I. Introduction
Neck pain is a common musculoskeletal disease
1). As the dependence on computer and smart phone technology increases, so does the prevalence of neck pain. The prevalence rate of neck pain also increases with age
2). As the pain progresses, neck pain can cause other serious problems such as temporomandibular joint pain, headache, dizziness, and nausea.
Headache sourced from the cervical spine or soft tissues in the neck is called cervicogenic headache
3). Theoretically, cervicogenic headache is a unilateral headache with symptoms and signs, such as a reduced range of motion and neck stiffness
4).
There are many treatments for neck pain and cervicogenic headache, such as pharmacological treatment, physical and manual therapy, psychological and behavioral treatment, anesthetic blockade and neurolysis, and surgical treatment
5). Medications such as antidepressants, antiepileptic drugs, analgesics, and muscle relaxants are used for pain control
6). Recent studies have reported that physical and manual therapies are effective at reducing headache frequency and intensity
7). However, pharmacologic treatment or manual therapy alone usually provides only modest improvement for this condition. Other studies suggest that no drugs effectively treat cervicogenic headache
3). The effects of the conventional therapies are limited, and the validity of many of the treatment guidelines is unclear
5). Because of the limited benefits of conventional therapy, many patients seek alternative and complementary medical treatments, such as acupuncture.
Acupuncture is one of the most popular and effective alternative and complementary medical treatments. Miniscalpel acupuncture (MA) tends to obtain better therapeutic effects on musculoskeletal pain compared with regular acupuncture treatment
8). The goal of MA is to recover the kinetic state of soft tissue through the peeling of adhesions and the removal of attached tissues, with the advantage of quicker recovery and pain reduction compared with regular acupuncture
9).
In the present study, we observed significant therapeutic effects of MA in 3 patients who visited the Acupuncture and Moxibustion department at the Daegu Oriental Hospital of Daegu Haany University, Republic of Korea for cervicogenic headache. Because the patients’ symptoms were severe and chronic, MA was used rather than acupuncture.
IV. Discussion
Cervicogenic headache is a common clinical disorder. There are some controversial issues regarding cervicogenic headache. One chapter in a leading headache textbook indicates that this concept of cervicogenic headache is not fully acknowledged
14). Although the notion that headaches can be generated from structures in the neck has long been established, only in the past two decades has the topic gained attention in mainstream headache and pain literature
5).
Headache and neck pain are closely related clinically. People with chronic neck pain or acute traumatic neck pain often complain of headache. Some patients with severe headache also complain of nausea and vomiting.
Cervicogenic headache is a unilateral headache with symptoms and signs, such as reduced range of motion and stiffness of the neck
4). Cervicogenic headache is not an independent disease but a myriad of symptoms. Nerves, nerve roots, ganglia, uncovertebral joints, facet joints, ligaments, and muscles may be involved in the induction of symptoms.
One study reported that approximately 70% of people with frequent headaches experience neck pain
15). Approximately 80% of patients with whiplash injuries report headaches within 2 months of injury
16). Approximately 25% of patients with whiplash continue to have neck pain for 2 years or longer, with the majority also complaining of headaches
17). The pathophysiology and cause of cervicogenic headache is controversial
18) but the pain is thought to be caused by muscular, neurologic, osseous, articular, or vascular structures in the neck
3).
Even though cervicogenic headache is commonly encountered in clinical practice, there is a lack of effective treatment. Cervicogenic headache is often treated using pharmacologic, non-pharmacologic, manipulative, anesthetic, or in some cases, surgical treatments. Medications used include analgesics, antidepressants, muscle relaxants, and antiepileptic drugs
6). Most patients become dependent on simple analgesics because they are desperate to find pain relief. However, medication alone is often ineffective or provides only limited benefit
18). Manual therapy and exercises are also used in treatment but it is often difficult to achieve a satisfying outcome with either
7).
Headache from neck disability can be explained from several diverse aspects. The mechanism of headache that occurs in the frontal and temporal areas tends to relate to the convergence between cervical nociceptive and trigeminal afferents in the trigeminocervical complex in the upper cervical spine
3). This may be the basis for the well-known patterns of referred pain from the trapezius and sternocleidomastoid muscles to the face and head
6).
In addition, many patients with migraine and tension-type headaches can find trigger points in the muscles of the head and neck region
10. Furthermore, secondary headache associated with neck injury or with various dysfunctions of the craniocervical structures are likely to have trigger points in the neck and head muscles. For example, occipital headache might be referred from the trapezius, sternocleidomastoid, semispinalis capitis, semispinalis cervicis, splenius cervicis, suboccipitals, occipital, digastric, or temporalis muscles. Vertex pain can be caused by the sternocleidomastoid and splenius capitis muscles. Temporal headaches can be referred from the trapezius, sternocleidomastoid, splenius cavicis, suboccipital, or semispinalis capitis muscles. The sternocleidomastoid, semispinalis capitis, frontalis, and zygomaticus major muscles can cause frontal headaches. It is recognized that trigger points are not simply a co-occurrence in head pain but may be activating factors for certain types of headaches
20). These facts can be used as the theoretical basis for treating the neck in patients with headache.
In the present study, MA treatment was performed to peel adhesions and remove attached tissues to recover the kinetic state of the soft tissues. GV16 is below the external occipital protuberance and has an insertion at the nuchal ligament and an origin at the trapezius muscle. GB20, which is 2–2.5 cm below the external occipital protuberance, is related to the rectus capitis posterior major and oblique capitis superior muscles. GB12 is 4–4.5 cm below the external occipital protuberance. GV12, at the C2 spinous process, has origins at the semispinalis capitis, obliquus capitis inferior, and the rectus capitis posterior major. BL10 is located on the side of the C2 spinous process. BL10 targets the facet joint. Apart from these MA points, the C4, C5, and C6 spinous processes are used as acupoints. The C4, C5, and C6 spinous processes have origins at the semispinalis capitis. GV14 is located at the C7 spinous process.
In the present study, all three patients complained of headache and neck pain. In cases 1 and 2, an instant decrease in pain occurred following the first treatment. In case 3, the headache score decreased after the second treatment. In cases 1, 2 and 3, the headache score decreased from 4 to 1, 3 to 0, and 3 to 1, respectively.
In all 3 cases, the VAS score started decreasing after the first treatment. The VAS score includes not only head pain, but also neck pain. Therefore, there were some differences in the VAS and headache scores. In case 3, after the first treatment, the headache score remained the same but the VAS score decreased from 5.3 to 4.5. The VAS score decreased from 8.5 to 1.9 in case 1, from 5 to 0.4 in case 2, and from 5.3 to 2 in case 3. In all three cases, the VAS score decreased gradually during treatment. Furthermore, all cases showed a decrease in the NDI score. Therefore, it is meaningful that the pain was significantly reduced following MA treatments. In addition, the improved symptoms persisted for more than four weeks. All three cases showed decreased scores in the VAS and headache scores at follow up. Further, all cases except case 2 showed a decrease in the NDI score at follow up. No adverse events occurred in any of the cases. From these results, we speculate that MA is effective and safe for the treatment of headache with neck pain. It can be assumed that these cases can be used as a reference for MA treatment for cervicogenic headache.
In the future, a comparative study with other treatment methods should be performed. Moreover, additional cases should be obtained to compare the therapeutic effects with those of Western medicine treatments.