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Abstract
Headache is a vast field with many different varieties of headaches and classifications. However, all headaches have a common anatomy and physiology. All headaches are mediated by the trigeminocervical nucleus, and are initiated by noxious stimulation of the endings of the nerves that synapse on this nucleus, by irritation of the nerves themselves, or by disinhibition of the nucleus. A mastery of the relevant anatomy and physiology of the trigeminocervical nociceptive system serves to predict and summarise the many varieties of headache systematically and with reference to their mechanisms.
... 1 Some of these headaches can be provoked by poor sitting postures. [2][3][4] In Europe, people spend 5 to 6 hours a day on sitting activities. 5 Higher prevalence of musculoskeletal complaints were, nevertheless, reported when daily use of the computer exceeded 3 hours. ...
... 23 In patients with posture-related headache, nociceptive cervical stimuli might first sensitize the trigeminocervical complex, whereas in time, repeated noxious input can cause central sensitization. 2,24 The latter has been mooted as an underlying mechanism in chronic tension-type headache. These patients present with an increased pain sensitivity in cephalic and extracephalic muscles. ...
... [43][44][45] Yet, little is known about mechanisms that provoke an increased tenderness. 2,31,45,46 A possible mechanism could be peripheral sensitization of cervical myofascial nociceptors caused by poor sitting postures. 28 Associations between pain and posture have been reported previously. ...
Objectives:
The purpose of this study was to compare pericranial tenderness of females with episodic cervical headache vs matched asymptomatic controls.
Methods:
Through a single-blind, cross-sectional study, pericranial tenderness was compared between 20 females with episodic cervical headaches (29.4 ± 13.2 years) and 20 age-matched female asymptomatic controls (30.1 ± 13.7 years). Pericranial tenderness was bilaterally measured in a headache-free period with the "total tenderness score" (TTS) in the suboccipital, temporal, frontal, masseter, upper trapezius (UT), levator scapula, and sternocleidomastoid (SCM) muscle insertions. Passive cervical mobility, headache intensity, frequency, and duration were secondary outcomes. Analysis was done with a 95% confidence level (SPSS version 22). The Mann-Whitney U-test was used to compare pericranial, cephalic, cervical, and muscle-specific tenderness between groups. Correlations between passive cervical mobility and headache characteristics and the TTS were estimated with Spearman's ρ.
Results:
The headache group (1.25 ± 0.89) showed a 2 times higher (P < .05) pericranial TTS compared to the control group (0.62 ± 0.70). Higher (P < .05) scores were observed for the left suboccipital, temporal, masseter, UT, levator scapula, and SCM muscles and the right suboccipital, frontal, UT, and levator scapula muscles. Grouping the tenderness scores into cervical (suboccipital, UT, levator scapula, SCM) and cephalic (frontal, temporal, masseter) regions revealed greater scores (P < .05) in the headache group. In the latter, the TTS was significantly positively correlated with passive cervical extension (ρ = 0.78).
Conclusion:
Consistent higher tenderness scores were observed and suggest involvement of sensitization in patients with episodic cervical headaches. A positive correlation was seen between passive cervical extension and sensitivity.
... The TON provides sensory innervations to the C2/C3 facet joint. 34 A posterior approach was used to anaesthetise the TON at three specific locations in accord with the International Spinal Injection Society's Guidelines. 35 36 Participants were positioned prone with the neck in partial flexion. ...
... 15 17 Diagnostic blocks were limited to the C2/C3 and C3/ C4 facet joints, even though the C0/C1 and C1/C2 articulations can cause headache. 34 To account for this limitation, positive symptomatic joint dysfunction was defined so that 'C2/C3-C3/C4 joint dysfunction' represented signs at these joints that were equal to or greater than signs at higher levels. Furthermore, the FRT was added to the clinical examination as an additional cervical sign to account for headache stemming from C1/C2. ...
Objectives
Neck pain commonly accompanies recurrent headaches such as migraine, tension-type and cervicogenic headache. Neck pain may be part of the headache symptom complex or a local source. Patients commonly seek neck treatment to alleviate headache, but this is only indicated when cervical musculoskeletal dysfunction is the source of pain. Clinical presentation of reduced cervical extension, painful cervical joint dysfunction and impaired muscle function collectively has been shown to identify cervicogenic headache among patients with recurrent headaches. The pattern’s validity has not been tested against the ‘gold standard’ of controlled diagnostic blocks. This study assessed the validity of this pattern of cervical musculoskeletal signs to identify a cervical source of headache and neck pain, against controlled diagnostic blocks, in patients with headache and neck pain.
Design
Prospective concurrent validity study that employed a diagnostic model building approach to analysis.
Setting
Hospital-based multidisciplinary outpatient clinic in Joliet, Illinois.
Participants
A convenience sample of participants who presented to a headache clinic with recurrent headaches associated with neck pain. Sixty participants were enrolled and thirty were included in the analysis.
Outcome measures
Participants underwent a clinical examination consisting of relevant tests of cervical musculoskeletal dysfunction. Controlled diagnostic blocks of C2/C3–C3/C4 established a cervical source of neck pain. Penalised logistic regression identified clinical signs to be included in a diagnostic model that best predicted participants’ responses to diagnostic blocks.
Results
Ten of thirty participants responded to diagnostic blocks. The full pattern of cervical musculoskeletal signs best predicted participants’ responses (expected prediction error = 0.57) and accounted for 65% of the variance in responses.
Conclusions
This study confirmed the validity of the musculoskeletal pattern to identify a cervical source of headache and neck pain. Adopting this criterion pattern may strengthen cervicogenic headache diagnosis and inform differential diagnosis of neck pain accompanying migraine and tension-type headache.
... The head researcher in the department of clinical research at Royal Newcastle Hospital in Australia has described headache as a vast field comprised of many different varieties of headaches and headache classifications. 10 Despite the fact that varying headache classifications exist, headaches appear to have a common anatomic and physiologic basis, where they are mediated by the trigeminocervical nucleus and are initiated by noxious stimulation of the endings of the nerves that synapse on this nucleus. 10 Moreover, it has been reported that afferent pain from the masticatory muscles affects a CNS sympathetic response, leading to increased blood flow, which can result in migraines. ...
... 10 Despite the fact that varying headache classifications exist, headaches appear to have a common anatomic and physiologic basis, where they are mediated by the trigeminocervical nucleus and are initiated by noxious stimulation of the endings of the nerves that synapse on this nucleus. 10 Moreover, it has been reported that afferent pain from the masticatory muscles affects a CNS sympathetic response, leading to increased blood flow, which can result in migraines. 11 Reducing this muscle sensory feedback has been shown to reduce migraines, as well as tension-type headaches. ...
The purpose of this case report is to share an incidence where a bite force imbalance and occlusal interferences contributed to chronic daily headaches.
A TekScan digital occlusal analyzer was used to evaluate the bite and systematically guide alterations to the patient's occlusion.
After the bite was adjusted and optimized, the patient reported a decrease in her headaches. Shortly afterward, she sustained trauma to her face that altered the way her bite came together. Via physical therapy modalities to heal the muscle, occlusion was restored to the pre-trauma relationship.
Once the patient's bite was balanced and the interferences removed, the headaches were greatly improved.
... 3 The cervical spine is closely linked to TMJ and can also produce headache, separate to the TMD-related headache. [4][5][6][7] Owing to the close neuro-anatomical [8][9][10][11][12] and biomechanical 13,14 relationships between the TMJ and the cervical spine, symptoms emanating from the two regions can appear to be similar and can be difficult for clinicians to distinguish. 12 Identifying the source can enable therapists to generate an optimal management regime 15,16 targeted towards the offending structures. ...
... 40 Cervicogenic headache is a headache form that needs to be considered by virtue of the neuro-anatomical link between the cervical spine and the temporomandibular joint. [8][9][10][11][12] Referred symptoms from the upper cervical spine can be similar, yet unrelated to TMD. 4 Grouping of headache patients irrespective of their physical or psychological cause is arguably inappropriate when the pathogeneses of the two headaches forms may be completely diverse. While there may be considerable overlap in symptomatology, and tension-type headaches may frequently be associated with stress, anxiety or emotional states, 48 the source and nature of the two types of headache may be different. ...
Objective: This systematic review critically evaluated the literature on the subjective and physical characteristics of TMD-related headache, a symptom secondary to the syndrome temporomandibular disorders (TMD). The specific research question is: 'what are the diagnostic criteria that confirm temporomandibular involvement in headache presentations?' Method: Electronic searches were conducted for MEDLINE, PubMed, and CINAHL from 1966 to September 2007. Hand searches for retrieved articles were also conducted to collect the data for this review. After applying inclusion criteria, 15 articles on TMD-related headache were found. Results: The symptoms of TMD-related headache are frequently unilateral and often present in the pre-auricular, temple and retro-orbital regions of the head. The principal physical characteristics include tenderness of the ipsilateral masticatory muscles and reduced jaw opening, often with mandibular deviation. Conclusion: Despite methodological problems such as low subject numbers and poorly documented sampling methods and inclusion criteria, the literature showed that TMD-related headache has identifiable diagnostic characteristics. This information could be used to develop guidelines to assist the identification of headaches which emanate from the temporomandibular structures.
... Furthermore, MTrps in the neck and head muscles can cause headaches [71] and the presence of MTrps in the trapezius muscle can lead to TMJ imbalance and overloading of the masticatory muscles [72,73]. The masticatory muscles are innervated by the trigeminal nerve and converge with the trigeminocervical nucleus, the nociceptive nucleus of the upper cervical spine, which can be a cause of cervical headaches [74]. In the future, the treatment of TMJ should be considered in the management of cervical headaches in clinical practice. ...
This study verified the effect of movement control training using a laser device on the neck pain and movement of patients with cervicogenic headache. A total of twenty outpatients recruited from two Busan hospitals were equally divided into two groups. The experimental group underwent movement control training with visual biofeedback, while the control group performed self-stretching. Both groups received therapeutic massage and upper cervical spine mobilization. A four-week intervention program was also conducted. Measurement tools including the cervical flexion–rotation test, visual analog scale, Headache Impact Test-6, pressure pain threshold, range of motion, sensory discrimination, and Neck Disability Index helped assess the participating patients before and after the intervention. Additionally, the Wilcoxon signed-rank test and the Mann–Whitney U test helped determine inter and intra-group variations, respectively, before and after the intervention. Most of the measurement regions revealed significant changes post-intervention within the experimental group, while only the cervical flexion–rotation test, visual analog scale, Headache Impact Test-6, and Neck Disability Index indicated significant changes post-intervention within the control group. There were also considerable inter-group differences. Thus, movement control training using a laser device more effectively improves neck pain and movement of patients with cervicogenic headache.
... Eye redness and tearing, nasal congestion, or runny nose are frequent in cluster headache (Fig. 2). [14,15] The guidelines for the treatment of migraine and chronic headaches propose the use of a simple screening questionnaire for the initial diagnosis of headaches. [16] The questions are based on diagnostic criteria defined by the IHS. ...
Introduction : Headache cephalalgia is the condition in which individuals feel pain in different parts of the head. It is one of the most common disorders believed to be amenable to self-treatment. The pharmacist can provide significant support to patients.
Aim : The aim of this study was to present the role of pharmacists in the prevention of headaches.
Materials and methods : We reviewed the available information in the biggest databases on the problem.
Results : Drug therapy is only part of an effective approach to the management of headaches. In many cases headache triggers can be identified and lifestyle changes instituted that reduce the frequency of attacks. Rest, sleep, and adequate hydration are often important components of successful management regimes. Patient education and detailed information for their disease can play an active role in the treatment. The reviewed literature shows the importance of the involvement of community pharmacists of the treatment of headache disorders.
As the most easily approachable healthcare providers pharmacists can assist patients in finding appropriate relief of headaches and ensure rational and safe headache treatment.
Conclusions : Pharmacists have a crucial role in optimizing the results of the medical therapy.
... This connection between the trigeminal nerve and upper cervical nerves is thought to be the reason for referred periorbital and occipital pain. 13,14 Stimulation at the C1 dorsal root ganglia (DRG) has been shown to evoke pain in the orbital/periorbital region, and this may play a role in the pain that occurs in this distribution during migraine and cluster headaches. 15 Anatomical C1 distributions are highly varied in the population, and as many as 50% of people do not have a fully-formed C1 DRG that sends projections to innervate peripheral tissues. ...
Introduction:
Migraine headache prevalence, etiology, and clinical presentations change from childhood to adulthood. Dural innervation plays a role in headache symptomatology, but the changes in innervation during development have not been fully explored in the literature.
Methods:
A narrative literature review on developmental innervation of cranial dura mater in the context of migraine headache.
Results:
Dural structures, nerve distributions, and pain attributed to migraine headache at varying stages of development are discussed herein with a focus on clinical findings and presentations.
Conclusions:
There are many differences in migraine presentation throughout development. Notably, the nervus spinosus and nervus tentorii may play a role in developmental differences in migraine headache presentations between children and adults.
... Compression of the cervical nerve roots through the atlanto-occipital and the atlanto-axial joints causes migraine due to the afference of cervical and trigeminal nerve fibers to the neurons of the trigeminal sensory nucleus [5]. All headaches are mediated by the trigeminocervical nucleus and are initiated by noxious stimulation of the endings of the nerves that synapse on this nucleus, by irritation of the nerves themselves, or by disinhibition of the nucleus [6]. Compression of the C1 and C2 nerves by an atlas misalignment can also cause facial pain through the nociceptive afferents from the trigeminal nerves. ...
... При продолжающейся болевой стимуляции постепенно развивается феномен центральной сенситизации с формированием зоны вторичной гипералгезии, которая распространяется шире зоны повреждения и обусловливает вовлечение в процесс чувствительного ядра тройничного нерва. Конвергенция афферентного возбуждения на тригеминоцервикальном ядре формирует возможность для направленной боли от шеи до тригеминальных сенсорных рецептивных полей на лице и голове, что и определяет клиническую картину заболевания [8]. Как правило, боль бывает умеренной или высокой интенсивности, скорее тупого, монотонного, чем пульсирующего характера, начинается от шейного отдела с распространением на затылочную и височно-лобно-глазничную область одноименной стороны, где на высоте приступа она может превышать по интенсивности боль в шейном отделе. ...
Aim:
To compare the efficacy of 2% articaine solution and 2% lidocaine solution used to perform therapeutic nerve blocks of the large occipital nerve in patients with cervicogenic headache.
Material and methods:
A randomized prospective comparative clinical study was conducted in two groups treated with articaine (n=22) or lidocaine (n=21). The therapeutic great occipital nerve blocks were performed on the 1st, 3d and 5th days of treatment. The efficacy of treatment was assessed by the pain intensity measured with the Visual Analogue scale (VAS) and the duration of individual pain paroxysms on the 5th and 10th days.
Results:
The baseline VAS pain intensity was 6.3±1.2 and 5.9±2.0 centimeters, whereas the duration of individual pain paroxysms was 7.8±2.3 and 9.1±2.8 hours in the articaine group and the lidocaine group, respectively. By the 5th day, there was a more dramatically decrease in VAS pain intensity and duration in the articaine group (up to 3.0±0.8 and 4.3±1.2 centimeters VAS (p<0.05)) compared to the lidocaine group (up to 1.9±0.6 to 4.8±1.3 hours (p<0.05)). By the 10th day, the pain intensity did not differ between groups (1.2±0.5 and 1.7±0.7 centimeters (p>0.05)). The duration of pain episodes was still lower in the articaine group (0.5±0.08 hours) compared to the lidocaine group (2.4±0.8 hours) (p<0.05).
Conclusion:
Therapeutic large occipital nerve blocks with 2% solution of articaine show the significant decrease in pain intensity and duration of pain paroxysms in a short period of time for patients with cervicogenic headache.
... Nociceptors are located in the terminal structures of meningeal and trigeminovascular afferents deriving from the ophthalmic division of the trigeminal nerve that innervate intracranial structures sensitive to pain, such as the dura mater and meningeal vasculature, large cerebral arteries and the paranasal sinuses. Headaches similar to migraine can be caused by stimulation of nerves that innervate these structures [53,54]. Animal models based on chemical provocations that use different vasodilating agents are probably the most investigated in preclinical research. ...
Migraine is a disorder affecting an increasing number of subjects. Currently, this disorder is not entirely understood, and limited therapeutic solutions are available. Migraine manifests as a debilitating headache associated with an altered sensory perception that may compromise the quality of life. Animal models have been developed using chemical, physical or genetic modifications, to evoke migraine-like hallmarks for the identification of novel molecules for the treatment of migraine. In this context, experimental models based on the use of chemicals as nitroglycerin or inflammatory soup were extensively used to mimic the acute state and the chronicity of the disorder. This manuscript is aimed to provide an overview of murine models used to investigate migraine pathophysiology. Pharmacological targets as 5-HT and calcitonin gene-related peptide (CGRP) receptors were evaluated for their relevance in the development of migraine therapeutics. Drug delivery systems using nanoparticles may be helpful for the enhancement of the brain targeting and bioavailability of anti-migraine drugs as triptans. In conclusion, the progresses in migraine management have been reached with the development of emerging agonists of 5-HT receptors and novel antagonists of CGRP receptors. The nanoformulations may represent a future perspective in which already known anti-migraine drugs showed to better exert their therapeutic effects.
... through centrally projecting fibers of bipolar neurons to the second-order neurons in the caudal brainstem or dorsal horn in the upper cervical medulla spinalis [1][2][3][4] (Fig. 2.2). The latter two structures constitute a functional unit called trigeminal spinal tractus or trigemino-cervical complex where the nociceptive information from the anterior and posterior part of the head and neck converge [1,4]. ...
The functional anatomy of the trigeminal nerve and upper cervical nerves in transmitting head and neck pain is briefly reviewed. The chapter will focus on specific structures that interventional approaches target in headache management. The aim is to provide a general view and an understanding of the mechanisms underlying peripheral nerve interventions in clinical practice.
... Tension type headache is characterised by a band like pain experienced in frontal, parietal and occipital regions, the duration of attacks ranging from few hours to several weeks (15 days per month for 6 months or 180 days per year) which is not associated with any underlying disease (18) . The International Society have designated the term Tension type headache to embrace a number of commonly used terms including tension headache, ordinary headache and psychogenic headache. ...
Abstract
Headache is one of the most common medical complaints of the general population. It could be a major symptom of a serious problem like subarachnoid haemorrhage or psychological factors like day to day ten- sion. The knowledge of physiological basis and mechanism of various types of headaches like Migraine, Cluster headache and Tension type headache has been discussed in this article with recent insights and current understanding with new and old evidences. The present article is an attempt to broadly cover this aspect.
... Trigeminal nerve lesions also can lead to pain in the floor of the mouth, teeth, mandible, anterior 2/3 of the tongue, palate, paranasal sinuses and infratemporal fossa (Sanders, 2010). The dorsal horn neurons of the upper cervical segments and the spinal nucleus of the trigeminal nerve do not have a defined boundary and converge on the trigemino-cervical nucleus (Bodguk, 1995;Olszewski, 1950). This means that painfulstimuli from the head, face, throat and upper cervical area are all delivered through afferents terminating on the second-order neurons within the trigemino-cervical nucleus. ...
Background
The etiopathogenesis of orofacial pain remains complex and a number of pain referral patterns for this region have been reported in the literature. The purpose of this report is to describe the assessment and successful clinical management of orofacial pain possibly attributable to the cervical origin.
Case description
A 55-year-old male teacher with a 3-year history of pain in the right lower jaw and radiating till ear consulted our institute for assessment and management. The patient was unsuccessfully treated for dental pain and trigeminal neuralgia. The patient’s functioning was grossly limited and the patient was unable to sleep because of severe pain. Current and previous medical and physical examinations revealed no infection, malignancies, and sinusitis. Palpation revealed no temporomandibular disorder, tenderness or myofascial trigger points. Examination of the cervical range of motion showed a reduction in rotation on right side. The patient was treated for upper cervical joint dysfunction with the mobilization of first three cervical vertebrae and motor control exercises. The patient had an almost complete resolution of symptoms and reported significant improvement in the Patient Specific Functional Scale (PSFS) and the Global Rating of Change (GRC) scale.
Conclusion
This case study demonstrates the importance of considering, assessing and treating cervical spine as a possible source of orofacial pain and the positive role of cervical mobilization on these disorders.
... The simplest of literature searches establishes a list of potential underlying causes of headache that is truly a litany of tribulation. The role of the trigemino-cervical reflex is well established [31,32] with the literature reporting that as much as 47% of the global population suffer with headache of which some 15 -20% are described as cervicogenic [33]. Thoracic outlet syndrome and in particular its variant of neurological thoracic outlet syndrome presents yet another clinical syndrome whose basis can frequently be related to or associated with sustained aberrant patterns of muscle tonicity, with manual therapy and management providing a first line of intervention. ...
The Vulcan Nerve Pinch has a memorable and unique place in the cultural iconography of Star Trek. The proposed Bow-string technique uses this image to anchor the proposal of a novel technique preliminarily described here. The technique may possess both diagnostic and therapeutic implications for somatic dysfunction in the cervical region. It is based upon the established viscoelastic properties of collagen, in particular time-dependent stress-relaxation. The technique is reliant upon a high level of patient-centred engagement and intervenes at the contralateral side to a patient’s active muscle effort. It is gentle, co-operative and runs for 2-4 minutes. It theoretically engenders significant collaginous material change (lengthening) through the stress-relaxation characteristic of collagen associated with the imposition of a fixed mechanical strain. It is anticipated that the technique may possess a considerably greater persistence of effect when compared with shorter duration, repetitive passive stretch techniques, reliant on patient relaxation.
... Literature suggesting the relationship between the neck muscle and occurrence of headache and migraine 5) report that there is a relationship between migraine, neck pain, and stiffness/tenderness of the neck area; convergence with the trigeminocervical nucleus between the trigeminal pathway and upper-cervical nociceptive pathway means the functional relationship between them for awareness of headache. Another paper reported that such convergence is the basis of the referred pain in the head and upper cervical region, and most refer red pains generated after stimulating the neck centripetal nerve fibers occur in the occipital region, forehead, and orbital region 11) . Yet another paper reported that the rate of headache attack occurrence is 34% in the neck and shoulder, followed by 39% in the temporal-parietal region and 37% in the forehead 12) . ...
Purpose: The headache is a symptom that various somatic or non-somatic disorders gives an effect to head and neck system. The neck and the shoulder pain is a common muscle pain that can not control and bothers the patient after chronic state. The headache and the neck and the shoulder muscle pain are treated with various conventional treatment methods. But, there are cases that symptoms did not resolve or increased in some clinical cases. And generally, the result of temporomandibular disorders (TMD) treatment is good. But, despite of a normal treatment was performed for TMD, there are cases that TMD symptoms did not resolved in clinical cases. In template clinic of Soonchunhyang University Bucheon Hospital, co-operative neurophysiologic treatment of Department of Neurosurgery and Dentistry are done for patients, who had head and neck pain or atypical symptoms that did not treated with various conventional treatment method such as surgery or medication etc. Materials and Methods: Four hundred fifty one patients who have treated in the template clinic, Soonchunhyang University Bucheon Hospital, from January of 2006 to December of 2008 were subjected in this study. Result: Overall average age was 31.9 years old. Ratio of numbers is 74.3% in female and 25.7% in male. The success rate of treatment in TMD symptom was 89.9%, in headache was 88.8%, in muscle pain was 81.6%. Statistically significance of differences visual analogue scale evaluation between before and after had been treated patients who have over average grade headache was calculated by paired t-test. P
... The following intracranial structures are pain-sensitive: meningeal arteries, proximal portions of the cerebral arteries, dura (skull base), and venous sinuses. Nociception is conducted by cranial nerves (CNs) V, VII, IX, X and the C1, C2 and C3 nerves, mainly to the trigeminocervical nucleus within the brainstem (Fig. 1 ) [ 2 ]. ...
Introduction:
Headache is usually considered a key symptom of intracranial hypertension (ICHT). However, there are no published experimental data to support the concept that increased intracranial pressure (ICP) is painful in humans.
Materials and methods:
This prospective study was performed in 16 patients with suspected normal-pressure hydrocephalus, necessitating a lumbar infusion test with measurement of cerebrospinal fluid (CSF) hydrodynamics. During the test, ICP was increased from baseline to a plateau. Headache was scored on a visual analog scale (VAS) (0 = no pain, 10 = very severe pain) at baseline ICP and when ICP plateaued.
Results:
At baseline, mean ICP was 11 ± 3.6 mmHg and VAS was 0. At plateau, mean ICP was 28 ± 9.5 mmHg and VAS was 0. There was a significant increase in ICP (p <0.001), but no increase in headache intensity (VAS). An acute (20-min) moderate increase in ICP was not accompanied by a headache.
Discussion:
We demonstrate that an acute, isolated increase in CSF pressure does not produce a headache. To occur, a headache needs activation of the pain-sensitive structures (dura and venous sinuses) or central activation of the cerebral nociceptive structures. This peripheral or central activation does not occur with an isolated increase in CSF pressure.
... The physiological communication between the first cervical spinal nerve roots and the spinal trigeminal tract, involving the ophthalmic branch of the trigeminal nerve, could trigger migraine attacks with pain radiating behind the corresponding eye [6][7][8][9]. Transcutaneous neurostimulation (TNS) applied to the supraorbital nerve is supposed to use this nerve pathway to spread the impulse from the frontalis muscle to peripheral muscles thus being recorded in other muscles far from the application area of stimulation. ...
The objective of this observational study is to report clinical and instrumental results obtained in 23 chronic migraine sufferers treated with transcutaneous neurostimulation with the Cefaly® device. The electrom
yography (EMG) parameters of the patients monitored before and during neurostimulation with the Cefaly® device showed a significant increase in the EMG amplitude and frequency values in the frontalis, anterior temporalis, auricularis posterior and middle trapezius muscles. The Cefaly® device could act on the inhibitory circuit in the spinal cord thus causing a neuromuscular facilitation and may help reduce contraction of frontalis muscles.
... Anatomically, there is a convergence between the afferent nerves of the upper three cervical nerves (C1 to C3) and trigeminal afferents, and therefore pain from the upper cervical structures can be perceived as pain in the frontal region of the head (29,30). Among the structures and muscles innervated by the three nerves is the trapezius, which therefore potentially can contribute to TTH. ...
Tension-type headache (TTH) is highly prevalent in the general population, and it is characterized by increased muscle tenderness with increasing headache frequency and intensity.
The aim of this case-control study was to compare muscle strength in neck and shoulder muscles in TTH patients and healthy controls by examining maximal voluntary isometric contraction (MVC) during shoulder abduction, neck flexion and extension as well as the extension/flexion strength ratio of the neck.
Sixty TTH patients and 30 sex- and age-matched healthy controls were included. Patients were included if they had TTH ≥8 days per month. The MVC neck extensor and flexor muscles were tested with the participant seated upright. MVC shoulder abduction was tested with the individual lying supine.
Compared to controls TTH patients had significantly weaker muscle strength in neck extension (p = 0.02), resulting in a significantly lower extension/flexion moment ratio (p = 0.03). TTH patients also showed a tendency toward significantly lower muscle strength in shoulder abduction (p = 0.05). Among the 60 TTH patients, 25 had frequent episodic TTH (FETTH), and 35 had chronic TTH (CTTH).
Patients with TTH exhibited decreased muscle strength in the neck extensor muscles, inducing a reduced cervical extension/flexion ratio compared to healthy people.
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... Nociceptors are present on the terminals of meningeal and trigeminovascular afferents arising from the ophthalmic division of the trigeminal nerve that innervate intracranial pain-sensitive structures such as the dura mater and meningeal vasculature as well as large cerebral arteries and sinuses [34][35][36][37]. Stimulation of nerves innervating these structures in humans gives rise to headaches that are remarkably similar to migraine [35][36][37][38]. ...
Many animal models of migraine have been described. Some of them have been useful in the development of new therapies. All of them have their shortcomings. Animal models of chronic migraine have been relatively less frequently described. Whether a rigid distinction between episodic and chronic migraine is useful when their underlying pathophysiology is likely to be the same and that migraine frequency probably depends on complex polygenic influences remains to be determined. Any model of chronic migraine must reflect the chronicity of the disorder and be reliable and validated with pharmacological interventions. Future animal models of chronic migraine are likely to involve recurrent activation of the trigeminal nociceptive system. Valid models would provide a means for investigating pathophysiological mechanism of the transformation from episodic to chronic migraine and may also be used to test the efficacy of potential preventive medications.
... The effectiveness of multiple treatments and duration of treatment effect have yet to be investigated, and would be necessary before attributing clinical utility to the results of this study. As sub-occipital muscular tension is known to play a role in the presentation of cervicogenic and tension-type headaches (Bogduk, 1995), it is plausible that the CV4 technique had an effect via inhibition and consequent relaxation of these muscles. Future studies could address this possibility by comparing the effect of the CV4 technique with the effect of suboccipital muscle inhibition in participants with tension-type headaches. ...
... These nerves relay pain signals to the trigeminocervical nucleus, which is the nociceptive nucleus of the head and upper neck. This convergence is hypothesized to be responsible for referred pain to the occiput and/or eyes [3]. The potential pain generators of CGH are diverse; they include atlanto-occipital joint, atlantoaxial (AA) joints, C2-3 zygapophysial joint, C2-3 intervertebral disc, cervical myofascial trigger points, and the upper cervical spinal nerves themselves. ...
Cervicogenic headache (CGH) is defined as referred pain from various cervical structures innervated by the upper three cervical spinal nerves. Such structures are potential pain generators, and include the atlanto-occipital joint, atlantoaxial joint, C2-3 zygapophysial joint, C2-3 intervertebral disc, cervical myofascial trigger points, as well as the cervical spinal nerves. Various interventional techniques, including cervical epidural steroid injection (CESI), have been proposed to treat this disorder. And while steroids administered by cervical epidural injection have been used in clinical practice to provide anti-inflammatory and analgesic effects that may alleviate pain in patients with CGH, the use of CESI in the diagnosis and treatment of CGH remains controversial. This article describes the neuroanatomy, neurophysiology, and classification of CGH as well as a review of the available literature describing CESI as treatment for this debilitating condition.
... This effect can be explained by the presence of close relations between the pars caudalis of the spinal nucleus of the trigeminal nerve and the dorsal horn of the spinal cord. 4,15,29 Increasing the rate of stimulation to 70-80 Hz can also enhance the backward stimulating effect. It is important to be aware of these anatomical interrelations, because they might sometimes be useful to increase the PNFSinduced pain control in patients affected by trigeminal neuralgia. ...
Object:
Peripheral nerve field stimulation has been successfully used for many neuropathic syndromes. However, it has been reported as a treatment for trigeminal neuropathic pain or persistent idiopathic facial pain only in the recent years.
Methods:
The authors present a review of the literature and their own series of 6 patients who were treated with peripheral nerve stimulation for facial neuropathic pain, reporting excellent pain relief and subsequent better social relations and quality of life.
Results:
On average, pain scores in these patients decreased from 10 to 2.7 on the visual analog scale during a 17-month follow-up (range 0-32 months). The authors also observed the ability to decrease trigeminal pain with occipital nerve stimulation, clinically confirming the previously reported existence of a close anatomical connection between the trigeminal and occipital nerves (trigeminocervical nucleus).
Conclusions:
Peripheral nerve field stimulation of the trigeminal and occipital nerves is a safe and effective treatment for trigeminal neuropathic pain and persistent idiopathic facial pain, when patients are strictly selected and electrodes are correctly placed under the hyperalgesia strip at the periphery of the allodynia region.
Masticatory muscle hyperactivity has been considered a significant factor in promoting and perpetuating dysfunctional symptoms observed in Temporomandibular Disorder patients. Many therapeutic modalities have evolved within dental medicine that attempt to lessen or resolve the varying symptoms frequently reported by dysfunctional patients. One such method, known as ultra low frequency (ULF) transcutaneous electrical neural stimulation (TENS), has been used to relax the masticatory musculature by applying an electrical stimulus to the efferent motor fibers of the Vth and VIIth cranial nerves, such that TENS can result in pain analgesia and patient sedation, restore compromised muscle physiology and increase muscle resting length. TENS also aids in establishing a neuromuscular maxillomandibular relationship by inducing a muscularly contracted involuntary arc of closure. This chapter will illustrate TENS as a treatment modality for Temporomandibular Disorders (TMD), explain how to employ TENS to obtain a neuromuscular maxillomandibular relationship, and describe a case report of TENS use in combination with T-Scan computerized occlusal analysis, to measurably and physiologically balance a removable anatomical acetyl resin orthotic overlay prosthesis. This chapter will also explain the interrelationships between TMD musculoskeletal problems and Posturo-Occlusal disorders, and how Disclusion Time Reduction therapy (DTR) with occlusal rebalancing, performed with the T-Scan 10/BioEMG synchronization, can improve whole body alignment. A few clinical case examples of how changing the occlusion with the T-Scan technology can improve whole body posture illustrates this important component of the chapter, as dental treatment is often provided without considering how occlusal changes affect a patient's body far away from the oral cavity. Lastly, the five Kinetic Chains that provide all human physiologic functionalities are described in detail, after which the chapter concludes with a discussion about the three problems of occlusion.
Masticatory muscle hyperactivity has been considered a significant factor in promoting and perpetuating dysfunctional symptoms observed in temporomandibular disorder patients. Many therapeutic modalities have evolved within dental medicine that attempt to lessen or resolve the varying symptoms frequently reported by dysfunctional patients. One such method, known as ultra-low frequency (ULF) transcutaneous electrical neural stimulation (TENS), has been used to relax the masticatory musculature by applying an electrical stimulus to the efferent motor fibers of the fifth and seventh cranial nerves, such that TENS can result in pain analgesia and patient sedation, restore compromised muscle physiology and increase muscle resting length. TENS also aids in establishing a neuromuscular maxillomandibular relationship by inducing a muscularly contracted involuntary arc of closure. This chapter will discuss TENS as a treatment modality for temporomandibular disorders (TMD), explain how to employ TENS to obtain a neuromuscular maxillomandibular relationship, and illustrate in a clinical case report the use of TENS in combination with the T-Scan Computerized Occlusal Analysis System to measurably and physiologically balance, a removable overlay anatomical acetyl resin orthotic prosthesis. This chapter will also detail the interrelationships between TMD musculoskeletal problems and posturo-occlusal disorders, and how disclusion time reduction therapy (DTR) with occlusal rebalancing, performed with the T-Scan 9/BioEMG synchronization, can improve whole body alignment. The chapter concludes with discussions about the problems with direct anatomic relationships, and the three problems of occlusion.
Deneysel Alzheimer Hastalığı Modelleri Betül DANIŞMAN Betül ÇİÇEK Deneysel Epilepsi Modelleri Güven AKÇAY Deneysel Migren Modelleri Güven AKÇAY Deneysel Multiple skleroz Modelleri Betül DANIŞMAN Deneysel Nöropatik Ağrı Hayvan Modelleri Büşra CESUR Deneysel Parkinson Hastalığı Hayvan Modelleri Dilara NEMUTLU SAMUR Deneysel Serebral İskemi Modelleri Güven AKÇAY Deneysel Travmatik Beyin Hasarı Modelleri Güven AKÇAY In Vivo Voltametri ile Nörotransmitter Ölçümleri Ahmet HACIMÜFTÜOĞLU Fatma YEŞİLYURT
ZUSAMMENFASSUNG
Migräne und Kopfschmerzen gehen oft mit Nackenschmerzen einher. Ob die Nackenschmerzen Symptom, Auslöser oder aufrechterhaltender Faktor der Kopfschmerzen sind, muss im Einzelfall durch eine Anamnese und eine evidenzbasierte Untersuchung festgestellt werden. Grundlage für diese Wechselwirkungen sind Konvergenzen des N. trigeminus mit afferenten Fasern der Spinalnerven C1–3 im trigeminalen Kerngebiet. Es existieren mittlerweile mehrere Übersichtsarbeiten, in denen muskuloskelettale Auffälligkeiten sowie die Wirksamkeit physiotherapeutischer Techniken analysiert werden. Demnach werden 5 physiotherapeutische Tests empfohlen, die bei Patienten mit Migräne häufiger positiv sind als bei Kontrollprobanden. In mehreren Reviews wird auf die Notwendigkeit einer Kombination von Techniken hingewiesen (Hands-off und Hands-on). Durch diese multimodalen Ansätze lassen sich bei einem Teil der Patienten Kopfschmerzen lindern und Migräneattacken reduzieren. Weitere methodisch solide Studien sind notwendig, um die Ergebnisse zu stützen.
Given the clinical presentation and neuroscientific evidence, it is undisputed that the hypothalamus plays a central role in cluster headache (CH) pathogenesis [1, 2]. But does an activation of the hypothalamus suffice in generating the perception of pain or are peripheral structures required? This chapter revolves around the question of nociceptive input: where does the pain in CH originate from? This is a question which, as of yet, has no conclusive answer [2–5]. However, looking at previous research and clinical observations, we might be able to make some assumptions and pose some qualified guesses.
In the past for patients undergoing craniotomies and craniectomies, headache was not identified as a significant complication of their procedure. However, there are a myriad of headache- and pain-related issues that arise in the post-craniotomy period. This pain can be acute pain or chronic pain. Acute pain arises in the postoperative period up to 2 months postsurgical intervention. Chronic pain occurs or persists 2 months after intervention and beyond. These headaches and pain syndromes are further subdivided by phenotype, type of surgery, and surgical approach. Focused management of acute postsurgical headaches can improve short-term outcomes and decrease analgesic-related ICU complications. Tailored therapy in chronic headache cases can improve quality of life. Chronic postsurgical headaches appear to mirror their nonsurgical counterparts in terms of therapy. It is important to recognize that these syndromes can arise in the postoperative period. There are a number of postsurgical syndromes associated with headaches that should be identified to facilitate treatment.
Headache is a symptom commonly treated by physical therapies. Towards evidence based practices, these therapies are being evaluated in randomized controlled trials. Tension headache has received most attention. Logically, physical treatments of the cervical musculoskeletal system are appropriate for the management of headaches arising from neck dysfunction; that is, cervicogenic headache. There are difficulties in always selecting suitable headache patients for study and for treatment in everyday clinical practice. This review examines the characteristics of cervicogenic headache for differential diagnosis. There is considerable symptomatic overlap between cervicogenic headache and other chronic headache forms such as tension headache and migraine without aura. The symptomatic criteria for cervicogenic headache are well researched, but current physical diagnostic criteria are often non-specific and non-discriminatory. The possibilities for new physical diagnostic criteria are explored with the aim of helping the clinician and researcher to better identify the cervicogenic headache patient. These are based on current research into physical impairments in the musculoskeletal system with neck pain.
Chronic Pain syndromes are common after traumatic brain injury. This chapter discusses common etiologies for pain syndromes, both central and peripheral, common clinical presentations and treatment approaches to managing the tarumatic brain injury patient with a chronic pain syndrome.
Knee Osteoarthritis is most common form of arthropathy. Osteoarthritis is the common condition
characterized by progressive damage to the articular cartilage and the presenting features are joint pain,
tenderness and decreased ROM. Risk factors are multifactorial and include older age, female gender, obesity,
previous joint injury, genetics and muscle weakness. Knee OA affects 33% of normal individuals above
the age of 65 years. The main objective of this review was to determine the role of proprioceptive exercises
in knee osteoarthritis. Also summarization of all evaluated work is done in various studies.Various studies
have been taken from google scholar, pub med, etc. that includes their role of proprioceptive exercises in
knee osteoarthritis .The selection of study, extraction of data and clinical relevance and the assessment of
methodological quality were performed independently. Therefore on basis of included articles the results
are laid down.Various studies which show the influence of knee osteoarthritis on joint proprioception are
used.This literature review has shown that influence of proprioceptive exercises for knee osteoarthritis
. Future studies should be focussed on assessment of effectiveness for the home –based proprioceptive
exercise programme for knee osteoarthritis.
Keywords: Knee, ankle, osteoarthritis, joint proprioception and proprioceptive exercises.
The Vulcan Nerve Pinch has a memorable and unique place in the cultural iconography of
Star Trek. This image is used to anchor the proposal of a novel manual technique, the Bowstring technique preliminarily described here. The technique may possess both diagnostic and therapeutic implications for regional somatic dysfunction in the cervical thoracic outlet. It is based upon the established viscoelastic properties of collagen, in particular the time-dependent stress-relaxation properties. It is suggested to rely upon a high level of patient centered engagement and intervenes at the contralateral side to a patient’s active muscle effort. It is gentle, co-operative and runs for 2 – 4 minutes. It theoretically engenders significant collaginous material change (lengthening) through the stress-relaxation characteristic of collagen associated with the imposition of a fixed mechanical strain. It is thought that the technique may possess a considerably greater persistence of effect, when compared with shorter duration, repetitive passive stretch techniques, reliant on patient relaxation.
The Vulcan Nerve Pinch – cultural iconography anchors the proposal of a novel manual approach, the Bow-string technique. Abstract The Vulcan Nerve Pinch has a memorable and unique place in the cultural iconography of Star Trek. This image is used to anchor the proposal of a novel manual technique, the Bow-string technique preliminarily described here. The technique may possess both diagnostic and therapeutic implications for regional somatic dysfunction in the cervical thoracic outlet. It is based upon the established viscoelastic properties of collagen, in particular the time-dependent stress-relaxation properties. It is suggested to rely upon a high level of patient centered engagement and intervenes at the contralateral side to a patient's active muscle effort. It is gentle, cooperative and runs for 2 – 4 minutes. It theoretically engenders significant collaginous material change (lengthening) through the stress-relaxation characteristic of collagen associated with the imposition of a fixed mechanical strain. It is thought that the technique may possess a considerably greater persistence of effect, when compared with shorter duration, repetitive passive stretch techniques, reliant on patient relaxation. 2 The Vulcan Nerve Pinch – cultural iconography anchors the proposal of a novel manual approach, the Bow-string technique.
Intracranial pressure (ICP) should ideally be measured in many conditions affecting the brain. The invasiveness and associated risks of the measurement modalities in current clinical practice restrict ICP monitoring to a small subset of patients whose diagnosis and treatment could benefit from ICP measurement. To expand validation of a previously proposed model-based approach to continuous, noninvasive, calibration-free, and patient-specific estimation of ICP to patients with subarachnoid hemorrhage (SAH), we made waveform recordings of cerebral blood flow velocity in several major cerebral arteries during routine, clinically indicated transcranial Doppler examinations for vasospasm, along with time-locked waveform recordings of radial artery blood pressure (APB), and ICP was measured via an intraventricular drain catheter. We also recorded the locations to which ICP and ABP were calibrated, to account for a possible hydrostatic pressure difference between measured ABP and the ABP value at a major cerebral vessel. We analyzed 21 data records from five patients and were able to identify 28 data windows from the middle cerebral artery that were of sufficient data quality for the ICP estimation approach. Across these windows, we obtained a mean estimation error of −0.7 mmHg and a standard deviation of the error of 4.0 mmHg. Our estimates show a low bias and reduced variability compared with those we have reported before.
Opzet van het onderzoek: Casusbespreking.Doel: Een behandeling beschrijven die bestaat uit een specifiek programma met actieve oefeningen en verbetering van de houding bij een persoon met cervicogene hoofdpijn.Achtergrond: De patiënt was een 46-jarige man met een voorgeschiedenis van cervicogene hoofdpijn sinds zeven jaar. Zijn symptomen waren constant met een gemiddelde intensiteit van 5/10 op een visueel analoge schaal waarbij 0 staat voor geen pijn en 10 voor ondraaglijke pijn. De pijnintensiteit in de week voorafgaand aan zijn eerste consult was gemiddeld 3/10 na triggerpointinjecties. De symptomen werden erger bij activiteiten waarbij hij de armen gebruikte en bij langdurig zitten.Methoden en metingen: De patiënt werd in een periode van drie maanden zeven keer behandeld. Er werden afwijkingen gevonden in de stand, spierfunctie en in de bewegingspatronen van de cervicale, scapulothoracale en lumbale regionen. Uitkomstmaten waren de frequentie en intensiteit van de hoofdpijn en de Neck Disability Index (ndi). De interventies bestonden uit correctie van de houding en van de bewegingspatronen bij actieve bewegingen van de cervicale wervelkolom en van de armen. Ook kreeg de patiënt functionele instructies ter minimalisering van het effect van het gewicht van de armen op de cervicale wervelkolom.Conclusie: Interventies bestaande uit correctie van de houding in de cervicale, scapulothoracale en lumbale regionen in combinatie met instructie van een specifiek programma met actieve oefeningen gericht op bewegingsafwijkingen in die drie regionen, waren bij deze patiënt succesvol tegen hoofdpijn en leverden functieverbetering op.
High complication rates have been cited following olfactory groove meningioma (OGM) resection but data are lacking on attendant risk factors. We aimed to review the complications following OGM resection and identify prognostic factors.
A retrospective review was performed on 34 consecutive patients who underwent primary OGM resection at a single London institution between March 2008 and February 2013. Collected data included patient comorbidities, pre-operative corticosteroid use, tumour characteristics, imaging features, operative details, extent of resection, histology, use of elective post-operative ventilation, complications, recurrence and mortality.
Complication rate was 39%. 58% of complications required intensive care or re-operation. Higher complication rates occurred with OGM > 40 mm diameter versus ≤ 40 mm (53 vs. 28%; p = 0.16); OGM with versus without severe perilesional oedema (59 vs. 19%; p = 0.26), more evident when corrected for tumour size; and patients receiving 1-2 days versus 3-5 days of pre-operative dexamethasone (75 vs. 19%; p = 0.016). Patients who were electively ventilated post-operatively versus those who were not had higher risk tumours but a lower complication rate (17 vs. 44%; p = 0.36) and a higher proportion making a good recovery (83 vs. 55%; p = 0.20). Complete versus incomplete resection had a higher complication rate (50 vs. 23%; p = 0.16) but no recurrence (0 vs. 25%; p = 0.07).
Risk of morbidity with OGM resection is high. Higher complication risk is associated with larger tumours and greater perilesional oedema. Pre-operative dexamethasone for 3-5 days versus shorter periods may reduce the risk of complications. We describe a characteristic pattern of perilesional oedema termed 'sabre-tooth' sign, whose presence is associated with a higher complication rate and may represent an important radiological prognostic sign. Elective post-operative ventilation for patients with high-risk tumours may reduce the risk of complications.
Cervicogenic headache is defined as headaches originating from cervical spine structures including cervical facet joints, cervical intervertebral discs, skeletal muscles, connective tissues, and neurovascular structures. Cervical facet injections with steroids have been used to alleviate cervicogenic headache secondary to cervical facet arthropathy. In this article, we will review the cervical spine anatomy, cervical facet injections, and the efficacy of cervical facet injections as a treatment for cervicogenic headache.
A consecutive series of 100 patients was studied to determine the prevalence of third occipital nerve headache in patients with chronic neck pain (> three months in duration) after whiplash. Seventy one patients complained of headache associated with their neck pain. Headache was the dominant complaint of 40 patients, but was only a secondary problem for the other 31. Each patient with headache underwent double blind, controlled diagnostic blocks of the third occipital nerve. On two separate occasions the nerve was blocked with either lignocaine or bupivacaine, in random order. The diagnosis of third occipital nerve headache was made only if both blocks completely relieved the patient's upper neck pain and headache and the relief lasted longer with bupivacaine. The prevalence of third occipital nerve headache among all 100 whiplash patients was 27% (95% confidence interval (95% CI) 18-36%) and among those with dominant headache the prevalence was as high as 53% (95% CI 37-68%). There were no distinguishing features on history or examination that enabled a definitive diagnosis to be made before the nerve blocks. Those patients with a positive diagnosis, however, were significantly more likely to be tender over the C2-3 zygapophysial joint (p = 0.01). Third occipital nerve headache is a common condition in patients with chronic neck pain and headache after whiplash. Third occipital nerve blocks are essential to make this diagnosis.
Based on the current classification of the International Headache Society, this revised and updated 7th Edition provides up-to-date, practical guidance on the very latest advances in research into the pathophysiology, clinical aspects, and treatment of all types of headache-including migraine, tension-type headache, cluster headache, and chronic daily headache. It provides an optimal blend of clinical know-how and relevant basic science, written in an easy-to-read, engaging style. Features a chapter organization based on the HIS classification of headache, making information easy to find. Delivers balanced coverage of the most recent scientific discoveries as well as tried and true clinical observations. Includes updated discussions on the pathophysiology and treatment of migraine, plus a new chapter on Trigeminal Autonomic Cephalgias (cluster headaches). Delivers a completely revised chapter on tension-type headache that reflects recent changes in clinical practice. Provides revisions based on updated guidelines presented at the International Headache Society, Congress of Headache, September 2003.
Contrast medium injected into the atlanto-axial joints during treatment with local anaesthetic and steroids has outlined the synovial cavities and shown occasional spread across the midline to the contralateral joint cavity. The technique of injection is described. Excellent pain relief lasting up to 7 months has been achieved. The simple technique may be utilised as a primary treatment or as pre-operative assessment.
The objective of this study—to determine whether interaction between the upper cervical dorsal roots and the trigeminal system occurs—was approached by investigation of single-unit responses to trigeminal and cervical-root volleys.A large volume of literature is available on single-unit responses in the lumbar enlargement; in particular, the ventral horn cells have been the subject of most of these reports. Cells in the dorsal horn lend themselves less satisfactorily to such studies, mostly because of their reduced size, exceptions being some large neurons in lamina I of Rexed (old terminology, N. megnocellularis pericornualis) and lamina IV (in the old terminology, the N. magnocellularis centralis is contained within lamina IV).As a result, the studies on their properties are still relatively few.2,9,14-16Interneurons in other regions have been the subject of a number of reports.1,3,5,6Material and Methods
Adult cats weighing between 4 and 10 pounds were used. In the
The relation of the descending tract of the trigeminal nerve to the upper cervical dorsal roots is of considerable physiological and clinical interest, particularly with reference to the mechanisms of hemicranial pain syndromes. This study describes in detail the distribution of trigeminal and cervical afferents in the upper cervical cord and indicates that anatomic convergence of these two systems is present throughout the dorsal horn in the first and second cervical segments. The distribution of trigeminal afferents at all brain-stem and cervical levels was studied and a contingent of fibers to the solitary nucleus was identified in every experiment. The possible significance of this in terms of function is discussed. Neurons of the semilunar ganglion do not establish direct reflex connections with motor nuclei of the brain stem; barring insignificant exceptions such connections require at least one interneuron.
When headache and head pain are attributable to an ocular or orbital cause the history and examination will usually suggest an ocular origin, e.g. correlation of the pain with use of the eyes or evident physical signs of ocular disease. Pain of ocular origin usually follows the distribution of the ophthalmic division of the trigeminal nerve which supplies the eye, the orbit, and the forehead, but may spread, if severe, and cause painful reflex contraction of the ipsilateral frontal and occipital muscles. Ocular causes of headache and head pain are: eyestrain (refractive errors and muscle imbalance); intraocular inflammation and hypertension; and diseases of the external eye and its adnexae.
Of 53 severely rheumatoid patients, 43% had cervical spine involvement, Six major categories were found: a) C1-C2 subluxation; b) serial subluxation; c) upward translocation of the odontoid; d) odontoid erosion; 3) apophyseal joint fusion; and f) miscellaneous findings of osteoporosis, endplate erosion, and disk space narrowing without osteophytosis. Although disease duration and activity appeared to correlate somewhat with the development of cervical spine disease, this was by no means universal. Rheumatoid cervical spine disease may be dangerous even in the absence of clinical signs and symptoms. It is therefore recommended that the cervical spine be evaluated in patients with severe rheumatoid disease before general anesthesia is scheduled irrespective of cervical spine complaints recorded in the chart.
Patients falling into the category for discussion in this article may be distinguished as belonging to one of three groups. First there will be patients with pain involving the ear. Most of these will present to the otolaryngologist and a number, but by no means all, will have ear disease. Then there will be patients with pain in the face and headache situated in the forehead or between the eyes. The majority of these will be convinced, and indeed may have been told, that they have sinus infection, but most of them will be wrong. The third and smallest group consists of patients, mainly those with sphenoid sinus disease and nasopharyngeal carcinoma, whose initial symptom may be headache, in whom other signs and symptoms are either late in appearing or are overlooked. These patients may not consult an otolaryngologist at the headache stage and the physician may require great perspicacity to discern that an otolaryngology consultation is desirable.
SYNOPSIS
Clinical features of 750 patients seen with an acute migraine attack at the Copenhagen Acute Headache Clinic were analyzed. In 47% pain quality was pulsating, in 42% pressing and in 11% other types. Unilateral pain was seen in 56% and bilateral in 44%. Half the patients had interictal headaches. In patients with severe pain the quality was significantly more often pulsating. Patients with bioccipital headache had significantly less visual disturbances than patients with other pain locations. On the basis of these findings the currently accepted definitions of migraine are criticized and a new and more precise definition is proposed. Considerable amounts of tenderness was found in the chewing and neck muscles. The location of tenderness corresponded largely to the location of the pain. Patients with associated symptoms and with pulsating pain quality had significantly more tenderness. There was no correlation between the duration of the attacks and the amount of muscle tenderness. Based on these data and other clinical evidence it is proposed that the muscle tenderness during a migraine attack is not secondary to migrainous pain but rather yet another manifestation of the attack and probably responsible for the pain.
The findings in 23 cases of occipital neuralgia are presented. The clinical features of the condition are pain and sensory change in the distribution of the relevant nerve, localised nerve trunk tenderness and a clear response to local forms of therapy. The clinical picture is often complicated by migrainous and trigeminal nerve features and the mechanisms by which these come about are discussed. Occipital neuralgia is generally neglected in both the standard textbooks and the literature. The condition occurs sufficiently commonly to warrant more consideration in the differential diagnosis of head pain than it has received to date.
Tenderness and pain thresholds in pericranial muscles were studied in a general population. A random sample of 1000 adults aged 25-64 years was drawn as part of the Glostrup Population Studies, and 740 adults were examined. This study was part of a multifacetted, epidemiological study of different headache disorders according to the new headache classification. Manual palpation and pressure pain threshold with an electronic pressure algometer were performed by observers blinded to other information such as the person's history of headache, previous illness and mental state. The muscles most commonly tender to manual palpation were the lateral pterygoid (55%), the trapezius (52%), and the sternocleido-mastoid muscles (51%). Females were more tender than men in all the muscles examined by manual palpation. In total, the young age group was more tender than the old age group (P = 0.03). Pressure pain thresholds on temporal muscles showed lower thresholds in women than in men (P less than 10(-3)), and in the total population thresholds increased with age (P less than 0.05). No side-to-side difference in tenderness by manual palpation was found, while the right side showed increased pain thresholds in right-handed individuals (P less than 10(-4)). No side-to-side difference was found in left-handed persons. This study provides data about the normal population and forms the necessary basis for evaluating the importance of muscle tenderness in headache subjects and other selected groups.
This study concerns the posterior ramus of the second cervical spinal n., or greater occipital of Arnold. By means of dissections in formalin embalmed cadavers, an attempt was made to define its winding course and to locate it in relation to clinical or radiographic landmarks, so as to provide a guide for infiltration of the nerve with local anesthetic. At the same time a dynamic study was made to elucidate the relations of the nerve to adjacent structures during the different movements of the neck. This allowed us to propose clinical tests of nerve involvement and to reveal the zones where the nerve is anatomically vulnerable.
One of the putative causes of headache is osteoarthritis of the C2-3 zygapophysial joint. A technique for blocking the third occipital nerve which innervates this joint was devised and used as a screening procedure for headache mediated by this nerve. Seven out of ten consecutive patients presenting with suspected cervical headache were found to suffer pain mediated by the third occipital nerve and stemming from a C2-3 zygapophysial joint. Because third occipital headache may be indistinguishable clinically from tension or other forms of headache, third occipital nerve blocks are advocated as means of establishing this largely unrecognised diagnosis.
Forty patients with tension headache and 40 healthy comparable control persons were palpated by the same "blinded" observer. Tenderness in 10 pericranial muscles on each side was rated on a four-point scale. A Total Tenderness Score was calculated for each individual by adding the scores from all palpated areas. Headache patients had significantly higher scores than controls and also significantly higher tenderness in each point separately. Median normal values and confidence limits for tenderness are given. Among 23 patients with daily headache a correlation was found between headache intensity and Total Tenderness Score. It is likely that the pathologic tenderness in patients with tension headache is the source of nociception, but pain mechanisms are more complex, as evidenced by discrepancy between tenderness and pain in some patients. Pathologic tenderness should be a contributing criterion to the diagnosis of tension headache (muscle contraction headache).
Twelve specimens of the upper cervical spine were functionally examined by using radiography, cineradiography and computerized tomographic (CT) scan. The range of rotation was measured from CT images after maximal rotations to both sides. The left alar ligament was then cut and the examination repeated. The alar and transverse ligaments could be differentiated on CT images in axial, sagittal, and coronal views. Rotation at occiput-atlas was 4.35 degrees to the right and 5.9 degrees to the left and at atlas-axis it was 31.4 degrees to the right and 33 degrees to the left. After one-sided lesion of the alar ligament, there was an overall increase of 10.8 degrees or 30% of original rotation to the opposite side, divided about equally between the occiput-atlas and the atlas-axis. It is concluded that a lesion (irreversible overstretching or rupture of alar ligaments) can result in rotatory hypermobility or instability of the upper cervical spine.
Nineteen upper cervical spine specimens were dissected to examine the macroscopic and functional anatomy of alar ligaments. They are on both sides, symmetrically placed, approximately 10-13 mm long and elliptical in cross-section 3 X 6 mm in diameter. The fiber orientation is dependent on the height of dens axis, mostly in the cranial caudal direction. In 12 specimens there was a ligamentous connection between dens and lateral mass of the atlas as a part of the alar ligament. In 2 specimens anterior atlanto-dental ligament was identified. The computerized tomographic (CT) images can clearly show alar ligaments in axial, coronal, and sagittal planes. The ligaments limit the axial rotation in the occipito-atlanto-axial complex (to the right by left alar and vice versa) as well as in side bending. The ligament is most stretched, and consequently most vulnerable, when the head is rotated and in addition flexed. This mechanism, common in whiplash injuries, could lead to irreversible overstretching or rupture of the ligaments especially as the ligaments consist of mainly collagen fibers.
Nine healthy adults and 43 patients with cervical spine injury were examined by using functional (computerized tomography) CT scanning. The ranges of axial rotation at the levels occiput C0-C1, C1-C2, and C2-C3 were measured. A rotation at C0-C1 greater than 8 degrees; at C1-C2, 56 degrees; or a right-left difference C0-C1 greater than 5 degrees and C1-2 greater than 8 degrees indicates hypermobility. A rotation at segment C1-C2 of less than 28 degrees indicates hypomobility. Surgical stabilization of rotatory instability could be considered as a possible therapeutic procedure.
A study of connections between C 1, C 2, and the spinal accessory nerve is reported. Four variations are described from anatomical and clinical points of view. Often the only pathway for the sensory fibers of C 1 to reach the spinal cord is through the rootlets of the eleventh cranial nerve.
The clinical picture, radiological findings and treatment of 22 patients with atlantoaxial subluxation and rheumatoid arthritis are described. This lesion, untreated, may result in damage to the spinal cord, paresis or sudden death. Occipital headache, present in 13 of 22 patients, was often aggravated by working with the head in forward flexion. Paresthesias were present in six patients. The spine of the axis was often prominent. In three patients there was objective evidence of cord compression with sensory and/or pyramidal signs. In eight the lesion was asymptomatic and discovered by routine lateral radiography in flexion, the position of maximum subluxation.Conservative treatment involved the continuous use of a cervical collar to limit neck flexion. This usually relieved subjective symptoms including headaches. Successful surgical fixation was performed in two individuals. Surgical indications included acute or chronic cord compression or severe symptoms unrelieved by a collar.
Patients with rheumatoid arthritis frequently have involvement of the cervical spine. The spectrum of clinical consequence ranges from no symptoms to severe neck pain, quadriparesis, or even death. The pathological changes include rheumatoid pannus and proliferating granuloma involving bone, ligaments, discs, muscles, and tendons of the cervical spine and skull.2,4,14 Radiological characteristics are gross cervical spine subluxations, narrow disc spaces, erosions, and osteoporosis. Rheumatoid arthritis of the cervical spine may occur without clinical or radiologic signs of the disease elsewhere.13
Present Study
This study is an analysis of 100 cases of definite or classic rheumatoid arthritis according to the American Rheumatism Association criteria.1 Clinical, radiologic, and serologic characteristics were determined with special emphasis on radiologic evidence of rheumatoid lesions of the cervical spine. Ten radiologic criteria for diagnosis of rheumatoid arthritis of the cervical spine were used (Table 1). Fig 1-3 illustrate examples of the criteria.All
Occipital neuralgia syndromes have been ascribed to a great many pathological alterations, some demonstrable and some hypothetical. Recently, occipital neuralgia has been attributed to developmental and posttraumatic lesions in the cervicocranial junction region, with the nerve roots at C-1 and C-2 considered to be the principal pain pathways. The authors describe a series of seven patients with an upper neck and occipital pain syndrome due to unilateral degenerative disease (arthrosis) of a C1-2 lateral articulation. Two of the cases are presented in detail. This disease is demonstrable by radiography through the open mouth by isotope bone scanning, and by computerized tomography scanning. Temporary relief may be obtained by anesthetic and steroid injection, and permanent relief achieved by C-2 dorsal rhizotomy.
Oral function was evaluated in a group of 13 patients with muscle contraction headache (MCH), 7 patients with common migraine (CM) and 18 patients with 'combination headache' (CM + MCH) and in a control group of 25 normal persons who had never had a headache. Malocclusion and loss of molars were rare in both groups. Impaired denture function and joint disturbances were more frequent in the headache patients but not significantly so. Clenching and grinding teeth and tongue pressure were all significantly more common in headache patients. Tenderness of pericranial muscles was present in all headache patients with severity increasing in the order CM, MCH, CM + MCH; it was absent in all the controls. On the average 9 tender spots were found per patient. Pressure on tender spots evoked pain in other areas (referred pain) in 29 of 38 headache patients. The abnormal tonic hyperactivity in the masticatory muscles and the neck may be the cause of tenderness which again may be an important source of pain in these patients.
SYNOPSIS
The clinical features of the headache and neck pain in 21 cases of spontaneous carotid dissection are described. Twenty of 21 patients had head pain or headache and of the 20, 12 had neck pain as well. One patient had neck pain only. Typically, the headache involved the ipsilateral forequarter of the head and neck pain was of local origin in the region of the upper few inches (10 cm.) of the internal carotid artery. Recognition of the headache as a prodromal manifestation may lead to prevention of a stroke through the use of anticoagulation.
A detailed description of the anatomy of the cervical dorsal rami is provided on the basis of the past literature and independent studies on five cadavers. In particular, the anatomy of the upper cervical dorsal rami and the innervation of the cervical zygapophyseal joints are described. The clinical significance of the cervical dorsal rami is discussed in relation to headache, occipital neuralgia, and neck pain. The surgical anatomy of cervical facet denervation is discussed. The radiologic anatomy of the medial branches of the cervical dorsal rami is described, and target points suitable for diagnostic blocks or facet denervation are illustrated.
The patterns of deep somatic pain referral were studied with paravertebral injections of 6 per cent. saline solution from the occiput to the sacrum, five subjects being used for each intervertebral level. The distributions were found to approximate a segmental plan, although they overlapped considerably and differed in location from the conventional dermatomes. Pain could not be induced in the radial aspect of the upper limbs and in the feet. Injections into individual peripheral limb muscles showed less regularity in suggesting segmental patterns. As opposed to the hyperalgesia of "Head's zones", areas of hypo-algesia, usually in a concentric manner, were found to overlie the locations of induced deep pain. Sympathetic and somatic (plexus) blocks did not interfere with the segmental referred pain produced by this method, thus suggesting a primarily spinal integrative mechanism. The character of the pain and its autonomic concomitants are described, and the theoretical implications are discussed.
Dissections of five human adult cadavers revealed that the C2 spinal ganglion bears a constant relationship to the dorsal aspect of the lateral atlanto-axial joint. Radiologically, the ganglion lies extradurally opposite the midpoint of the silhouette of the lateral atlanto-axial joint space. Needles can be introduced onto this target point using fluoroscopic control and used to perform selective local anesthetic blocks of the C2 spinal nerve. This technique is applicable in cases where it is difficult to decide on clinical grounds whether occipital headaches are due to an upper cervical abnormality or are a symptom of tension headache or common migraine. In particular the technique anesthetizes the otherwise inaccessible articular branches of the median and lateral atlanto-axial joints which may be an occult source of headache.
The anatomy of the vertebral nerve was investigated in humans and in monkeys. The effect of stimulation of the vertebral nerve and the cervical sympathetic trunk in the monkey was studied. The vertebral nerves in man and monkey represent a series of deep grey rami communicantes which form intersegmental neural arcades around the vertebral artery between C7 and C3. Above C3 the vertebral artery is accompanied by direct branches from the C1-3 ventral rami. Electrical stimulation of either the vertebral nerve or the cervical sympathetic trunk had a minimal effect on vertebral blood flow. In contrast, sympathetic stimulation had pronounced effects on carotid flow and resistance. Anatomically and physiologically there are no grounds to support the hypothesis that irritation of the "vertebral nerve" is the pathogenetic mechanism of cervical migraine.
Neck pain: joint pain or trigger points?
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CT-functional diagnostics of the rotatory instability of the upper cervical spine. Part 2: an evaluation on healthy adults and patients with suspected instability
- Dvorak