From a philosophical point of view this includes the consideration of wellness or health as a positive state. The is an appreciation of the organismic unity of the human body an d its inherent healing capacity. Crucial is the abiding concern for the inter-relationship between structure and function. Part of the problem of dealing with patients with headaches relates to the scope of the problem. Although headaches are one of the most frequent presenting complaints to both the general practitioner and neurologic specialist (representing up to 25 million visits per year), frequently therapy is less than satisfactory.

What we use to think of as vascular or tension headaches we now know as more typically mixed. This is complicated by the multifactorial nature of headaches including physical, psychological, familial, ethnic, and cultural features.

An osteopathic evaluation as a diagnostic differential aid begins with a psychosocial assessment looking for signs of anxiety, with signs of sympathetic nervous system overactivity, signs of depression, with heightened pain awareness, and signs of anger, expressed or unexpressed. The presence of stress, both acute and chronic, can result in unexpected shifts in roles and expectations. For example, the presence of poor coping strategies may be observed with increased smoking and/or alcohol intake, and with altered sexuality, avoidance of work, and finally issues of secondary gain (seeking of compensation, economic dependence, frequent contacts with the health system).

A thorough history with particular attention to the quality of the pain, its severity, its temporal characteristics, and particularly its localization is mandatory. Pain sensitive structures include the eyes, ears, nose, and mouth. Intracranial structures include such structures as the skin, subcutaneous tissue, scalp, fascia, muscles, arteries, joints, and periosteum. Even the cranial nerves 5, 7, 9 and 10 and the upper cervical nerves 2 and 3 can be pain sensitive. A complete physical exam of both general and neurologic anatomy is required but is most often normal. This must be followed by a detailed neuromuscular assessment.

The neuromuscular assessment includes active and static body analysis with observation and palpation of the following for levels of contraction and tenderness: facial and mandibular attachments and temporomandibular joints, the temporalis, masseter, buccinator, and pterygoid muscles. Analysis next evaluates the basioccipital attachments of the atlas for anterior, posterior, and lateral symmetry, and superficial and deep cervical palpation from the skin to the synovial joint. Analysis continues to the rotational characteristics of the head, cervical spine and shoulder girdle, palpation of the effects of fascial and ligamentous attachments, particularly in the upper rib cage and the upper thoracic region. Continued evaluation for mechanical pelvic dys function and lower extremity dysfunction includes measurements of the short leg syndrome. At the other extreme is the evaluation for rhythmic cranial activity and suture mobility in the cranium with particular attention to the relationship between symptoms and signs and the reproducibility of painful symptoms during the examination. This can be helpful in identifying the mechanical syndromes which either present as primary biomechanical causes of headaches or as secondary maladaptive consequences of other primary factors in producing headaches. These biomechanical syndromes include temporo-mandibular joint syndrome, maloccusive dental syndromes, cervical spine disease, including spondylosis, facet dysfunction and disc disease, trauma whether recalled or not, cranial neuralgias, cranial suture syndromes, anatomic short leg syndromes, nerve encroachment syndromes, eye strain and referred pain syndromes. This includes the myofascial pain syndromes about which I will have more to say. It follows that the evaluation provides an assessment which can provide direction towards the formulation and execution of a therapeutic plan.

The manipulative prescription is derived form the careful clinical assessment. For primary joint dysfunction involving the facets, direct or indirect techniques might be applied. High velocity low amplitude joint mobilizations, patient assisted isometr ic corrections, gentle articulations, myofascial approaches, or indirect, resistance unloading techniques might be appropriate. These indirect techniques are particularly useful in the traumatized patient who often cannot tolerate much confrontation with their barriers of resistance. As is typically the case, a 'joint' is dysfunctional in the context of a larger functional neuromusculoskeletal complex. In this model, simply 'fixing' the joint is insufficient. Myofascial treatments with their focus on functionally related neuromusculoskeletal structures are particularly relevant in this setting. Whether direct or indirect, these techniques work on both viscoelastic and neuroreflexive mechanisms to release tightly bound muscular/ skeletal/ tendinoliga mentous complexes. Headaches may of course be a consequence of pain of myofascial origin with distant reference. For these myofascial therapy is especially well suited. Muscle energy techniques utilizing post-isometric relaxation and reciprocal inhibition may also be very useful. Further, they may be readily transformed into therapeutic exercises. Headache frequently follow direct cranial trauma. Whether the trauma is major or minor, many times the headaches may be persistent. In these situations often there is tenderness of the cranial sutures and craniosacral releasing techniques may be most successful.

With migraine, the patient presents acutely with signs of autonomic dysfunction (ptosis, anisocoria, pallor, flushing, diaphoresis) as well as somatic dysfunction. The somatic dysfunction may be regularly seen both during and between migraine attacks. Special attention must be paid to the characteristics of the cervicothoracic junction (site of the sympathetic outflow), the upper ribs, the scalenes, upper trapezii, sternocleidomastoids, semispinalis capitis and cervicis, spelnius and cervicis, temporalis, masseters, and occipitofrontalis muscles, and the craniocervical junction. In the acute phase of a migraine, manipulation treatments must be modified. Those which augment blood flow (i.e. releasing biomechanical complexes with restrictive circulatory features) can aggravate the headache by augmenting blood flow through a dilated and chemically altered vascular bed. More gentle, indirect and direct techniques without a lot of aggressive muscle stretching are better tolerated. Use of methods to reduce venous and lymphatic congestion also may help reduce symptoms. In between migraine attacks a wider variety of treatment approaches become appropriate.

One particular caution regards the potential for injury to the vertebral artery with manipulations to the cervical spine. These are particularly related to those maneuvers utilizing excessive rotation and hyperextension of the craniocervical junction an d especially with high velocity forces. These circumstances should be avoided.

The therapeutic benefits of osteopathic manipulative therapy are related to the restoration of optimal neuromusculoskeletal mechanics. Undoubtedly, there are therapeutic modalities to the restoration of optimal neuromusculosketal mechanics. Undoubtedly, there are therapeutic results from the laying on of hands, from placebo effects, from the effects of empathic concern, the patient's belief in the therapist, trust in the therapy being used, and their expectation for relief.

Myofascial pain syndrome will be addressed in greater detail because it plays a special role in cervicogenic headaches. It is a condition in which pain of a persistent and aching type is referred to a localized region of the body--from trigger points in one or more muscles in the area. Furthermore, this syndrome is associated with the palpable presence of tender nodules in the neck and shoulder girdle and palpable bands in any muscle which contain one or more focal points of exquisite tenderness known as trigger points. Pressing these points gives rise to both local and referred pain and the pattern of pain referral from tender points in individual muscles is the same in different people. It is in the management of myofascial pain syndromes that acupuncture has a particular role.

The development of neural hyperactivity at trigger points is one of the commonest causes of musculoskeletal pain. Unfortunately, it is often poorly recognized and inadequately managed. Trigger points may be found in skeletal muscles and their tendons, the capsules and ligaments of joints, the periosteum, and the skin. A trigger point may be either latent or active depending on the degree to which it is activated. These points are exquisitely tender and when firmly palpated cause the patient to flinch . Active trigger points are responsible for the referral of pain both locally and at distant sites. Each muscle has its own characteristic pattern of pain referral from trigger points contained within. The spontaneous pattern of pain complained of by a patient may be reproduced by exerting sustained pressure on , or inserting a needle into, an active trigger point. Trigger points may be activated as either a primary or secondary event. A most important primary activator is trauma. Direct injury, sudden strain, excessive or unusual exercises, or repeated episodes of minor trauma or repetitive overloading all constitute sufficient trauma in the right situation. Once primary activation occurs, secondary activation can occur in synergistic muscles or as a referral from primary myofascial trigger points, visceral disease, or another somatic disorder like degenerative disc or facet disease. These satellite trigger points tend to cluster along the pathways of traditionally described acupuncture meridians. Active trigger points are sometimes associated with autonomic disturbances (sweating, pilerection). A muscle containing active trigger points undergoes shortening and becomes somewhat weakened. Attempting to stretch the muscle results in pain developing before its normal range is reached. A local twitch response may be observed when a palpable band in a muscle is plucked. A trigger point and its neural hyperactivity may subside spontaneously or it may be maintained indefinitely as a result of motor or sympathetic efferent activity creating a perpetuating circuit. The only way that these points can be identified is through the careful examination of the muscloskeletal system and the taking of an appropriate history.

Trigger points may be deactivated by injecting them, pressing on them, stretching their containing muscles or most effectively needling them dry. These presumably work by stimulating A-delta afferents which can help block C-afferent input from trigger points. Superficial needling is all that is needed because the A-delta afferents are primarily located in the skin and just beneath. These trigger points have a high correspondence with acupuncture points. This is particularly interesting in that acupuncture points are localized areas which are densely innervate by A-delta afferents and sympathetic fibers. it is likely that A-delta innervated acupuncture points in the skin and subcutaneous tissues lie above intramuscularly placed predominantly C-affere nt innervated trigger points. By using disposable, stainless steel acupuncture needles in appropriate acupuncture points for brief periods of time, trigger points may be deactivated and in so doing, restoration of mobility in the associated muscles can b e achieve. By avoiding injections one can avoid the complications of the injected substances and still enjoy full therapeutic benefit. Side effects of trigger point acupuncture include vasovagal reactions (needle shock), post-treatment drowsiness (probably endorphin mediated), and damage to underlying viscera if anatomic safeguards are abrogated. Local hemorrhage in those with bleeding disorders is an unusual complication. The beneficial effects are elicited by spinal cord modulation as already mentio ned (A-delta override of C-afferents), as well as, the elicitation of surpraspinal activation of higher centers with direct activation of the descending endogenous opioid system. 

Revised: January 1, 2011