The Craniocervical Junction and Headache Disorders


Headaches disorders are amongst the most common conditions that people seek treatment from a doctor. While most people will experience a headache of some form,  there are those who develop chronic and repetitive bouts with headaches of different types.

Unlike people who may struggle with an occasional stress headache or feel the effects from an alcohol induced hangover, people with these chronic headaches have a neurological disorder. These headache disorders can stem from:

  • Migraines
  • Cluster headache
  • Post-traumatic/Post-concussive headache
  • Chronic pain/Temporomandibular joint disorders
  • Tension headache
  • Chronic daily headache
  • And more

Each headache has unique characteristics that help to make an effective diagnosis for effective treatment. However, when we look at the reality of a daily patient interaction, we see that people with these headache disorders can have traits that overlap. (Remember this point because this is something I’ll come back to later)

That makes these headaches  extremely burdensome on the patient, but it can also be challenging for a doctor or therapist to find effective solutions. This is particularly challenging considering the rise of medication overuse headaches as a clinical entity in 2004.

Medication overuse headaches were once classified as rebound headaches because of the way headaches could come back with a vengeance after the pain-relieving effects of a medication wore off. It became re-classified in part due to the alarming number of patients showing a regression in their headache symptoms after prolonged and frequent use of medication. While the physiology of this disorder is widely unknown, it does show characteristics of physical dependency as seen with drug withdrawals.

As drug therapies become less effective for this subset of headache patients, there has become a growing need to identify non-pharmacologic strategies to help patients with headache disorders. For many of these patients, a possible solution might lie in the neck.

Headaches and the Cervical Spine

The concept of neck problems contributing to headache disorders isn’t new. Cervicogenic headache is a term coined in 1983 to describe patients suffering from simultaneous head and neck pain [1]. The term has grown to have diagnostic criteria that include:

  • Single sided head pain radiating from the top of the neck
  • Aggravation by specific neck positions
  • Reduced upper cervical motion or painful range of motion
  • Presence of muscular trigger points
  • Normal imaging
  • Unresponsiveness to pharmacologics

Cervicogenic headache does have a contentious history as a distinct clinical entity. Critics have argued that the soft nature of the diagnostic criteria. In the past, cervicogenic headaches seemed to be diagnosed by the effectiveness of cervical spine therapies in relieving the headache. You can see how this complicates the study of these headaches as a distinct clinical entity. In recent years, nerve blocks or ablations in targeted areas of the cervical spine have been used to determine if the cervical spine is the cause of the headache, but these also require more invasive procedures to make an assessment [2].

Headaches originating from the neck seems to have the biggest role in chronic headaches that begin after a concussion or whiplash. Headaches that emerge after these injuries are commonly classified as cervicogenic headache.The neurophysiologic effects of a concussion tend to disappear 7-14 days after the trauma but the ligament and muscle injuries from a head injury can persist leading to a default diagnosis of cervicogenic headace. The study of cervicogenic headache has revealed quite a bit about the physiology of how the neck can play a role in head pain, even those associated with migraine headache [3].

One problem with this idea is that fact that a traumatic injury can sometimes lead to patients who have never suffered a migraine before, can display migrainous symptoms after an injury [4]. This is also complicated by the fact that conservative cervical spine interventions like spinal manipulation and manual therapy appear to be effective in cervicogenic headache [5], but not in migraine [6] in clinical trials.

What do these headaches have in common? How are they different? Can we use their similarities to develop effective treatment strategies for headaches that are resistent to medications?

The Physiology of Headache Pain

There’s a common source for pain related to the head and neck. That source is a bundle of neurons located in the brain stem called the trigeminocervical nucleus (TCN). This nucleus is a hub for nociceptors in the brain. Nociceptors are receptors that transmit information about noxious stimuli to the brain, usually in the form of tissue injury.

While the feeling of pain is far more complex than the sheer amount of nociception your brain receives, for the sake of simplicity in this article, we will say that nociceptors are fibers that carry pain signals. Your TCN is a major player in head AND neck pain.

Head and neck pain pathway

This area in the brain stem is like the Grand Central Station for all of the pain sensing fibers in the head and neck. From the trigeminal nerve you have pain sensing fibers from the face, jaw, teeth, arteries, and meninges, while the neck has fibers from the joints, ligaments, muscles, and skin coming from C1, C2, and C3 nerve roots. All of these fibers converge onto TVN which has to decide if it’s worth going up to the big kahuna at the top of the brain called the cerebral cortex.

For neurovascular headaches like migraine and cluster headaches, it’s suspected that the pain carrying fibers from the arteries in the brain or the outer covering of the brain called the meninges getting irritated by pulsing arteries. These fibers are carried to the  TVN by the trigeminal nerve. For cervicogenic headaches, it’s suspected that the pain generators are coming from the muscles, nerves, or joints from the upper neck.

These overlapping structures allow for some of the referred pain patterns seen in migraine patients expressing neck pain, and also for cervicogenic dysfunction to lead to headaches. It also means that if 2 pieces of anatomy share a neurological pathway, then sometimes treating one area can lead to relief in another.

Interventions in the Cervical Spine and Headache Outcomes

So we know that the convergence of these neural fibers allows for some overlap of pain sensation regardless of the type of headache. What does the research say about treating headaches with cervical spine interventions?

The answer seems to match what you think it would be.

For cervicogenic headaches, recent studies seem to support the idea that addressing the neck with spinal manipulation can be helpful and even provide some relatively long term impact. A 2016 paper showed that upper cervical and thoracic manipulation helped cervicogenic headache patients at 3 months compared to exercise and mobilization [7]. A review paper of several studies on cervicogenic headache and manipulation seems well in favor of treating the neck compared to controls [8].

For migraines, the evidence isn’t so favorable for manual intervetions. There aren’t that many clinical trials to look at, and the ones that are available appear to show no effect [9]. From a pathophysiological standpoint it makes sense because they seem to be clinically distinct entities. However, the clinical experience of people like myself who practice in an upper cervical model of chiropractic have had a much different experience.

There is some evidence that suggests that cervical spine problems may be present as a sub-type of migraine patients [10]. There is also evidence that greater occipital nerve blocks [11] and non-invasive vagal nerve stimulation in the neck [12] can decrease the frequency of headache days and may effectively abort a migraine attack.

A 2016 study by Woodfield studied 11 patients with chronic migraines showing improvements in migraine frequency while receiving a vectored correction to the atlas vertebra [13]. The study also showed some significant effects in intracranial compliance in patients with cerebrovenous drainage abnormalities.

Case Study on NUCCA atlas procedure on venous drainage routes in a migraine patient.

While the concept of cerebrospinal venous abnormalities have been a controversial topic in multiple sclerosis, it may provide insight into some patients with chronic migraine. Multiple studies have documented venous drainage abnormalities in migraine patients and even mTBI, but the significance behind these observations are unknown [13] [14] [15].

Where To Go From Here?

There’s still a lot to learn about the anatomy and physiology of headache disorders. When you consider that migraine headaches are the most common neurological disease in the world.

Predicted research dollars compared to diseae burden

Lots of work needs to be done to understand what treatments will work for which patients, but there’s still some hope that treating the neck may be a key strategy to help people with chronic headache disorders.




How to Spot a Personal Injury Predator


  • The famously dirty personal injury industry
  • When profit leads to failed patient care
  • How to spot predatory practices

Personal injury (PI) is an famously dirty industry. When people think about PI, you usually think about ambulance chasing attorneys taking up local billboards, radio, and television commercials. In a state like Florida where just the act of a car crash can make you eligible for $2500 of personal injury protection at minimum, and many eligible for $10,000 of coverage from their insurance company, it has opened the door for many avenues of scams and unscrupulous activity.

Common fraud activity include people paid to stage accidents, forced referrals from tow truck companies, enticing victims with cash payments to go to certain clinics, and more.

Attorneys get a bad rap (some of them deserve it), but when it comes to your health after an accident it may be the doctor you choose that could be the biggest threat to your health and your money.

When Profit Leads to Failed Patient Care

While attorneys get most of the blame for a corrupt delivery system, unethical practices by healthcare providers have contributed to the problem.

There is an unspoken trust between medical providers and the public to always practice with the best interests of the patient in mind. While doctors will try their best to insulate themselves from getting too involved with the business side of medicine, the personal injury business has made it difficult to practice strictly based on clinical findings.

Health providers face pressure from patients and attorneys to help build a case for larger settlements. New doctors have large student debts to pay on top of trying to support their families. No one is trying to harm the patient, but it’s easy to see how money can muddy the waters of patient care.

So many patients are subjected to unnecessary imaging and procedures because of pressure from attorneys and patients to pad the medical bills and build a case for lawsuit. MRI’s are so widely prescribed for personal injury cases because the findings can show greater injury despite the fact that the correlation between imaging findings and pain are surprisingly weak.

Many patients with no pain have abnormal MRI findings, but these images can unreasonably scare and confuse patients about the real causes of their pain. Image Credit: Adam Meakins

Many patients with no pain have abnormal MRI findings, but these images can unreasonably scare and confuse patients about the real causes of their pain.
Image Credit: Adam Meakins

In some cases, offices and facilities have become places that exclusively see injured patients for the sake of billing thousands of dollars from insurance with little regard for appropriate management. Their only goal is to increase their billing as high as possible until the injury benefits are exhausted, and the patient is released from care regardless of whether they received the care they need.

This not only robs patients of benefits that may provide them with appropriate care from other providers, but it also causes patients take money out of the pocket of consumers as insurance premiums rise to pay for these unethical practices.

So what’s a person supposed to do? Here are some thoughts:

  1. Ask About the Expected Services and Fees Involved: When patients have the expectation that insurance will be paying for their services, they rarely ask about what services will be performed and the cost of these services.This might be okay if you have private insurance, but in capped payment systems like personal injury protection, doctors may be prescribing the same tests and procedures for all patients to get the bill to rise as fast as possible.Transparency in costs helps to control spending. If you knew that your x-rays were going to cost $500 of your own money, you’re a lot less likely to get it done unless you felt like it was necessary.If a doctor or staff is elusive about their fees and services saying things like “Oh don’t worry about that, your insurance will cover it.” Then press them on it. You will eventually get the explanation for their billing, and see if what they say and do actually matches up.

    Treat your insurance dollars like they are your own dollars, because when benefits start to run out and you’re not better, you may ultimately end up paying yourself.

  2. Check Your EOB’s and Your Statements: Insurance companies will send you an explanation of benefits to show patients what was billed for and what they paid for those services.In shady practices, you may see billing for services you’ve never received before. Patients who have never had an ultrasound machine touch them will see ultrasound in their billing. Patients who do a few arm circles may see a bill showing that 30 minutes of exercise is on the bill.This is a crime, and it’s called fraudulent billing, or just fraud for short. In the most extreme cases, you may see dates of service billed for days you know that you were never in the office.
  3. Are You Getting the Same 3 things Done over and over with no results?: Doctors who care about their clinical outcomes will design treatment plans based on your specific injury and how well you are responding to care.A sign that you are in a injury mill type practice is if you are being scheduled for the same treatments multiple times per week with no regard for how you are responding to care. This usually looks like getting electric stimulation and ultrasound placed on you by staff, a chiropractor manipulating your spine, and some vague recommendations for exercises. This is done 3-5x per week and the treatment doesn’t change despite the fact that you don’t feel any better, and sometimes continue to feel worse.Good practice is to triage your case based on the severity of your injuries. If you have a severe acute injury, you may need medical management from patches, meds, or injections so that you can feel functional as you go towards physical rehabilitation. Good practice also involves getting you to an appropriate specialist if you are not improving in a timely manner.

    When offices are not paying attention to whether the patient is getting better from their treatment, then it is a sign that they are trying to max out your benefits as quickly as possible.

  4. Are you being coerced to seeing certain doctors?:  Patients are always in control over what doctor they wish to see. If you have a comfort level with a certain doctor, then you always have the ability to find out if that doctor accepts personal injury claims.Some PIP schemes are set up to funnel patients into specific doctors’ offices for reasons that are not about helping the patient. At times people can be pushed into these offices by attorneys or patient runners saying they have to see a certain doctor for the purposes of the case. Some schemes will even go out and give patients financial compensation to go to specific offices which is outrageously illegal.This is a sign that there is an illegal kickback system involved that is built to just get maximum reimbursement from the PIP system.

Predatory PIP Practices Hurt Us All

So what’s the big deal if a practice is trying to max out your insurance money? After all, if you as a patient aren’t paying the bill then why should you care?

The truth is that these types of practices hurts us all. It hurts attorneys who are trying to build a business ethically in a dirty system that will spend more to get an advantage. It hurts doctors who treat patients for the best clinical outcome who may see insurance reimbursement go down to combat fraud.

Most of all, it hurts us all as people who want to trust attorneys, doctors, and the insurance company. As a doctor, you’ll usually expect me to trash insurance companies for cutting payments, but in terms of PIP many times it’s just a response to fraudulent or unethical billing practices. Insurance companies raise premiums on us all when fraud gets out of hand, and in some cases it makes it really hard to get insured at a reasonable rate after an accident lawsuit.

I have no sympathy for a multi-billion dollar industry, but I can certainly see why the system is built the way it is when I observe some of the scams that are run by people that are supposed to be the gate keepers of patient health.

This industry may be too far beyond repair and reform, but maybe it can get a little bit cleaner when patients are informed enough to call it out.