Treat cervicogenic headaches with dry needling and manual therapy

Cervicogenic headache refers to a headache of cervical origin.¹ The International Headache Society (IHS) has classified headaches as primary, where there is no other causative factor, or secondary, where the headache occurs in close temporal relationship to another disorder to which it is attributed.²

A cervicogenic headache is a secondary headache caused by a cervical spine disorder and its component bone, nerve/nerve root disc, and/or soft tissue elements.^1,3–5 It is expected to have referred pain perceived in the head from a source in the neck.^1,6,7 People with cervicogenic headaches often have reduced range of motion in their neck and worsen their headaches with specific movements of their neck or pressure applied to certain spots on their neck. The headaches are often side-locked (on one side only), and the pain may radiate from the neck/back of the head up to the front of the head or behind the eye.^3,4,6 The headache may or may not be associated with neck pain. Diagnostic criteria have been established for cervicogenic headache, but its presenting characteristics may be difficult to distinguish from other headaches, such as migraine or tension-type headache.³

Dry needling and acupuncture

Dry needling and acupuncture are both techniques involving the insertion of thin needles into the body for therapeutic purposes. However, they have different origins, philosophies and intended outcomes. Acupuncture is part of traditional Chinese medicine, and acupuncture has been practiced for thousands of years. Dry needling (also known as Western medical acupuncture) primarily uses a Western medicine philosophy grounded in anatomy and physiology and focuses on musculoskeletal issues.

There are overlaps and similarities in the two. Both involve the use of thin, sterile needles. Both are used as modalities for pain relief and improving bodily function. Both require skilled practitioners for safe and effective use, though practitioner training and certification differ. The difference is primarily philosophical. Acupuncture aims to restore health and balance by stimulating specific points along the meridians. In contrast, dry needling focuses on an anatomic basis to treat musculoskeletal conditions and aid in physical rehabilitation.⁸

The following literature review provides literature on both dry needling and acupuncture.

Treatment of cervicogenic headaches via dry needling

A systematic review has investigated the effectiveness of dry needling and conventional physiotherapy in managing cervicogenic headaches or tension-type headaches.⁹ Two included clinical trials with tension-type headache participants demonstrated statistically significant improvements following dry needling.⁹ Furthermore, one case report study with a cervicogenic headache female that was included in the systematic review showed significant improvement in pain and neck disability index after nine treatment sessions of dry needling combined with manual therapy.⁹ Since that review, another article explored superficial and deep dry needling to treat cervicogenic headache.¹⁰ The study’s results demonstrate the application of dry needling of suboccipital and upper trapezius muscles induces a significant improvement in headache symptoms, functional rating index and range of motion in patients with cervicogenic headaches. Additionally, they found deep dry needling had greater effects on cervical range of motion and function.¹⁰

The acupuncture literature provides further evidence for the use of dry needling for the treatment of headaches. A systematic review of the literature investigated whether acupuncture is more effective than routine care, “sham” acupuncture and other interventions in reducing headache frequency in adults with episodic or chronic tension-type headaches. The results indicated that acupuncture is effective for treating frequent episodic or chronic tension-type headaches, but further trials, particularly comparing acupuncture with other treatment options, such as physical therapy, massage or exercise, are needed.¹¹ In another systematic review, the authors assessed the effectiveness of acupuncture in reducing headache frequency in patients with migraine. The results showed consistent evidence that acupuncture provides additional benefit to the treatment of acute migraine attacks only or routine care.¹²

The authors also suggested that acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment and has fewer adverse effects.¹² They concluded that acupuncture should be considered a treatment option for patients with migraine willing to undergo this treatment.¹²

Recently, authors in the Cochrane Collaboration reviewed the effects of acupuncture on preventing tension-type headaches.¹³ After searching for all relevant studies, they identified two studies comparing acupuncture to usual care, four studies comparing acupuncture to physiotherapy, massage or exercise treatment and seven studies comparing acupuncture to a sham (placebo) acupuncture treatment. They concluded that based on this evidence, people with frequent tension-type headaches will probably have slightly fewer headaches three to four months after beginning a course of acupuncture. Specifically, people will probably have fewer “headache days” per month, and probably more people will have half as many headaches.¹³

Treatment of cervicogenic headaches via manipulation

Manual therapy can be very effective in conjunction with dry needling in treating cervicogenic headaches.^14,15 The primary focus of manual therapy is to restore normal arthrokinematics of the cervical region, with special attention paid to the upper cervical spine. For this discussion, we will define the upper cervical spine as the atlantooccipital joint, the axio-atlantal joint and the joints of the C2-3 segment. Restoring the function of these segments is paramount in finding a lasting solution to cervicogenic headaches.

A likely symptom generator can be an excessive extension of the occiput on the atlas in functional postures. This compromises the suboccipital space and can result in compression forces acting on the structures found in the suboccipital space. The most notable structures in question are the greater and lesser occipital nerves. These nerves can be part of the cause for the typical cervicogenic pain pattern radiating from the posterior aspect of the neck around the lateral aspect of the head just above the ear and terminating above the eyes. This is often termed a “ram’s horn” presentation. A common posture like “forward head posture,” where the occiput tends to rotate posteriorly on the atlas, often results in soft tissue and joint dysfunction that can be treated with manual therapy.

The research shows that with competent hands, manual therapy can be a very effective treatment modality for cervicogenic headaches by improving the function of the upper cervical spine. One randomized controlled trial found that manual therapy effectively improved upper cervical mobility and provided immediate headache relief in patients with cervicogenic headaches.¹⁴ Another randomized, double-blind, placebo-controlled trial showed that improving C1-2 mobility via mobilizations reduced symptoms by 54% in individuals with cervicogenic headaches.¹⁵ A randomized controlled trial of manual therapy in combination with exercise therapy found that manual therapy and exercise therapy were both effective in reducing headache symptoms, with a combination of the two being the most effective treatment. This approach demonstrated a statistically significant reduction in headache frequency and intensity sustained at the 12-month follow-up assessment.¹⁷ One pilot study of patients with cervicogenic headaches showed that addressing primary passive trigger points via manual therapy improved cervical range of motion and deep neck flexor function and reduced the presence of primary passive trigger points.¹⁶

Final thoughts: Combined treatment of cervicogenic headaches

The research supports that dry needling and manual therapy are proven techniques in treating cervicogenic headaches.^{9,10,13,15,16} Both techniques can stand alone as effective approaches; however, their combination can be far superior in addressing cervicogenic headaches because of their unique and distinct target tissues.¹⁸ Dry needling targets soft tissue, while manual therapy can be utilized to target joint dysfunction. Dry needling is an excellent way to make manual therapy more effective and comfortable for the patient.

BRIAN V. HORTZ, PHD, AT, SFDN, is director of research and education at Structure and Function Education. For more information, email brian@structureandfunction.net or visit structureandfunction.net.

References

All accessed October 28, 2024.

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