Treatment of Cervicogenic Headaches
Treatment of cervicogenic headaches is rooted in treatment of the structures of the neck causing or referring pain into the head. Dr. Hurley uses a combination of therapies to treat the neck joints, muscles, discs, or nerves thought to be generating the headache pain. These therapies can include using targeted physical therapy to improve strength of the neck and shoulder muscles or chiropractic manipulation and mobilization to decompress the nerves in the neck and mobilize the mid, or thoracic spine. Various physical therapy routines may be used to accomplish these goals, including, cranio-sacral, muscle energy, strain-counterstrain, traction, Feldenkrais, and myofascial release, among others.
In addition to a highly individualized physical therapy routine, Dr. Hurley may also recommend the use of medications and/or injection therapy to calm the nerves and reduce the inflammation in the neck, including trigger point injections, nerve blocks, and Botox injections. More delicate and specialized, precisely placed epidural and facet injections are always performed using x-ray guidance to ensure exact placement of the medication, and they are almost always performed with the patient lightly sedated by an anesthesiologist. Dr. Hurley is one of the most experienced physicians in the world performing these injections. Special care should be taken given the close proximity to the spinal cord in the cervical spine.
Dr. Hurley believes it is the upper cervical facet joints in particular that are the major players in production of occipital headaches and pain referred to the forehead and eyes. Often MRI scans will show disc disease at the lower or middle levels of the cervical spine. In fact, levels C 4-5,C 5-6 and C 6-7 are the most common levels where disc degeneration starts, where bulging discs are identified and where herniated discs occur. Nevertheless, these levels do not in and of themselves usually lead to headaches. They can lead to arm and shoulder pain, and reactive muscle spasms. These muscles in turn are attached to the upper levels of the cervical spine, and by creating pressure there can be an indirect cause of cervicogenic headaches. Injections or surgeries at these levels, however, often lead to unsatisfactory levels of relief or headaches, or only transient changes in headache patterns.
Dr. Hurley as worked with thousands and thousands of headache patients from around the nation for the past fifteen years or more, and is convinced it is the change in alignment and pressure on the upper cervical spine joints and structures, and their relationship to the skull articulations which most lead to sub-occipital generated headaches. These are the joints most vulnerable in whiplash injuries. They are most vulnerable in rotational, hyper-extension or axial load impacts in concussion injuries. They are most compromised and over-loaded in the chronic poor postures of head-forward driving and computer-use positions in which we sit for hours and hours, day after day. Over time, older patients have rounded upper backs and shoulder areas, which force them to hyper-extend or tilt back their heads and necks to look forward. Such postures require continuous work by neck muscles and compress the area in the back of the neck where the head and spine join together.
Most interventional spine physicians do not take on these very delicate areas to inject, nor should they without a vast amount of training and experience. Where some medical articles refer to studies involving a few injections to these areas, Dr. Hurley has performed upwards of 7,000 to 10,000 of such joint injections over the past fifteen years, making him one of the world’s most experienced experts in this area.
Such injections are highly dangerous in the wrong hands. They are extra delicate due to exposure of spinal arteries and vessels which course to the brain in that area, as well as due to the exposure of the spinal cord itself in that region and the opening at the base of the skull leading to the brain. The bone structures of the skull and teeth must be seen “through” on the X-ray images as one is performing the procedure under fluoroscopic guidance. There is no room for error. A physician must approach such procedures with highest amount of respect, judicious caution and awareness of the anatomy of the target area. Dr. Hurley feels that only the most highly trained practitioners should attempt such blocks. As such, there in fact are not too many physicians who perform such injections, and hence, not many patients are told about them by their physicians, and as a result do not have access to this treatment option as part of their headache management program.
Tender spots in muscles, called trigger points, can be very effectively treated with trigger point injections. These trigger points, or tender spots in the muscle can refer pain to the neck and the head, resulting in headaches. Dr. Hurley frequently uses trigger point injections to treat patients with cervicogenic headaches. Usually these are done in combination with deeper joint or epidural blocks to maximize effectiveness.
Occipital nerve blocks are other injections that may be used by Dr. Hurley to treat cervicogenic headaches. An occipital nerve block is an injection of a steroid or other medication around the greater and lesser occipital nerves that are located on the back of the head just above the neck area. As mentioned above, these nerves supply sensation to the scalp, the skin of the back of the head. They can be directly injured by a blow to the back of the head, such as hitting the back of the head against the corner of furniture in a fall, or slamming the back of the head when standing up quickly under a table, an open trunk lid of a car or an overhanging pipe in a basement for example. Such injured nerves usually present with a sense of burning, or electric shocks or “ants crawling on my scalp”. This is different than the deeper, more penetrating pain of headaches that wrap up over the head to the forehead, or through the head to behind the eyes. These are not pure occipital nerve pain patterns, but occipital nerve blocks can still help decrease some of the pain components. The deeper headache patterns are analogous to the light produced from a flashlight, whereby the flashlight itself may be one of the structures, such as a facet joint, in the top of the neck, and the light that it projects is the headache in the back of the eyes. A true occipital nerve pain or a pinched nerve from a herniated disc is more like a light switch connected to the actual light by a wire. The light switch is the spot where the nerve is pinched, and the pain directly travels along the literal wire of the nerve causing pain along or at the far end of that pathway.
Botox is another tool Dr. Hurley uses to treat cervicogenic headaches. Botox has been shown to relax the muscles, as well as interfere in the pain signals sent by the nerves to the brain. Muscles may get stuck in a hyper-contracted state, and not be able to be relaxed by medications, stretching or by manual therapies. Such a condition is termed dystonia. Botox is a muted form of a powerful nerve toxin that has been pharmacologically modulated to be safely applicable to human muscles. The nerve muscle connection is blocked in tiny amounts when applied to appropriate locations, and some of this hyper-contracted dystonia is released. Botox injections should not be administered more often than every three to four months. They must be performed only by a practitioner knowledgeable in spine, vascular and pulmonary anatomy, and experienced in such injections. Risks are that too much weakness may be caused, or that structures such as the lungs, vital blood vessels or the spinal cord itself may be inadvertently injected.
Dr. Hurley also may recommend rhizotomies to patients where the injections had a good, but short-term effect. A rhizotomy uses a simple probe to apply thermal energy (heat) via radiofrequency waves to the impinged or painful nerve. Different than the use of such procedures elsewhere in the spine, the application for treatment of cervicogenic headaches is unique. Usually, a trial injection of the C2 and C3 origins of the greater and lesser occipital nerves is performed to determine if such blocks give adequate headache relief, and if the scalp numbness which may be produced is an acceptable side effect to the patient. If so, then a subsequent appointment is made to do the heat treatment, cauterizing these same nerves and hopefully getting them to, in a sense, shut down. Such effect can last up to six to eighteen months, and can be repeated if effective. Again, such procedures are very delicate, and are not offered by many practitioners.
For a few patients, where occipital headaches are recalcitrant to all these forms of treatment, adding together medications, injections, physical therapies and life-style changes, including posture, work and stress management, an implantable device called a nerve stimulator may tried in an attempt to interrupt the pain signals coming from the back of the head into the upper spinal cord and triggering headaches. In Dr. Hurley’s experience, it is only a very small subset of headache patients who get dramatic lasting benefit from such procedures. One does a temporary trial first of a test electrode threaded under the skin for about a week to see if enough benefit is obtained to make a surgical implantation of a more permanent device warranted. One must be aware, that as with any implanted electrical device (for example, a pacemaker), spinal stimulators, being composed of electrical wires and tiny current generating implanted batteries, preclude the patient from getting MRI’s for anything once the device is in place. Such a trade-off, given the ubiquitous use of MRI’s in medicine at this time in testing for a myriad of disorders, must be seriously weighed.
As for clinical pattern, for the most part, the obvious cervicogenic headaches are literally pointed to by patients: “doctor, my headaches are always here” (back of head, base of skull, often connected with peri-scapular muscle pain); and then “it goes over the back of my head to the front” or “it then turns into my migraine and becomes a headache in my forehead, or behind my eyes or in my eyes.” The toughest headache pattern which Dr. Hurley has found to knock out with cervical procedures are the strictly temporal region headaches, though this pattern can be successfully attacked by adding botox to the temporalis muscles during the procedure.
Headaches are multi-factorial in nature. Many people have a myriad of complicating factors leading to their suffering. But even in the face of such a jumble of potential pain generators and compounders, Dr. Hurley has had consistent, reasonable, and often dramatic, success with at least treating the extra-cranial components of headaches.
If you would like to schedule an appointment with Dr. Hurley, email him at firstname.lastname@example.org or call 847-933-3700.