Massaging over the greater occipital nerve reduces the intensity of migraine attacks: evidence for inhibitory trigemino-cervical convergence mechanisms

Cervicogenic headache - How to recognize and treat

Cervicogenic headache, described almost 100 years ago, only had its clinical awakening at the end of the century with the work of Professor Sjaastad. Its classic definition is the induction of trigeminal symptoms from cervical disorders, thanks to trigeminocervical convergence mechanisms. For this reason, it can manifest several features typical of migraine, leading to diagnostic errors. Classically, subjects complain of fixed unilateral headaches, with cervical onset and trigeminal irradiation, associated with reduced neck mobility and flexion strength. The headache is mild to moderate, described as pulsatile or compressive, accompanied by nausea, vomiting, photophobia, phonophobia, and may present autonomic symptoms and dizziness. The pain duration varies from one day to weeks, and its frequency is unpredictable. A history of whiplash injury is common. The differential diagnosis encompasses migraine and tension-type headache. Management includes physiotherapy rehabilitation, anesthetic blocks, and selectively surgical procedures. In this article, all these aspects were extensively covered.

Potential mechanisms for osteopathic manipulative treatment to alleviate migraine-like pain in female rats

Introduction

Migraines are the leading cause of disability in the United States, and the use of non-pharmaceutical treatments like osteopathic manipulative treatment (OMT) has shown promise. Despite its potential, the lack of mechanistic understanding has hindered widespread adoption. This study aims to investigate the efficacy of OMT in treating acute migraines and unravel its underlying mechanisms of action.

Methods

Female rats were subjected to a "two-hit" approach to induce migraine-like pain. This involved bilateral injections of Complete Freund's Adjuvant (CFA) into the trapezius muscle (1st hit) followed by exposure to Umbellulone, a human migraine trigger, on Day 6 post-CFA (2nd hit). Soft tissue and articulatory techniques were applied to the cervical region for acute abortive or repeated prophylactic treatment. Cutaneous allodynia and trigeminal system activation were assessed through behavioral tests and immunohistochemical staining.

Results

Following Umbellulone inhalation, CFA-primed rats exhibited periorbital and hind paw allodynia. Immediate application of OMT after Umbellulone inhalation as an abortive treatment partially alleviated cutaneous allodynia. With OMT applied thrice as a prophylactic measure, complete suppression of tactile hypersensitivity was observed. Prophylactic OMT also prevented the increase of c-fos signals in the trigeminal nucleus caudalis and the elevation of calcitonin gene-related peptide expression in trigeminal ganglia induced by CFA and Umbellulone exposure at 2 h post-inhalation.

Discussion

These findings provide mechanistic insights into OMT's migraine-relief potential and underscore its viability as a non-pharmacological avenue for managing migraines.

The Untold Story of Occipital Nerve Stimulation in Patients With Cluster Headache: Surgical Technique in Relation to Clinical Efficacy

OBJECTIVES

Approximately one in every 1000 adults experiences cluster headache (CH). Although occipital nerve stimulation (ONS) appears encouraging in treatment for most patients with refractory CH, some patients do not reach adequate pain relief with ONS. A reason for failure of ONS might be anatomical variations and different surgical approaches. Therefore, an extensive literature analysis was performed, and cadaveric experimentation was combined with our clinical experience to provide a standardized proposal for ONS and obtain optimal management of patients with refractory CH.

MATERIALS AND METHODS

Data from 36 articles published between 1998 and 2023 were analyzed to retrieve information on the anatomical landmarks and surgical technique of ONS. For the cadaveric experimentation (N = 1), two electrodes were inserted from the region over the foramen magnum and projected toward the lower third of the mastoid process.

RESULTS

The existence of multiple approaches of ONS has been confirmed by the present analysis. Discrepancies have been found in the anatomical locations and corresponding landmarks of the greater and lesser occipital nerve. The surgical approaches differed in patient positioning, electrode placement, and imaging techniques, with an overall efficacy range of 35.7% to 90%.

CONCLUSIONS

Reports on the surgical approach of ONS remain contradictory, hence emphasizing the need for standardization. Only if all implanting physicians perform the ONS surgery using a standardized protocol, can future data be combined and outcomes compared and analyzed.

Brief Myofascial Intervention Modulates Visual Event-Related Potential Response to Emotional Photographic Contents: A Pilot Study

The use of touch for the treatment of psychiatric disorders is increasingly investigated, as it is shown that cognitive symptoms can be improved by various forms of massage. To investigate if the effect of massage is measurable using classical visual event-related potential components (P1, P2, late positive potential (LPP)), we performed a preliminary study on six participants using myofascial induction massage. Participants were shown emotionally valenced or neutral images before and after a 20 min myofascial massage. We found general increases in P2 amplitude following the intervention across all conditions (both neutral and affective), indicating increased attention or salience to visual stimuli. The magnitude of change was visibly larger for unpleasant stimuli, suggesting that visual perception and attention were modulated specifically in response to unpleasant visual images. The LPP showed reductions in amplitude after myofascial massage, suggesting increased emotional modulation following intervention, as a result of possible DMN alterations, consistent with region and function. We conclude that brief myofascial intervention supports other research in the field, finding that physical touch and massage techniques can alter cognition and perception. We posit further research to investigate its future use as an intervention for both physical and cognitive modulation. Importantly, we provide preliminary evidence that the neural processes that resonate with this type of massage involve complex feedforward and backward cortical pathways, of which a significant portion participate in modulating the visual perception of external stimuli.

Bening paraxysmal torticollis is a sensoriomotos trigeminocervical convergence merchanisms? Experimental evidence

Introduction Benign paroxysmal torticollis (BPT) is likely an age-sensitive, childhood periodic syndromes that are commonly precursors of migraine, with atypical postural behavior (torticollis) to start early and self-limited, which of unknown etiology. Objective To prove the existence of forms of sensorimotor convergence between the trigeminal nerve and upper cervical roots respectively. Methods Ninety-five rats Norvegicus were submitted to infraorbital nerve blockade using botulinum neurotoxin type A (BoNT/A) (n=48) controlled by isotonic saline solution animals (ISS) (n=47). After 84 days the animals were evaluated on their motor functions using open field test and postural behavior. Results Of the 48 animals in the BoNT/A group one animal showed the torticollis ipsilateral to BoNT/A injection. The macroscopic analysis showed fasciculations on clavotrapezius muscle. The biopsy with optical and electronic microscopy of this muscle showed changes suggestive of denervation secondary to BoNT/A. Conclusion We suggested the existence of a pathway sensoriomotor probably in the brainstem involves the trigeminal system and cervical motoneurons.  

Preventive effect of greater occipital nerve block on patients with episodic migraine: A randomized double-blind placebo-controlled clinical trial

OBJECTIVE

Since the data regarding the efficacy of greater occipital in episodic migraines are rare, we aimed to examine the efficacy of greater occipital block in the prophylaxis of episodic migraines without aura and compare different injectable drug regimens.

METHODS

In a randomized, double-blind placebo-controlled trial, adult patients suffering from episodic migraines without aura were randomized to one of the following: triamcinolone, lidocaine, triamcinolone plus lidocaine, and saline. Patients were assessed at baseline, one week, two weeks, and four weeks after the injection for severity and duration of headaches and side effects.

RESULTS

Fifty-five patients completed the study. Repeated measures ANOVA indicated that the severity and duration decreased significantly after the greater occipital block (P < 0.001, P = 0.001 respectively) in all four groups. However, there was no difference between groups at any study time points (P > 0.05). In paired sample T-test, only groups 2 and 3 with lidocaine as a part of the injection showed a significant decrease in frequency compared to the baseline (P = 0.002, P = 0.019). Three patients reported side effects with a possible association with triamcinolone.

CONCLUSION

Greater occipital block with a local anesthetic significantly decreases the number of attacks in episodic migraine, whereas no injection was superior to the placebo in regards to the duration and severity of the headaches.Trial Registration Information: Iranian Registry of Clinical Trials (IRCT). Registration number: IRCT2017070334879N1. https://www.irct.ir/trial/26537.

Increased migraine-free intervals with multifocal repetitive transcranial magnetic stimulation

INTRODUCTION

Episodic migraine is a debilitating condition associated with vast impairments of health, daily living, and life quality. Several prophylactic treatments exist, having a moderate ratio of action related to side effects and therapy costs. Repetitive transcranial magnetic stimulation (rTMS) is an evidence based therapy in several neuropsychiatric conditions, showing robust efficacy in alleviating specific symptoms. However, its efficacy in migraine disorders is unequivocal and might be tightly linked to the applied rTMS protocol. We hypothesized that multifocal rTMS paradigm could improve clinical outcomes in patients with episodic migraine by reducing the number of migraine days, frequency and intensity of migraine attacks, and improve the quality of life.

METHODS

We conducted an experimental, double-blind, randomized controlled study by applying a multifocal rTMS paradigm. Patients with episodic migraine with or without aura were enrolled in two centers from August 2018, to December 2019, and randomized to receive either real (n = 37) or sham (sham coil stimulation, n = 28) multifocal rTMS for six sessions over two weeks. Patients, physicians, and raters were blinded to the applied protocol. The experimental multifocal rTMS protocol included two components; first, swipe stimulation of 13 trains of 140 pulses/train, 67 Hz, 60% of RMT, and 2s intertrain interval and second, spot burst stimulation of 33 trains of 15 pulses/train, 67 Hz, 85% of RMT, and 8s intertrain interval. Reduction >50% from the baseline in migraine days (as primary outcome) and frequency and intensity of migraine attacks (as key secondary outcomes) over a 12-week period were assessed. To balance the baseline variables between the treatment arms, we applied the propensity score matching through the logistic regression.

RESULTS

Among 65 randomized patients, sixty (age 39.7 ± 11.6; 52 females; real rTMS n = 33 and sham rTMS n = 27) completed the trial and five patients dropped out. Over 12 weeks, the responder's rate in the number of migraine days was significantly higher in the real rTMS compared to the sham group (42% vs. 26%, p < 0.05). The mean migraine days per month decreased from 7.6 to 4.3 days in the real rTMS group and from 6.2 to 4.3 days in the sham rTMS group, resulting in a difference with real vs. sham rTMS of -3.2 days (p < 0.05). Similarly, over the 12-week period, the responder's rate in the reduction of migraine attacks frequency was higher in the real rTMS compared to the sham group (42% vs 33%, p < 0.05). No serious adverse events were observed.

CONCLUSION

Our pilot study shows compelling evidence in a double placebo-controlled trial that multifocal rTMS is an effective and well-tolerated preventive treatment in patients with episodic migraine.

The impact of myofascial release and stretching techniques on the clinical outcomes of migraine headache: A randomized controlled trial

Background

Migraine patients often have painful trigger points, especially in the area of head and neck. Thus, we aimed to investigate the effect of myofascial release and stretching techniques in the management of migraine headache.

Materials and Methods

This was a randomized controlled trial study on 40 migraine patients. The subjects in the experimental group received three sessions with a duration of 20 min per session techniques. Databases were analyzed using 2 × 3 repeated-measures analyses of variance (P < 0.05).

Results

Experimental group showed a significant reduction in pain intensity (P < 0.001) and the neck disability index score (P < 0.001) and an increase in cervical range of motion (P < 0.001) in all time points after the intervention as compared with baseline and control group (P < 0.001).

Conclusion

Myofascial release and stretching techniques were effective in improving symptoms in patients with migraine headache.

The Impact of Soft Tissue Techniques in the Management of Migraine Headache: A Randomized Controlled Trial

Objective

Individuals with migraine often present with postural faults and muscle tension that are associated with myofascial trigger points (MTrPs). These trigger points may be a contributory factor to the development of migraine headaches. There are many treatments aimed at eliminating MTrPs, such as soft tissue techniques, laser therapy, and needling therapies. Thus, we performed a randomized controlled trial study to investigate the efficacy of soft tissue techniques in the management of migraine headache.

Methods

This study was conducted among individuals with migraine headache in Shiraz in 2018. Forty participants were randomly divided into 2 groups: the soft tissue techniques (treatment) group and the placebo control group. Participants in the treatment group were treated over 6 sessions in 2 weeks (combined MTrP therapy and stretching). Headache parameters, drug consumption, score on the Headache Disability Index, and pressure pain threshold (PPT) were measured before and after the intervention and after a 1-month follow-up period. Data were analyzed with 2 × 3 repeated-measures analyses of variance to investigate the differences in variables between the 2 groups.

Results

Compared with baseline and the control group, the treatment group showed a significant reduction in headache parameters (P < .001), drug consumption (P < .001), and Headache Disability Index score (P < .001) immediately after the intervention and after a 1-month follow-up period (all Ps < .001). PPT levels increased in the treatment group in comparison with the control group (P < .001).

Conclusion

The soft tissue techniques were helpful for improving certain aspects of migraine, such as headache parameters, drug consumption, functional disability, and PPT levels of cervical muscles.

Effects of Dry Needling Technique Into Trigger Points of the Sternocleidomastoid Muscle in Migraine Headache: A Randomized Controlled Trial

OBJECTIVE

The study aimed to investigate the effect of dry needling into trigger points of the sternocleidomastoid muscle in migraine headache patients.

DESIGN

Forty subjects with a migraine headache, originating from myofacial trigger points into the sternocleidomastoid muscle (20 subjects in dry needling group and 20 subjects in control group) volunteered to participate in this study. The subjects in the treatment group received three sessions of dry needling in the myofascial trigger point region. Headache frequency, headache intensity, headache duration, drug consumption, muscle thickness, pressure pain threshold, and cervical range of motion were assessed before, immediately after intervention, and at 1-mo follow-up period. In addition, this article was extracted from Iranian Register of Clinical Trials Number IRCT20171219037956N1.

RESULTS

The experimental group showed significant reduction in the headache parameters immediately after the intervention and at 1-mo follow-up, as compared with the control group. The pressure pain threshold of sternocleidomastoid muscle, cervical range of motion, and muscle thickness significantly increased in the dry needling group in comparison with the control group (P < 0.001).

CONCLUSIONS

The application of dry needling technique caused an improvement in symptoms of migraine patients. Therefore, this technique may be prescribed for treating migraine patients with myofacial trigger points in the sternocleidomastoid muscle.

[Peripheral neurostimulation in headache treatment]

According to rough estimates, at least one third of the population in developed countries suffers, to varying degrees, from certain forms of primary headache, the modern pharmacotherapy of which is not always effective and has a number of limitations. The non-pharmacological treatment of headache can be an alternative to the prescription of pharmacological agents and the only possible assistance option for patients developing drug-resistant cephalalgias. This review describes various methods of electrical neuromodulation that are used for the management of primary headaches. The authors provide information on current stages in implementation of implantable and non-invasive equipment into clinical practice, which makes possible electrical stimulations of peripheral nerves and of the sphenopalatine ganglion, as well as allows transcranial magnetic stimulation. Also the appearance and usage of portable electrical devices available on the world market are described, and mechanisms that can underlie anticephalgic action of neuromodulation therapy are discussed. Special attention is paid to the methods that are applied for electrostimulation of the vagus nerve and occipital nerves.

A Neuroscience Perspective of Physical Treatment of Headache and Neck Pain

The most prevalent primary headaches tension-type headache and migraine are frequently associated with neck pain. A wide variety of treatment options is available for people with headache and neck pain. Some of these interventions are recommended in guidelines on headache: self-management strategies, pharmacological and non-pharmacological interventions. Physical treatment is a frequently applied treatment for headache. Although this treatment for headache is predominantly targeted on the cervical spine, the neurophysiological background of this intervention remains unclear. Recent knowledge from neuroscience will enhance clinical reasoning in physical treatment of headache. Therefore, we summarize the neuro- anatomical and—physiological findings on headache and neck pain from experimental research in both animals and humans. Several neurophysiological models (referred pain, central sensitization) are proposed to understand the co-occurrence of headache and neck pain. This information can be of added value in understanding the use of physical treatment as a treatment option for patients with headache and neck pain.

Management of refractory chronic migraine using ultrasound-guided pulsed radiofrequency of greater occipital nerve: Two case reports

RATIONALE

Although various oral medications and procedures are applied for managing migraine, their efficacy remains limited. To control migraine that does not respond to conventional treatments, we conducted pulsed radiofrequency (PRF) stimulation to the greater occipital nerve (GON) in 2 patients.

PATIENT CONCERNS

Patients 1 and 2 complained of chronic throbbing, pulsating, and tight headaches. Their headache intensities scored 8 and 7 on a numeric rating scale (NRS), respectively. Patient 1 experienced the headache bilaterally in the frontal, retro-orbital, parietal, and occipital regions. The initial onset of the symptoms was more than 15 years ago. Patient 2 complained of headaches in the left frontal, retro-orbital, parietal, and occipital regions, which occurred first more than 14 years ago.

DIAGNOSES

According to the International Classification of Headache Disorder-3 beta criteria, the patients were diagnosed with chronic migraine.

INTERVENTIONS

Oral medications, GON block with bupivacaine and dexamethasone, and botulinum toxin injections did not alleviate the patients' migraine.The PRF stimulation on GON was performed under the guidance of ultrasound, at 5 Hz and 5-millisecond pulsed width for 360 seconds at 45 V. The electrode tip temperature was maintained at or below 42°C.

OUTCOMES

Two weeks after applying PRF, the pain was reduced to NRS 3 in both patients, who also reported that the headache became bearable after PRF. The effectiveness of PRF on GON lasted for at least 3 months in both patients, and no adverse effects were observed.

LESSONS

Our findings suggested that the application of PRF on GON can be a useful option for treating refractory chronic migraine.

Increased mechanosensivity of the greater occipital nerve in subjects with side-dominant head and neck pain - a diagnostic case-control study

Objectives: To investigate differences in pressure pain thresholds (PPTs) and longitudinal mechanosensitivity of the greater occipital nerve (GON) between patients with side-dominant head and neck pain (SDHNP) and healthy controls. Evaluation of neural sensitivity is not a standard procedure in the physical examination of headache patients but may influence treatment decisions. Methods: Two blinded investigators evaluated PPTs on two different locations bilaterally over the GON as well as the occipitalis longsitting-slump (OLSS) in subjects with SDHNP (n = 38)) and healthy controls (n = 38). Results: Pressure pain sensitivity of the GON was lower at the occiput in patients compared to controls (p = 0.001). Differences in pressure sensitivity of the GON at the nucheal line, or between the dominant headache side and the non-dominant side were not found (p > 0.05). The OLSS showed significant higher pain intensity in SDHNP (p < 0.001). In comparison to the non-dominant side, the dominant side was significantly more sensitive (p = 0.004). Discussion: Palpation of the GON at the occiput and the OLSS may be potentially relevant tests in SDHNP. One explanation for an increased bilateral sensitivity may be sensitization mechanisms. Future research should investigate the efficacy of neurodynamic techniques directed at the GON. Level of Evidence: 3b.

Multisensory Integration in Migraine: Recent Developments

There are well-documented unimodal sensory differences in migraine compared to control groups both during, and between migraine attacks. There is also some evidence of multisensory integration differences in migraine groups compared to control groups, however the literature on this topic is more limited. There are interesting avenues in the area of visual–vestibular integration, which might have practical implications, e.g., motion sickness and nausea in migraine. Recent work has been investigating the possibility of visual–auditory integration in migraine, and found possible differences in the susceptibility to the sound-induced flash illusion in particular, which could give insights into relative excitability of different areas of the cortex, and also into mechanisms for the illusions themselves. This review updates the most recent literature and also highlights potentially fruitful areas of research to understand one of the most common neurological disorders.

Inhibitory effect of high-frequency greater occipital nerve electrical stimulation on trigeminovascular nociceptive processing in rats

Electrical stimulation of the greater occipital nerve (GON) has recently shown promise as an effective non-pharmacological prophylactic therapy for drug-resistant chronic primary headaches, but the neurobiological mechanisms underlying its anticephalgic action are not elucidated. Considering that the spinal trigeminal nucleus (STN) is a key segmental structure playing a prominent role in pathophysiology of headaches, in the present study we evaluated the effects of GON electrical stimulation on ongoing and evoked firing of the dura-sensitive STN neurons. The experiments were carried out on urethane/chloralose-anesthetized, paralyzed and artificially ventilated male Wistar rats. Extracellular recordings were made from 11 neurons within the caudal part of the STN that received convergent input from the ipsilateral facial cutaneous receptive fields, dura mater and GON. In each experiment, five various combinations of the GON stimulation frequency (50, 75, 100 Hz) and intensity (1, 3, 6 V) were tested successively in 10 min interval. At all parameter sets, preconditioning GON stimulation (250 ms train of pulses applied before each recording) produced suppression of both the ongoing activity of the STN neurons and their responses to electrical stimulation of the dura mater. The inhibitory effect depended mostly on the GON stimulation intensity, being maximally pronounced when a stimulus of 6 V was applied. Thus, the GON stimulation-induced inhibition of trigeminovascular nociceptive processing at the level of STN has been demonstrated for the first time. The data obtained can contribute to a deeper understanding of neurophysiological mechanisms underlying the therapeutic efficacy of GON stimulation in primary headaches.

A pilot study to investigate the short-term effects of specific soft tissue massage on upper cervical movement impairment in patients with cervicogenic headache

OBJECTIVES

Upper cervical movement impairment and muscle dysfunction have been identified as core components of cervicogenic headache (CGH) pathogenesis. The purpose of this single-group pre-post test pilot study was to investigate the short-term effects of a specific soft tissue massage (SSTM) intervention to the cervical spine on range of upper cervical motion.

METHODS

Eight subjects (mean age 28.1 years) with published criteria of CGH (mean history of headache for 7.1 years) were investigated. Range of rotation of the upper cervical spine to the left and right was determined by the flexion-rotation test. Movement was assessed in three phases: pre-intervention, intervention, and post-intervention. The SSTM intervention consisted of an 8-minute soft tissue massage to the cervical muscles bilaterally.

RESULTS

Pre-intervention measures of flexion-rotation test range of motion prior to the intervention over two assessment points were consistent. In contrast, a repeated measures analysis of variance revealed a significant improvement in range of rotation to the left and right after the first (P<0.01), second (P<0.01), but not third intervention (P = 0.19), from an average range of 27.5° at baseline to 45.9° at the third treatment session. After the 2-week post-intervention phase, range of motion remained stable without decline, and was considered full range.

DISCUSSION

This pilot study provides preliminary evidence of the potential for SSTM to improve, at least in the short-term, upper cervical range of motion in people with CGH.

Ottawa Panel evidence-based clinical practice guidelines on therapeutic massage for neck pain

OBJECTIVE

To update evidence-based clinical practice guideline (EBCPG) on the use of massage compared to a control or other treatments for adults (>18 years) suffering from sub-acute and chronic neck pain.

METHODS

A literature search was performed from January 1, 1948 to December 31, 2010 for relevant articles. The Ottawa Panel created inclusion criteria focusing on high methodological quality and grading methods. Recommendations were assigned a grade (A, B, C, C+, D, D+, D-) based on strength of evidence.

RESULTS

A total of 45 recommendations from ten articles were developed including 8 positive recommendations (6 grade A and 2 grade C+) and 23 neutral recommendations (12 grade C and 11 grade D).

DISCUSSION

Therapeutic massage can decrease pain, tenderness, and improve range of motion for sub-acute and chronic neck pain.

CONCLUSION

The Ottawa Panel was able to demonstrate that the massage interventions are effective for relieving immediate post-treatment neck pain symptoms, but data is insufficient for long-term effects.

Reduction of current migraine headache pain following neck massage and spinal manipulation

BACKGROUND

Migraine headache significantly impacts the health of individuals and of society. The application of simple physical nonpharmacological techniques could greatly reduce the therapeutic costs and side effects in acute onset of such headaches.

METHODS

Ten male patients (mean age was 32.0 ± 10.59 years) with acute onset of a migraine headache according to IHS-2004 diagnostic criteria were enrolled in the study. Neck and upper thoracic spine massage and manipulation technique was performed. Headache pain intensity was assessed before and after the intervention by means of a verbal analog scale.

RESULTS

Following treatment, headache pain intensity was significantly reduced compared to the pretreatment values (1.85 ± 1.11 vs. 5.80 ± 2.25, p = .005). As a percentage, this represents a mean pain reduction of 68.77% ± 18.56. No side effects were observed, and all of the patients reported satisfaction with the intervention.

CONCLUSION

Our results show that the applied cervical and upper thoracic massage and manipulation technique could reduce the headache attack pain intensity in patients with migraine headaches, though further testing, including study designs that make use of control groups, is needed.