Professional Papers

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Conservative management of
cervical tension cephalalgia
Franklin Schoenoltz, DC, DABCO
Arcadia, California

Doctors of Chiropractic have long recognized the therapeutic value of ma-

nipulative therapy in the management of cervical tension cephalalgia. From a
clinical standpoint, the role of manipulation in headache has been somewhat
controversial. An attempt is made to present a clinical approach to a neuro-
musculoskeletal disorder which responds favorable to chiropractic manipula-
tive procedures.
Dr Franklin Schoenholtz is a diplomate of the
American Board of Chiropractic Orthopedists,
and maintains a private practice at 226-228 East
Introduction Foothill Blvd, Arcadia, California 91006. He taught
Diversified Technique and Undergraduate Ortho-
The causes of headache are legion. It is one of the most pedics at the Los Angeles College of Chiropractic
from 1964-1976. Presently, Dr Schoenholtz is the
common and confusing symptoms faced in private practice. secretary-treasurer of the Board of Regents at
It is conceivable that as this entity is understood, the mecha- LACC. He has authored numerous articles on the
nisms that determine its various causes will be able to be manipulative management of various musculosk-
eletal conditions. The most recent, “Conservative
classified. Management of Temporomandibular Joint Dys-
We will address ourselves to the most common headache, function,” appeared in the August 1978 issue of
known by several terms such as tension headache, cervi- the ACA Journal.
cal tension cephalalgia, suboccipital cephalalgia, etc. We will
exclude intracranial headaches or those which are secondary to through the foramen magnum.
generalized disease. These nerves are vulnerable to irritation from the
myofascial attachment of the cervical muscles to
Pathophysiology the base of the skull, muscles through which they
transverse. Neural discharges or firings from ex-
The functional importance of the musculoskeletal structure tracranial tissues may result from abnormal psycho-
requires that particular attention be directed to the myofascial logical reactions mediated via muscular contraction.
tissue as well as the articular components. In disorders of the Because of the combination of the irritation of C-1
myofascia, the pain and suboccipital muscle spasm must first and C-2, which are primarily sensory, and suboc-
be brought to terms. cipital muscle spasm, patients may complain of pain
The nerves in this region lie in close proximity to the verte- at the upper neck region accompanied by tingling in
bral artery, at its point of angulation, prior to entering the skull the occipitoparietal region (Figure 1).

ACA Journal of Chiropractic /June 1979

Copyright The Journal of the American Chiropractic Association

Copyright Dr Franklin Schoenholtz 2009

Symptoms and signs
There is general agreement that stress may precipitate headache
attacks and that the over-conscientious or perfectionistic individual
is especially susceptible to develop this syndrome.
Frequently, the patient complains of pain in the neck and suboc-
cipital region, radiating up and over the whole of the posterior por-
tion of the skull. Headaches and neckaches occur concurrently, are
generally intermittent, and usually originate from the neck.
The syndrome is not only influenced by position and activity, but
can happen as a result of certain positions and activities. Localized
signs in the neck may include stiffness and muscle tension.
Many patients develop symptoms at the end of a stress-filled day.
However, it is interesting to note that the syndrome has also oc-
curred the morning after the patient held his head in an unsuitable
position during sleep.
Examination
The patient’s complaints may be misleading because the area
of complaint may be different from the actual site of the irrita-
tion. Therefore, the physical examination should include attempts
to reproduce the pain by palpation of the myofascia or by passive
stretching.
Figure 1. The sensory distribution of the greater and less-
er occipital nerves is in the posterior and lateral portion
of the scalp. The shaded area represents hyperesthesia or
anesthesia of the scalp which may occur from compress-
ibility or irritation of these nerve roots.
Palpation of the osseous structures of the cervical
spine will usually reveal vertebral derangement.
Localized tender points in the occipitocervical junction
are revealed on palpatory examination. The atlanto-
occipitial joint may be remarkably fixed, and deep pres-
sure palpation may reproduce occipitoparietal tingling.
Investigation of this area should be conducted with
the patient relaxed, in a sitting position, and with the
head maintained in a forward flexed position. Palpa-
tion of the occipitocervical junction will often reveal the
epicenter of the pain.
Neurological examination will reveal no positive
changes, but the deep tendon reflexes are frequently
very active. The patient may appear tense and ap-
prehensive; tachycardia and mild hypertension may be
present.
Even though a high proportion of cervical-occipital
headaches have a mechanical basis, each patient must
be examined individually. Other causes such as eye
strain, sinusitis, digestive disturbance and neurological
diseases must be excluded.
Radiological examination
Functional x-rays, such as the three lateral views
taken of the patient sitting upright (the Davis Series),
may assist the doctor in confirming his palpatory mobil-
ity tests.
Range of motion is a function of the confining liga-
ments, but the range of motion is not only covered by
the ligaments. Other factors include weight bearing an
the tone of the muscles, which also influence the move-
ments.
When evaluating the lateral radiographs, evidence of
hypomobility or fixation of the atlanto-occipital joint may
be seen, thus confirming clinical findings.
Treatment
Combined therapy in this type of syndrome includes
the use of manipulation, soft tissue technique, traction
and psychological support.
The design of therapy should include combinations of
modalities, to be used to reinforce each other in alleviat-
ing the symptoms.
Manipulative therapy is well suited to the patient’s
needs as one of the essential modalities for manag-
ing the musculoskeletal component of cervical tension
cephalalgia.
Musculoskeletal structure and function are governed
by recognized mechanical principles in which weight
 he pushes down on the forehead; the right hand remains
immobile in order to exercise counterpressure (Figure 3).
The doctor then cups his left hand against the table
and slowly raises his elbow (and to some lesser degree,
his wrist), bending the patient’s head to one side in com-
bined extension and lateral flexion. Maintain this position
for a moment, and then release. The procedure should
be repeated several times, since it often reduces pain by
stretching and relaxing rigid muscles.
Invariably, the source of the muscle irritation can be
traced to the articulation connected with the muscle. It
then becomes necessary to correct the cause of the articu-
lar lesions.

Manipulative technique

Manipulation, well-selected and correctly performed,

Figure 2. Intermittent motorized head halter traction
should be arranged so that the pull will be in a 30°
forward-flexed position with a cold pack placed under
the patient’s neck.
bearing forces and factors of stress and strain have a most impor-
tant role.
To achieve the maximum benefit from any form of therapy, the
doctor should use discretionary latitude in choice of treatment.
Variations in treatment must be made in response to the patient’s
reaction, which may change from visit to visit.
often constitutes and appropriate therapeutic solution.
It should be very specific. The effort should be directed
toward the articular derangement at the site of muscle
contracture.
The doctor stands at the patient’s head while the patient
is supine; with his left hand, the doctor supports the head
of the patient placed in left rotation (reverse technique
for the opposite side). The lateral edge of the axis should
make contact with the radial border of the right index fin-
ger. Rotate and extend the cervical spine to its maximum,

Intermittent motorized traction

When the muscle spasm is primarily in the posterior cervical

region, head-halter cervical traction may be helpful. The traction
should be arranged so that the pull will be in a 30° forward-flexion
position, allowing the posterior joints to open. Intermittent motor-
ized traction gently stretches the posterior cervical musculature,
thus improving mobility. It has been this author’s experience that
a coldpack placed under the patient’s neck while traction is being
applied is of great benefit because of its decongestive physiologi-
cal action and anesthetic effect (Figure 2).

Manual traction maneuver

As a precursor to manipulation, a manual traction maneuver

may be employed which stretches the posterior cervical spasm
and mobilizes the upper cervical spinal joints.
Te doctor stands at the left of the patient while the patient is
Figure 3. Movement of the cervical spine be-
in a supine position. The doctor places his left forearm under the
comes combined extension and lateral flexion as
cervical spine, his hand flat on the table and, using his right hand, the head is bent to one side.
taking up all the slack; by exercising a quick, firm, forward-
and-left thrust of the right index finger, the corrective adjust-
ment will be made in the direction of the movement. It should
be emphasized that only the left hand supports the head of
the patient (Figure 4).
Muscle spasm is usually secondary to mechanical disturbanc-
es, but may outlast them, thus maintaining a pain-generating
cycle. Effective manipulation stretches the involved structures
producing a sudden limited traction of contracted muscles and
other elements of the joints. This stimulates the correspond-
ing proprioceptors and induces a reflex action. The technique
attempts to interrupt the pain cycle, correct the articular lesion
and alleviate the symptoms.
Psychologic Factors
The various psychologic mechanisms at work in creating this
syndrome may vary greatly and should always be considered
when the symptoms do not fit into a known clinical pattern. It
is important that the doctor inform the patient of the nature
of the disorder as accurately as possible. Sometimes, the basic
problem may be unalterable and the doctor’s advisory role
becomes paramount.
A major responsibility may lie in easing the anxieties of the
patient. The clinician has to understand the patient’s character,
Figure 4. Contact is made on the lateral edge of the
axis with the radial border of the right index finger. The
thrust is made with the index finger forward and to the
left in the direction of the movement for the corrective
adjustment to be made. The left hand only supports the
head of the patient.
personality, individuality and weakness.
The doctor can be of considerable aid to the patient in de-
veloping new patterns of daily living that will provide a healthy
control of the pathopsychologic state. Psychologic factors are
often significant in the management of altered musculoskeletal
function.
To achieve optimum treatment results, the responsibility of
management may have to be shared. When sympathetic at-
titudes and demonstrated reassurance fail to help the patient,
it may be time to seek specialized consultation for the patient
with either a psychologist or psychiatrist.
Bibliography
1.Bourdillon, Spinal Manipulation, 1975.
2.Cailliet, Soft Tissue Pain and Disability, 1977.
3.Cyriax, Textbook of Orthopedic Medicine, 1975
4.Cyriax, Treatment of Pain by Manipulation, 1976.
5.Finnerson, Diagnosis and Management of Pain Syndromes,
1963.
6.Hart, The Treatment of Chronic Pain, 1974.
7.Hoag, Osteopathic Medicine, 1969.
8.Hoppenfield, Physical Examination of the Spine and Extremi-
ties, 1976.
9.Jackson, Cervical Syndrome, 1971.
10.Maigne, Orthopedic Medicine, 1976
11.Stoddard, Manual of Osteopathic Practice, 1969
12.Stoddard, Manual of Osteopathic Technique, 1974.
13.Tobis, Approaches to the Validation of Manipulation, 1977.
14.Zohn-Mennell, Musucloskeletal Pain, 1976.