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CCJ-and-headache

The Craniocervical Junction and Headache Disorders

CCJ-and-headache

 

  • Chronic headaches come in different types
  • The neck and headache disorders
  • The craniocervical junction, NUCCA, and migraines

Headaches disorders are among the most common conditions that people seek treatment from a doctor. While most people will experience a headache of some form,  there are those who develop chronic and repetitive bouts with headaches of different types.

Each headache has unique characteristics that help to make an effective diagnosis for effective treatment. However, when we look at the reality of a daily patient interaction, we see that people with these headache disorders can have traits that overlap. (Remember this point because this is something I’ll come back to later)

That makes these headaches  extremely burdensome on the patient, but it can also be challenging for a doctor or therapist to find effective solutions. The chronic use of medications has led to the emergence of medication overuse headaches as the third leading cause of chronic headaches in the United States.

Medication overuse headaches were once classified as rebound headaches because of the way headaches could come back with a vengeance after the pain-relieving effects of a medication wore off. It became re-classified in part due to the alarming number of patients showing a regression in their headache symptoms after prolonged and frequent use of medication. While the physiology of this disorder is widely unknown, it does show characteristics of physical dependency as seen with drug withdrawals.

As drug therapies become less effective for this subset of headache patients, there has become a growing need to identify non-pharmacologic strategies to help patients with headache disorders. For many of these patients, a possible solution might lie in the neck.

The Neck and Headache Disorders

Headaches caused by a neck problem are usually classified as a subtype known as cervicogenic headaches. People with cervicogenic headaches are usually those with chronic headache along that is associated with neck pain, whiplash, or a resistance to most medications.  Studies on chiropractic and cervicogenic headaches are mixed, but it is mostly accepted that these types of headaches can be responsive to traditional spinal manipulation [1].

The study of these headaches has helped us understand the neurology behind head and neck pain in general. There’s a lot of really sensitive anatomy in your neck. Structures ranging from the muscles, ligaments, joints, nerves, arteries, and nerves. Things like whiplash, concussion, and even sub-concussive head injuries can damage some of these structures causing pain receptors to fire into your brain stem.

The muscles in the deep part of the neck have been implicated in headache disorderrs

The muscles in the deep part of the neck have been implicated in headache disorders

That’s where things can get a little bit screwy. The area in the brain stem that gets pain signals from the neck also receives pain signals from the head and face too! When nerve fibers from different parts of the body converge onto one location called the trigeminocervical nucleus (TVN), it allows for 2 things:

  1. It allows dysfunction in what part of the body to be felt in other parts of the body. It’s like when you have a pinched nerve in your back but you feel it in your leg, or when someone has a heart attack, they may feel it in their left arm.
  2. It allows the opportunity for treatments in one part of the body to have the ability to reduce pain in other areas. i.e – targeting TMJ and the neck to help with head pain

But What About Neurovascular Headaches Like Migraine?

Neurovascular headaches are those attributed to problems in the blood vessels in the head or brain. Migraine and cluster headaches are the main classes of chronic neurovascular headaches.

From a basic science standpoint, the neck still seems to be a problem area for migraine patients. We also know that patients with migraine also tend to have overlapping pain in parts of their neck too. However, from a clinical research standpoint, most studies on treating the neck in migraine patients have been underwhelming.

Findings like these challenge my beliefs because while I know the research says that treating the neck is not likely going to get you far, the results in my practice seem to dispute that.

The Cranialcervical Junction and Headaches

As an office focused on upper cervical chiropractic, we often see headache patients who have chronic and treatment resistant headaches. They’ve usually been through multiple rounds of different medications and have bounced around through various specialists from renowned neurologists, to local chiropractors.

Despite seeing these patients with significant challenges, our success rate in chronic migraine headache is pretty high. About 85% of our patients with a primary complaint of migraine headache reported a favorable outcome after 8 weeks on a progress exam.

 

How I imagine Brad Pitt would react if he had chronic migraines and didn't anymore

How I imagine Brad Pitt would react if he had chronic migraines and didn’t anymore

Of course I wish everyone got better, and I spend a lot of time reading and going to seminars trying to get answers for the other 15%. We just have a high degree of confidence that even some of the most challenging headache cases seem to do well when we address the upper neck.

If so many people get relief in our office, but clinical trials on chiropractic show limited effect, then what gives?

The big thing is that I don’t practice the same way that most chiropractors practice. Our office uses precise x-rays of the top of the neck called the craniocervical junction and we use very low-force techniques like the NUCCA procedure to address the neck. We also take pre and post x-rays to verify that we’ve changed the way the head sits on top of the neck.

  • Maybe previous chiropractic studies didn’t use techniques that accurately identified the problem area in the spine?
  • Maybe the way the spine was manipulated was not well suited to the specific patients?
  • Maybe the adjustments used didn’t actually show a structural change in the craniocervical region? It’s hard to say.

However,  a small 2015 study on patients suffering from chronic migraine headaches showed that the correction of the atlas vertebra using precise upper cervical methods showed a reduction in headache days and high patient satisfaction.

Obviously we can’t generalize these findings to every migraine patient because there was no control group and migraine studies have a high rate of placebo, but this is clearly something worth studying more.

Is It Worth It?

So I can’t tell someone if getting their atlas corrected is going to be worth it. For many people, the prospect of having far fewer headaches is worth any price. For others, you may have become so used to having headaches that you have learned to live with it and don’t mind the pain.

What I can say is that getting the atlas corrected through the NUCCA procedure is a really safe way to address some of the real anatomical and physiologic causes of many headaches.

The only things I can say for sure are this:

  1. If your atlas is a major cause or contributor to your headache syndrome, we’ll know it pretty quickly as you will likely respond to this within a few weeks.
  2. We will do everything in our power to help you find solutions to this disabling secondary condition, even if it means we have to refer you to another provider that is better equipped to help.

 

Talk to Dr. Chung

 

 

TMJ and neck

Why Pain Can’t Tell You Where You Need Treatment: A TMJ Case Study

TMJ and neck

Jaw pain/TMJD is a very frequent problem we see in the office. It’s so frequent that I spend one day each week inside of a dental office in West Palm Beach doing consultations with a great local area dentist that specializes in pain syndromes of the jaw.

Most of the patients that see us with jaw pain have already seen a variety of jaw specialists. They’ve had MRI’s done, mouth pieces made, and various therapies done on the area of pain.

The problem of course is that pain, especially chronic pain, does a poor job of telling us what is wrong with you. Chronic pain is complex. Chronic pain is misleading. Chronic pain is also a poor locator for pathology.

Identifying the Pain Source

One of the common questions asked during a case history is to highlight or point to the area where you feel pain. It can be useful sometimes when pain patterns are reflecting specific nerve roots, and it also gives a general vicinity for a doctor to examine more closely. For most cases of chronic pain, examining the area of injury often leads to dead ends. There’s no damaged tissue to treat or remove that’s likely to explain why someone hurts.

Patients with TMJ pain frequently seek the treatment of these specialized dentists, and most of them do really well when in the right hands. However, sometimes jaw pain isn’t truly a problem in the jaw. Sometimes it’s a pain problem somewhere else in the body.

I recently took care of a patients who were was referred by another chiropractor. The patient had been to 6 different jaw and mouth specialists but could not get any form of relief from treating the jaw.

When we examined the patient, we didn’t pay much attention to the jaw itself. The patient already had imaging and tests done to their mouth already, so I wanted to spend my time elsewhere.

We found that the patient had poor motion in their shoulder and neck area on the right side. They were also showing a large amount of forward head posture characteristic of anterior head syndrome. Surprisingly, the patient’s jaw seemed to move pretty well. There wasn’t the clunky abnormal opening and closing of the jaw that you would usually see in a TMJ where the jaw displays a large side to side movement. From my view, the patient’s jaw movement looked really great, but the patient’s neck was moving poorly.

Correct the Neck and Pain Self-Resolves

We did our normal protocols with this patient. We did a gentle NUCCA correction to the patient’s neck. We post-x-rayed the neck to verify a neck improvement, and then we waited. You can see the x-ray results below.

Pre and Post X-ray shows a small shift, but an almost perfect correction.

Pre and Post X-ray shows a small shift, but an almost perfect correction.

3 days after her first appointment, we had our first follow-up appointment scheduled. The patient had gone 3 consecutive days without any jaw pain at all for the first time in 2 years!

Pretty good, but would it last?

3 months later, we re-examined the patient. The patient was now going 1 month between appointments because it would be important to see if the patient could go that long a distance between appointments without pain. The jaw was still moving normally, but now their head and neck could move in all ranges of motion smoothly. The patient also stopped showing a persistent right tilt of their head.

Most importantly, the patient could now talk with no restrictions, and had no more food limitations on what she could eat. For all intents and purposes, she became a normal teenager again.

Final Thoughts

Now if we had kept on trying to treat the jaw and identify pathology in the jaw, would she still have gotten better?

It’s hard to say, but after 2 years of doing every jaw therapy under the sun, it just seemed to make sense to look at other pieces of anatomy.

The complexity of chronic pain often means that we can’t look at things linearly. We have to know that someone has pain in one region, but we also have to think about all the different anatomy that shares a connection with the part of the body that hurts. This doesn’t mean that every person with chronic jaw pain will get better from a neck adjustment, because that’s not true either.

It means that we have to take care of people and see them for what they are globally instead of treating them as an object with a specific piece of meat that hurts today.

 

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