Welcome to Journal Corner's Literature Review of the Month. This months topic centers on Chiropractic's effectiveness in the treatment of headache pain.

Donald R. Murphy, D.C., D.A.C.A.N.
Rhode Island Spine Center
Providence, RI

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Link to more Headache and Abstract information for December, 1995

There has been a great deal coming out in the literature recently regarding the role of the cervical spine in headaches, and the role that we as chiropractors can play in the diagnosis and treatment of this troubling disorder. This comes at a good time, as the Agency for Health Care Policy and Research headache panel is convening to review the literature on this topic and make their recommendations, similar to the way in which this was recently done for acute low back pain in adults. The above articles are but a sample of the types of things that are being investigated, and the findings should be of great interest to the profession.

The first article reports on a study that attempted to determine whether the atlanto-occipital and atlanto-axial joints can be a source of pain generation and what type of pain pattern would be generated by irritating the capsules of those joints. Injection studies such as this have been performed before in the spine and pain referral maps have been constructed. These maps are often very helpful in determining the source of a patient's spinal complaint.

The joints of 5 volunteers were injected with iothalamate meglumine under fluoroscopic monitoring. The volunteers were asked to describe the nature of the pain generated, rate the severity of the pain on a scale of 0-10 and describe the anatomical distribution of the pain.

The results showed that the pain generated by the injections was most commonly of a deep, dull, aching quality with a mean pain rating of 5 (range was 2-7). The atlanto-axial joints produced pain that was well localized to the upper cervical spine and the suboccipital area, posteriorly and laterally. The atlanto-occipital joints produced pain that covered the upper cervical spine, sometimes extending to the mid and lower cervical spine as well as the occipital, parietal and temporal areas of the head. These patterns were fairly consistent with those found in previous joint injection studies. The findings demonstrated that these joints, particularly the atlanto-occipital, may be a cause of headache and helps the clinician in trying to determine the source of headache pain based on the pain pattern in conjunction with the rest of the clinical workup.

The second study looked at 12 patients with postconcussion headache (PCH) and compared them with a control group for forward head posture measured on x ray, active ROM, motion palpation, coordination on the cervical flexion movement pattern a la Janda and muscle tightness in the cervical musculature.

It showed acceptable interexaminer reliability for the examination of forward head posture, ROM and cervical flexion movement pattern. They found slightly increased forward head posture in PCH sufferers, though this was not significant. The most striking difference between the groups was the presence of symptomatic joint dysfunction. There was complete agreement between patient and examiner as to whether a particular joint was symptomatic and almost complete agreement as to which joint was symptomatic. Hypomobility was found in the control group, but this was asymptomatic, showing that palpating for pain is important in assessing the significance of joint dysfunction. Symptomatic joint dysfunction was found in the PCH group most commonly at the C1-2 and C2-3 levels.

There was no difference in active ROM between the 2 groups, but pain and crepidation was more common in the PCH patients, especially when the neck was passively taken to end range, showing that looking at active ROM only may lead to false negative findings.

There was a higher incidence of moderate tightness in the PCH group, especially in the upper cervical extensor muscles.

This study showed that people with PCH, which is often attributed to intracranial rather than cervical processes, can be distinguished from normals by the presence of joint, muscle and locomotor dysfunction in the cervical spine.

The third paper reports a study that analyzed 10 patients diagnosed with cervical headaches. Outcome measures consisted of a headache diary and visual analogue scale. Patients were treated 2-3 times/ week for 4-5 weeks. The results showed that the frequency, duration and intensity of the headaches all decreased during the treatment phase and that this regressed somewhat during the follow up period but remained below pretreatment levels. The most common area where dysfunction was found was C2-3, which is consistent with the study by Treleavan, et al reported above.

The next paper by Boline, et al was a chiropractic study done and the Northwestern College of Chiropractic Center for Clinical Studies and looked at 150 patients diagnosed with chronic tension headache at least 3 months duration. Each patient was treated for 6 weeks with either manipulation, which was to any area of the spine deemed appropriate, with emphasis on the upper cervical, or 10-30 mg amitriptylline. Outcome measures were headache diary and the SF36, a self-report questionnaire. It showed that both groups improved to statistically similar levels on all measures but at 4 weeks follow up amitriptylline group degraded virtually to pre treatment levels while the manipulation group maintained their improvement.

Significantly, 81% of the amitriptylline group experienced side effects including dry mouth, drowsiness and weight gain. The only side effects in the manipulation group were that 3 patients had neck stiffness after the first treatment which disappeared in all cases.

Analysis of patient expectation of a positive outcome revealed that this was not a factor in the results.

Finally, in article number 5, a random sample of 826 persons in the general public in Denmark was contacted via questionnaire in an attempt to estimate the prevalence of cervicogenic headache. The International Headache Society criteria for cervicogenic headache was utilized. The results showed that 17.8% of those responding fit the criteria, suggesting that this is the prevalence of cervicogenic headache in the general population. This is interesting in that some people think cervicogenic headache is rare, but light of the Boline, et al study which did not restrict the study population to those patients who fit the IHS criteria for cervicogenic headache, showed such good success with cervical spine-directed treatment, ie, manipulation, it would appear the cervical spine involvement in headache is more prevalent than this. Perhaps the IHS criteria are too stringent and need to be revised to reflect the potential for multiple factors being involved in headache syndromes.

The papers reviewed here represent some exciting directions that the scientific literature is going in the demonstration of the role that the locomotor system, particularly the cervical spine, can play in the development of, and thus the treatment of, common headache syndromes. Certainly the most significant of these studies for the chiropractic profession is the Boline, et al trial which showed superiority of manipulation over amitriptylline over the long term. This supports the long held argument that chiropractors have made that medication oftentimes temporarily masks the symptoms but that the effect does not last after termination of the drug. It also shows that the positive effects of manipulation last beyond the point of termination. This study has the potential to have a long standing influence on health care policy.

So in the area of headache, we are moving in exciting directions and the ultimate hope is that this new knowledge can be used for the improvement of our patient care.

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