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The Thinking Practitioner Podcast:
Episode 31: Cervicogenic Headaches: As If We Need Another Type

Broadcast date: 01/20/2021
©Copyright The Thinking Practitioner Podcast, Til Luchau & Whitney Lowe

Whitney Lowe:

Welcome to the Thinking Practitioner Podcast.

Til Luchau:

A podcast where we dig into the fascinating issues, conditions, and quandaries in the massage and manual therapy world today.

Whitney Lowe:

I'm Whitney Lowe.

Til Luchau:

And I'm Til Luchau. Welcome to the Thinking Practitioner.

Whitney Lowe:

Welcome to the Thinking Practitioner.

Hello, this is Whitney Lowe, and our opening sponsor today is Books of Discovery. Books of Discovery has been a part of massage therapy education for over 20 years. Thousands of schools around the world teach with their textbooks, e-textbooks, and digital resources.

In these trying times, this beloved publisher is dedicated to helping educators with online, friendly, digital resources that make instruction easier, and more effective in the classroom or virtually. Books of Discovery likes to say, "Learning adventures start here."

They see that same spirit here on The Thinking Practitioner Podcast, and they're proud to support our work, knowing we share the mission to bring the massage community enlivening content that advances our profession. They invite you to check out their collection of e-textbooks, and digital learning resources for pathology, kinesiology, anatomy, and physiology at booksofdiscovery.com. We thank Andrew Biel, and the Books of Discovery team for their support, and be sure to check out their great offer for our Thinking Practitioner listeners.

Whitney Lowe:

Til how are you, how have you been?

Til Luchau:

I've been pretty good for the shape I'm in, and for the shape the world's in, you could say. It's an interesting time. An interesting time continues, but I'm doing all right Whitney. How about you?

Whitney Lowe:

Doing well. We've had a bit of a time off break here. We've been doing some other solo interviews, which has been fun, and we're back together again today for some interesting deep dives. What are we into today?

Til Luchau:

Well, I want to talk about headaches. In particular cervicogenic headaches, or an interesting, almost from a manual therapy point of view, third kind of headache. Not like we needed any more kinds, because there are hundreds of officially recognized kinds of headaches.

There are certainly a lot of reasons to have headaches, but this one might be particularly relevant to our current state in the world. Cervicogenic headaches meaning headaches that are thought to start in the neck.

Whitney Lowe:

Okay. Cervico meaning neck, and genic meaning?

Til Luchau:

Yeah. Genic being generated by, or originating in the neck. That's right.

Whitney Lowe:

I'm curious to hear about this new type of headache classification here. Let's dive in and look at this a little bit. Tell me about some of the types, and categories that we currently think about there.

Til Luchau:

I will, and I should mention, this is in a handout. I'm just going to put this outline into a handout, and put it in some of the hands on stuff that we're going to talk about. I'll give that URL now, but it's also in the show notes. The URL for the handout is a-t.tv/ttp-cgh.

Check out that handout if you want to follow along, or check out the techniques we'll be talking about. Whitney, you asked about ... Speaking of mouthfuls, that URL is a mouthful. You did great on that new Books of Discovery spot. That's nice to hear what they're saying now, and it's great to have their support still. They've been such a great resource to our entire profession for so long.

Whitney Lowe:

Indeed, yeah.

Til Luchau:

Thanks for enumerating what they're doing there.

Whitney Lowe:

Yeah.

Til Luchau:

But you were also asking about headache types, and this may be a new type, it probably is a newer type, the cervicogenic type, the classic types are generally thought to be primary headaches, and secondary headaches. The primary headaches, are headaches that just seem to be their own thing. They just arise on their own.

Sometimes they're called idiopathic headaches, meaning no apparent cause, or we're not sure about the cause, but in this case primary means or idiopathic in this case means, they just seem to be their own condition. Classically those include tension or myofascial headaches, and the other one being migraine, and neurogenic headaches, which also includes things like cluster headache, et cetera, Hemicrania continua, things like that, they're some more rare forms of headaches in the migraine family.

Whitney Lowe:

Yeah.

Til Luchau:

Then secondary headaches, the other group of headaches are headaches that are caused by another condition. That's where it really starts to get numerous, because there are so many things that cause headaches. I think we've added for sure Zoom headaches-

Whitney Lowe:

Yes, indeed.

Til Luchau:

As one of the newer types of secondary headaches. But other classic examples of secondary headaches, could be things like a dehydration headache, or a sinus headache, or a long list of medical conditions that bring headaches along with it. So I should, while I'm thinking about it, mention it right here, that headaches are a sign often of something else going on, and it's always good to know what that is, and know that your client, or patient with a headache has been evaluated for some of the other things that might be causing their headache.

Whitney Lowe:

Let me ask a question about the categories here in terms of what we talk about when we say primary headaches being tension or myofascial. So, would you say in this category also include tension being ... Let's say psychological tension. Just overall stress, is that falling into this category as well? Are we thinking mostly biomechanical?

Til Luchau:

No, that's a really good question, are we talking about psychological tension and being uptight? Are we talking about mechanical tension on the tissue? Those are both mechanisms the type of headache, pain itself is called a tension headache, which it does imply a mechanism, but isn't so much explaining the mechanism as a type of headache.

What's really weird for us as manual therapists is that's even considered a primary type of headache, because we go, "Wait a minute. Sure, if you're either psychologically stressed or mechanically tight. That's going to make your head hurt. That's secondary to the mechanical tension or the psychological stress."

Whitney Lowe:

Yeah.

Til Luchau:

This categorization which is really commonly used is the main one used in conventional medicine, doesn't make a lot of sense for us as manual therapists. This is actually a classification system that was designed by neurologists, to understand what class of drugs to prescribe.

Whitney Lowe:

Interesting.

Til Luchau:

That's another way to think about it. It's an attempt to say, what headaches seem to be their own thing? In our point of view, actually the tension headaches don't. The tension there becomes because someone's tight, either tissue-wise or stressed. The migraines are a little more tricky, because we are still figuring out the migraine story. And our explanation for it evolves, and even just in the last couple of decades, we have a very different explanation for what causes a migraine. The mechanism of a migraine.

You could say it's closer to something that just arrives on its own. It seems to be brain activity that just causes the migraine for example.

Whitney Lowe:

Yeah. I was going to ask too, when we look at these kinds of things, we're going to talk a little bit more as we delve into this, in terms of mechanisms of what manual therapy may do with some of these things, because clearly I think this is another area where we don't really understand some of why some of the things that we do may work in certain kinds of situation, while some of these might seem to be being caused by the factors that there is not a real clear cut mechanism of action there for our manual therapy, but it works.

Til Luchau:

Yeah. And you're making me think, why do I even need to know what type of headache it is as a manual therapist, as a massage therapist, or a structural integration practitioner, whatever. I can actually work them in different ways, and my expectations can be tuned to the type it might be. In the headache training we do, we go into this in more detail, but it's not to diagnose it, and decide this is what the headache is, because they say about half of people that are told they have migraines don't, and half of the people that do have migraines are missed in the diagnosis.

It's pretty hard to actually diagnose something like a migraine. In terms of a strategic starting place, or a working hypothesis, as a hands on therapist, these categories are actually useful, partly because like you said, the mechanism could be different in each case, and the way we approach it can be different.

Whitney Lowe:

Yeah.

Til Luchau:

Shall I say something about prevalence? Should I say something about the how?

Whitney Lowe:

Yeah. Let's talk about that a little bit, how? Because this is something we have to think about in the clinic, what might we be seeing because of how frequent it is?

Til Luchau:

That's right. How many people are walking in with this going on?

Whitney Lowe:

Yeah.

Til Luchau:

Tension headaches, they say about almost 40% of people get one every year. In one given year about 40% of people have a headache, through their lifetime, 90% plus people will have a tension headache. That's an amazing number to me, because that implies that 10% of people don't have a tension headache, which is ... That's true, when I have large groups of people I've asked this question, "Raise your hand if you've never had a headache." There is a number of people that raise their hand.

Whitney Lowe:

Really?

Til Luchau:

Yeah. That's awesome.

Whitney Lowe:

That is amazing.

Til Luchau:

Who knows what other problems they have in life. But there is that, at least they don't have the headache problem. Migraine prevalence, 12 to 14% in North America, now it varies quite a bit around the world. We're down to a low of 1 1/2% in Hong Kong. So, 1/10 our way.

Whitney Lowe:

Do you think that's based on categorical reporting, or what would make those statistics vary that insignificantly?

Til Luchau:

That's a really good question. Because it's even sometimes they wonder about translation, if you're doing the study in a different language, and you're assessing for migraine trends in different language, are we assessing for the same thing? It could be that the differences around the world are due to either different ways it's categorized, or even language differences.

The studies that have tried to correct for those factors do show quite a bit of variation around the world with Asia, and Africa being the places in the world with far less incidence of migraines. Then Peru, being the migraine capital of the world with around 32% of people having migraines there at some point in their life.

Whitney Lowe:

That's fascinating. You got to wonder what that's about. I wonder too, how much of this is like you said, culturally infused with what it's okay to talk about. In some cultures it's really not so okay to be complaining of pain. So a lot of people may under-report in those kinds of cultures.

Til Luchau:

Well, now we're talking a whole episode right there. There is an episode at least around migraine, but it's the way that we talk about pain, and what's reported is a big topic.

Whitney Lowe:

I think it was Doug Nelson, I think, said something to me one time. He is of Scandinavian descent. And he said in his familial culture or in the culture there, apparently it's not so easy to talk about, or encourage to talk about being in pain. He said there is a saying that they have about, something really hurts. It hurts so bad I almost said something about it.

Til Luchau:

That's right.

Whitney Lowe:

There may be that reporting factor coming in with some of this. The Peru thing is really interesting to look at what this has to do with the Andes or the water.

Til Luchau:

I'm resisting that rabbit hole, because we're actually not talking about migraines today. We're going to talk about I thought cervicogenic headaches.

Whitney Lowe:

Yeah.

Til Luchau:

Which while we're talking prevalence, there is something like two to 4% of people in any given year, although that varies by researcher, because of definition. It could be up to 20% of people at some point in their life have a cervicogenic headache according to literature.

Whitney Lowe:

Yeah. I saw those prevalence statistics, and to me, that really seems low. At least from the lens of bias that I look through of the people that we see with postural challenges, or a hypertonic cervical muscles, and corresponding headaches at the same time. Maybe that's a self selection criteria of who comes to see us is that group of people.

Til Luchau:

Yeah. Honestly, I think it may be the study's definition of cervicogenic, because again we go back to our idea of a tension headache. As hands on therapists we see all kinds of headaches that respond when we lower people's tension. Could be that we see all kinds of headaches that get better when we reduce the difficulty their necks are going through.

Whitney Lowe:

Yeah.

Til Luchau:

That aren't in the official classifications of cervicogenic headaches.

Whitney Lowe:

Yeah.

Til Luchau:

The traditional classification, or let's say the working definition for cervicogenic headaches is a headache that has its origin in the neck somehow, and it's related to some kind of "dysfunction" in the neck.

Whitney Lowe:

Right.

Til Luchau:

But a headache that gets better when you work the neck is also a diagnostic criteria, we find a lot of those. We find a lot of headaches that get better when you work the neck for various reasons.

Whitney Lowe:

So, if it does, does that automatically classify that as being cervicogenic if you're saying, "Well, we did something to the neck, and the headache improved. It must have been coming from the neck."

Til Luchau:

For the purposes of a study probably not. But for the purposes of my practice, good enough for me. If I can make it better, then I got it. We're done. It does seem to be quite a bit of power the neck has. I should mention as an aside, there are stories of people's migraines being worsened by neck work.

So, that's something to be cautious if you suspect a migraine. Someone especially the visual disturbances or nausea. Those are go slow signs where you be cautious with neck work to see how that goes. Other than that a lot of headache feels better when you work the neck, including tension headaches.

Whitney Lowe:

Yeah. Quite like so many things that we encounter around the body, it's probably not one single thing doing it. Lots of times it's probably a conjunction of factors of what we're doing with the manual therapy, and the room, and the lighting, and the soft music, or whatever the things are that we're pulling together to help them.

The question might be, is it a "footogenic" headache, if a person has a headache, and you work their feet, and their headache goes away?

Til Luchau:

Nice. New classification. We needed that.

Whitney Lowe:

Right.

Til Luchau:

That's true. That's right. That's a good point.

Whitney Lowe:

I mean, I think that happens a fair amount.

Til Luchau:

It does. Absolutely, and the way in isn't always what we expect. Our imagined mechanism isn't always the strategy that's the most effective in our work too. That's definitely the case with headaches. There is lots of things that help headaches. In fact, back to that primary secondary thing, conventionally it's thought that things like manual therapy would be better at secondary headaches, than they would at primary headaches. Primary headaches are just their own thing.

But most people involved in manual therapy know that you can do a lot for a tension headache as we said. We can actually do a lot for dehydration headache. Someone hasn't been drinking water, they show up in my practice, I can often relieve their headache. Now, guess how quickly it's going to come back? Really quickly if they don't drink more water.

That's probably the case for a lot of these headaches too. Especially if there is contributors, either an underlying cause like dehydration. Or even like you said, the way I'm standing, sitting, moving, the amount of time I'm sitting on Zoom. That headache is going to be more likely to return if those aren't changed also.

Whitney Lowe:

As we look at some of these different things, we talked about some of these classifications that may be helpful for us. Does the classification significantly change the way you work? Do you see that making a big shift in the way you approach an individual?

Til Luchau:

Yeah. On a simple level, if they have visual disturbance, or nausea, I'm suspecting, my working hypothesis is that it may be a migraine type headache, in which case my goals are different. My approach is different. There is a lot to say about that, we're not doing the migraine episode. But if they have a pain in the neck, if this is the classic sign of a cervicogenic headache, if they have a pain that starts in their neck and moves to their head, I think cervicogenic starts in the neck.

So, let's approach it as perhaps something that is involving either sensitivity of the neck, or movement restriction of the neck. That's the way I distinguish those.

Now, the complicating thing of course is that there is a lot of overlap between the classifications, or people have more than one at once. So, that people that have a headache start in the neck will sometimes have a visual disturbance too. There are migraine-like symptoms that come with a cervicogenic headache sometimes.

I mean, we can simplify it again to that working strategy as a manual therapist. If someone says, "My headache started in my neck and moved up." I'm going to start in the neck too, or at least I'm going to start in the neck in my thinking. I might not actually go touch the neck first, but that's the primary place of interest for me.

Whitney Lowe:

One of the papers that we're going to reference here in the show notes that's talking about recognizing those cervicogenic headaches, had some interesting things in it about methods to evaluate this, and recognize that. Let's talk a little bit about some of those. What are some of those key characteristics that we would tend to see as clinical pieces that we might evaluate, being something to indicate cervicogenic involvement versus some of the other types?

Til Luchau:

That's an important thing too is like, what are the characteristics of cervicogenic headaches? How do we recognize them? Like I mentioned, they start in the neck, as stiffness, as painful movement, or as tenderness in the neck. The point tenderness thing is complicated, because a lot of people are sensitive around the neck if you poke them.

But for sure, a neck that's stiff, and then turns into a headache, or has painful movement, that's probably cervicogenic like I said. Unilateral, meaning it's just one side of the head, especially when the pain in the head is on the same side as the neck. People will have some neck stiffness that comes up as their migraine appears. But if the pain switched sides to the other side of the head, the neck isn't probably the major contributor there.

Whitney Lowe:

One thing I wanted to also put in here that I can't remember if we said this when we were defining them, I think you mentioned this at the beginning, but just in case we didn't, and to go over again, that a lot of the classification of the cervicogenic headaches focused on primarily what appears to be some type of manual or some type of dysfunctional either mechanics, or involvement of the first three cervical vertebrae region, as opposed to the entire neck. For some reason that's emphasized a bit more.

Til Luchau:

Yeah.

Whitney Lowe:

I would like to believe that probably a lot of times it's involving a lot more of it, but there does seem to be some stuff in the literature focusing on those top three vertebrae.

Til Luchau:

They're the ones that move the most. They're also the joints where the occipital nerves exit and go up to the back of the head, so headaches involving the back of the head are probably involving those occipital nerves that are exiting between C1, two, three.

Classically that's the zone of the neck that starts to be involved in cervicogenic headache, the upper cervicals. Some of the Toby Hall's paper, which is really cool, the one we're going to link to in the show notes, Hall 2010, we'll put that in the show notes there. Actually it's 2008. He's focusing on the joints quite a bit. His style emphasizes joint sensitivity or joint mechanics.

Whitney Lowe:

Yeah.

Til Luchau:

So, that's a classic way that cervicogenic headaches are thought about too as a joint issue. But if you dig into it a little more, there is lots of recognition that there is other tissues that can be sensitized or be nociceptive drivers, the term you've called it. The superficial fascia, or the skin itself, or the intermuscular septa, or the neural tissues of the neck, the nerves themselves or even the vasculature deeper in the neck can be sources of that nociceptive pain.

Whitney Lowe:

A lot of those particular tissue, it is interesting. I see this a lot in a good bit of the literature that comes from some of those other fields that are focused on spinal manipulative therapy, that there is a big focus on the joint structures, and the innervated capsular tissues, and the functioning of those joints. Sometimes, in my opinion, at the expense of looking at the roles some of the other soft tissues around that.

Til Luchau:

Yeah, we need a soft tissue therapist to do that research.

Whitney Lowe:

We do.

Til Luchau:

I mean, when I read those I think, "Okay, this was done by somebody who is trained in joint manipulation." That's fair, we're looking for the ways that the work that we know, and the work we do has effects, or doesn't have effects. There is more and more and soft tissue research coming up, but we haven't caught up to all of the joint based research you could say.

Whitney Lowe:

What you had mentioned too about the symptoms that people tend to present with, especially because the vast majority of our neck rotation is happening at the very top levels of the cervical vertebrae, that's where the motion restrictions may tend to show up. So, that's a good way to look at potential cervicogenic involvement, for sure.

Til Luchau:

Well, motion restriction is a whole topic in itself. But that's true, there is more motion on average in people's upper cervical spines. It's that motion, the upper cervical spine that's being focused on with cervicogenic headaches.

Whitney Lowe:

Yeah.

Til Luchau:

I'm absolutely with you Whitney, that sometimes you work down the base of the neck or way outside of the neck, and someone's headache gets better too.

Whitney Lowe:

Yeah.

Til Luchau:

It's probably cervicogenic as well.

Whitney Lowe:

One of the most common things that we hear, at least in our profession in terms of ... I don't know if I want to use the word blame, but causal effects perhaps for people having headaches is forward head posture. What are your thoughts on the role of forward head posture in driving cervicogenic pain problems, and headache involvement?

Til Luchau:

Well, Toby Hall said it well. He said that forward head posture is pretty common. And it's been really difficult in a research sense to correlate with headache. It's not like more people with forward head posture have more headaches. It's hard to say it's a major cause, or the holy grail, or the main thing, but it does seem to be a factor, especially in individuals.

If your headache gets worse when you do a lot of sitting looking at a screen, some of that might be the mechanical effects of having your head far from your body.

Whitney Lowe:

Yeah.

Til Luchau:

What's interesting too is that corrective exercises thought to reposition the head, also haven't been shown to always decrease people's pain. If you look at it the other way around too, things that actually train people, or help people practice not having head forward posture don't always make their headaches better either. It could be a factor, but I don't think it's always the factor.

Whitney Lowe:

It's not the necessarily be all end all. It's interesting too, this is one of the secret things that you can never know. But in the physical medicine approaches, which try to focus on getting somebody to adapt new and different postures, or new mechanical patterns, let's say to stop doing so much forward head posture while you're sitting at your desk looking at the computer.

You teach the patient, or the individual to do some of these things. But the big enchilada there is how much compliance is there really with them doing that and making those kinds of changes once they get out of-

Til Luchau:

Do they actually do what you recommended or suggested that they do?

Whitney Lowe:

Yeah. Because I'm a firm believer that a lot of those things are repeated neuromuscular patterns that have to be reinforced over, and over, and over again, a lot. I mean, I'm a walking example of that, because I know there is a lot of controversy about the role of posture, and pain, and how does let's say something like forward head posture contribute to pain, but I know for me personally-

Til Luchau:

What are you a walking example of? I can't wait to hear this. What is it?

Whitney Lowe:

Of forward head posture causing pain.

Til Luchau:

Yes.

Whitney Lowe:

Because I have habitual patterns that I think started in my adolescent years, because I was a saxophone player, and wore a heavy saxophone around my neck a lot when I was growing. I've always had forward head posture, but the more I'm doing things for long periods in that position, like when I stand at the kitchen counter, and cook dinner, and chop vegetables, and do things for 45 minutes or something, my back hurts in a relatively short period of time, and it's muscular. It is absolutely clearly muscular.

I can stop it from hurting by changing my head position. And so, I try to be attentive to that change over and over again. But it's not easy. It's one of those compliance things that I know has to be reinforced every day, every time I do that to make those changes.

Til Luchau:

So, in a study of yourself you do notice that head forward posture correlates with pain.

Whitney Lowe:

Yeah.

Til Luchau:

And the patient compliance correlates with an improvement, that when you do the things that you know can help, they help.

Whitney Lowe:

Yeah.

Til Luchau:

That sounds fair. Fair enough. Me too, I've actually heard that wearing a heavy sax on a lanyard there around your neck is a great corrective for head backward posture, that actually pulls your head forward somewhat. I'm kidding about that. That's a big thing, that weight. I think so much of what we do is frontally oriented.

The whole nature of the front of the body, we curl around it perhaps for various reasons that that's the tendency, there is a whole lot more forward head posture. At some point, whether it's the 42 pound head idea of Eric Dalton's, or what, I don't know, but at some point, that mechanical forces of having your head forward are likely to cause more strain, and more work. That's what seems true.

When we go backwards and try to reverse engineer that and say, if we just do our backwards head postures, like learn how to play the saxophone behind your back or something. Is that going to help? That's more complicated, and you're right. Patient compliance is a big variable in there. But then there is also multi-causal factors in there too.

With cervicogenic headaches it's actually what has been more clearly correlated to that headache than head forward posture is pain with rotation, or you can have pain with retraction, like actually pulling your head back. Like you're doing the head backward position, you're being a compliant patient. That gives some people headaches. That's still a cervicogenic headache, that active retraction of the head too.

Whitney Lowe:

I think some of these evaluation things too are made a bit more challenging in that a lot of times we're looking for things that would reproduce or exacerbate an existing pain complaint. Like the mobility limitations in the rotational movements. I've seen this frequently where somebody will have headache pain, and limited movement in the cervical region.

We might think, "Okay, this is somewhat cervicogenic oriented, but the rotational movements don't make the pain worse, they'll just limit movement.

Til Luchau:

That's right.

Whitney Lowe:

Then we work on their movement, free the movement up, get that person to an upgraded range of motion and then the headache improves.

Til Luchau:

That's right.

Whitney Lowe:

But the dysfunctional movement doesn't produce an increase in pain necessarily all the time.

Til Luchau:

No. In fact, there is studies that show people with headaches don't have less movement with their neck.

Whitney Lowe:

Yeah.

Til Luchau:

And actually people with headaches have the same movement in their neck. It's not that necessarily that the change in movement is causing their headache, which is too bad, because as manual therapists, or massage therapists or whatever, we're used to feeling movement, and if we can find a movement that's restricted, often when we get that to move more, people feel better.

So that leads us to believe that people not feeling good is equal to a movement restriction, and what you're saying is, "No, that's not always the case."

Whitney Lowe:

Yeah. Right.

Til Luchau:

That's a big shift by the way in just the way we think about it as therapists too.

Whitney Lowe:

Yeah. As we talk about this in terms of ... Clearly there is things that we would do in the treatment room with people that would be helpful for them, with a wide variety of manual therapy approaches that we might make. As we're talking about that patient compliance piece, what self-care things do you see helping people mostly with that kind of stuff? Because I think there is a lot of things that people could be doing that would be helpful.

Til Luchau:

There are. I don't want to talk about that. I'm a little stuck on my outline there. I want to talk a little more about sensitivity. Is that okay?

Whitney Lowe:

Yeah.

Til Luchau:

Someone comes in with a headache, there are some classic tests you can do like flexion-rotation test, which I'll put a picture of in the handout, that will show you movement differences, rotation differences from side to side.

Whitney Lowe:

Can you briefly explain that for everybody? Also, for those that don't get to look at the handout.

Til Luchau:

That's right. Client is either sitting or supine. Let's say they're lying supine, face up on the table. If you lift the head gently into some cervical flexion, like chin to chest, in a position of comfort. Then in that position rotate the head, that's the flexion-rotation test.

Now, the flexing the neck, bringing the chin to the chest is thought to immobilize most of the joints in the neck, except for C1, C2, because of the angle of its facets it actually turns really freely even in flexion, even when the rest of the neck is in flexion, while the other ones have their movement inhibited by being in flexion.

That tests tends to isolate the movement into C1, C2. So you put someone in flexion, bring their chin to the chest, gently rotate their head, and you look, and you can use their nose as a dial, and see, does it turn more one way than the other? Mobility testing.

So far so good, that's pretty cool, because when you can see it that tangibly, and you can do things that you see a change really dramatically, it's exciting.

Whitney Lowe:

Yeah.

Til Luchau:

Now, the trend as you mentioned in manual therapy in general, but in our field in particular is to orient around sensitivity or pain, more than just mobility. That seems more directly related to people's experience, and their symptoms, and it seems to actually have more useful effects. So, even more interesting to me is when I do that flexion-rotation test, and turn their head and they go, "Oh yeah, there is my headache pain."

Whitney Lowe:

That is in fact reproducing it.

Til Luchau:

That's right, reproducing it or provoking it. I think, bingo, we've caught a fish, which is the opposite way that most of our instincts say, "Let's do something that makes it feel better." But if I find something that actually provokes it a little bit, or reminds someone of the feeling, then I go, "Okay, we're doing a movement that's relevant to their pain in some way."

Whitney Lowe:

From a biopsychosocial perspective of getting the client on board with what we're doing, it sounds like what you're saying here too is that this is the value in letting the patient or client that you're working with understand there is an evaluation or assessment process that you're doing, and that is going to drive your choice of how you're going to address this with them in the future, in a way that gets them on board with saying, "Okay, I'm okay with having some discomfort because you're exploring where this is for me. And I'm okay knowing that this is going to feel better hopefully when you start working with me."

Til Luchau:

Well, yes and I think of it actually as me getting on board with them. It's not just them getting on board with me, so that I can challenge them in some other areas. It may be so, but it's also me getting on board with what's most important to them. If they're coming to me with a headache, I could be missing the boat by just focusing on a map or a paradigm that doesn't really match what they're experiencing.

Whitney Lowe:

Yeah.

Til Luchau:

We're doing a really sophisticated, high level protocol, that if they don't feel any difference they're not on board with all. I'm not in a sense saying I have gotten on board with them. If I can do something that lets them know, "Oh, here is exactly what you're complaining about. Feel that?" Then they know that I'm on board with them.

Then from there I'll proceed with things to actually shift their pain experience, not to shift their mobility, or shift their craniosacral rhythm, or shift their fascial glide or whatever other mechanism I might be postulating would be affecting the pain.

Whitney Lowe:

For those who may have missed the episode we did a couple of issues back there with Mark Bishop, talking about expectations, this is a great place to tie some of that in, of looking at the role of the expectation of your treatment or of some of those outcomes being less dependent on what you're physically doing in changing the tissues and like you said, getting on board, and getting on the same train with them.

Til Luchau:

That's interesting. If they feel that I'm doing something that's related to their headache. Then you're saying that might align with their expectation for improvement?

Whitney Lowe:

Yeah. And I think that has potential positive outcomes for us, for sure.

Til Luchau:

Okay. I made a little list of ways that I work with sensitivity that are maybe similar, they have some overlap with the ways we work with tissue. But really when I find something that's sensitive, no matter where it is in the body, often I think about calming the autonomic reaction to that sensitivity. Because so much of the suffering we have with pain is our reaction to pain.

If I can help calm someone's general fight or flight reaction, the autonomic reaction, then that helps pain diminish, but it also helps my reaction to pain to be less disturbing.

Whitney Lowe:

What would you say are some of the best strategies for encouraging that autonomic calming?

Til Luchau:

Everything you and I know professionally is aimed to that in some ways.

Whitney Lowe:

So, probably not a direct tapotement on their neck with a sharp tool, that probably won't work.

Til Luchau:

Yeah. Fair enough. Things that are painful don't tend to, they don't tend to calm the sympathetic measurements. They don't lower blood pressure, et cetera. Things that are painful don't tend to do that. But it's hard to generalize, because there are things that are deep, and things that are dramatic, and extreme, that actually do calm the nervous system in a good way.

Whitney Lowe:

Yeah.

Til Luchau:

But it's not as simple as push here, and the autonomic nervous system gets calmed, it's all of those things that we've mentioned that we do, and the way we...

Whitney Lowe:

Yeah, patient specific, that it differs from one person to the next as well.

Til Luchau:

That's right. I think most professionals listening to the podcast will have some idea about how to calm the nervous system.

Whitney Lowe:

Yeah. I think so.

Til Luchau:

If they don't, write us, and we'll do a whole episode on it, or something like that.

Whitney Lowe:

Okay. Good. Proceed there.

Til Luchau:

Descending modulation, we talked about that. It's all the ways that the brain, and some of what Mark Bishop was talking about too, the way the client's brain can literally turn down the signal coming from the body, the nociceptive signal, essentially inhibit or downwardly modulate that signal. That comes from like you said, expectations. It comes from context. It comes from the ways, the meaning that the treatment has, all those kinds of things, and much more.

Sensory refinement is number three on my list there, if you're following on the outline. That's just the fact that if I feel things more, they hurt less in a weird paradoxical way. You can think of something that hurts, like a headache being overwhelming sensation. Well, what's really bizarre is if I take time to ... In most headaches, you can't always do if you have the headache, sometimes it takes someone else's help.

If I can get really precise about exactly where it hurts, what it's like, and take time to really turn towards the sensation as the person having the headache, and get refined about what it's like. Often that pain intensity diminishes. If the intensity is diminished, then certainly the unpleasantness does.

Whitney Lowe:

It's interesting. As you're going through this list I'm having these callback awareness to some of our previous episodes. Now this is making me think about the homunculus in a recent episode that we just did about the little man in the brain.

That central refinement, or the cortical smudging that we talked about, of trying to sharpen that map of where things go about the sensory attunement that you're talking about here. I think that's a really key factor in many of these situations.

Til Luchau:

That's right. Un-smudging, by getting it really defined in my awareness, but also the recoloring idea from that episode too. The idea that we could actually just recolor that coloring book of the brain with a slightly different shade. That's some of that last one on that list too, the remapping, reevaluation and reframing.

If someone feels their headache pain get better, often just that experience helps them understand it better. They realize, there is not something broken in my brain, for example, or it's not a hopeless situation. Just having some relief even temporarily can help people shift the way they react and think about their headache pain.

That's a big topic, but there is lots of ways that our work does that, it helps people remap, reevaluate, reframe their pain experience.

Whitney Lowe:

Nice. So key factors there on sensitivity. Anything else on that piece that we'd want to look at regarding that?

You have referred to it, but I'm just going to hit that part in the outline too that their headaches in general are really responsive to contextual factors. All pain is really, not even most pain. But especially headaches ... In fact, some of the most interesting placebo research, it comes out of a Bernadette's Clinic in Italy, in the Italian Alps, where if you take someone up high altitude, a lot of people have headaches.

So, it uses that, invites them up to a high clinic to do placebo research, where he does essentially all these different contextual interventions, and experiments to see which ones make their altitude induced headaches better, and it turns out that quite a few of them do.

Whitney Lowe:

Interesting. We do know context is key for us in so many instances there.

Til Luchau:

Context, relationship, expectations, on and on down that list.

Whitney Lowe:

Let's go back. We were going to talk a moment ago, I had asked you about some self-care factors there, where we cleaned up a lot of additional things in the sensitivity piece. What do you think about some of the most helpful self-care things to get the motivated client moving, and doing things the things that we need for them to do.

Til Luchau:

Motivated or not, maybe that is where it starts is assessing motivation, but prevention is the best cure. So, anything you can do to reconfigure your triggers, your environment, your context. Even if it's just changing your desk, lowering your monitor, raising your monitor, whatever, getting a better chair. Getting lighting, moving around. That can help really quite a bit with the self-care piece. As well as everything we know about, get up and move, don't always sit in the same way.

Til Luchau:

It isn't the magic chair, maybe it's the magic two or three chairs, or seating arrangements that you use to keep things varied up.

Whitney Lowe:

Yeah. And it's the getting up and changing chairs that also is important as well.

Til Luchau:

Right.

Whitney Lowe:

It's the moving around kind of thing.

Til Luchau:

Yeah. When we finally get these high level studies on Zoom headaches, I think they're going to find that part of the factor is that this online world takes us right out of our sense of time, and sense of our body.

Meanwhile, our body is in time, and is in objective reality, and having all sorts of effects. So that to remember your body, to come back to it and move it around some too.

Whitney Lowe:

Right.

Til Luchau:

Strengthening is an interesting place. In physical therapy we focus traditionally quite a bit on strengthening for someone who had cervicogenic headaches. It turns out that a lot of the strengthening exercises, like I mentioned for forward head posture and such, don't help with cervicogenic headaches any more than just general exercise and strengthening does.

Just working out with anything you do that feels good that you do. It turns out to have a bigger effect on headaches than the best possible exercise that you don't do. So, the exercise you do is the one that's going to really help in any strengthening there, the upper limb.

Whitney Lowe:

This has been one of my pet peeves in picking on a little bit some of the approaches that are done frequently within the physiotherapy world, of looking at for example postural imbalances, like the forward head posture. And saying, "Well, your head is forward. So, you need to strengthen those muscles that are opposing that particular movement to get back in balance."

This to me seems to go so frequently back to the issue of like, people in many instances don't really have a strength deficit, what they have is a motor control problem that has to do with reminding themselves to be in proper positions, or in different positions, things like that. Much more so than there is a strength deficit.

Til Luchau:

Yes, and that is complex. One of arguments of the way strength training helps, is it helps us be more aware of our body, and more likely to feel, and just remember to have better motor control.

Whitney Lowe:

Yeah.

Til Luchau:

That's one point of view. Of course, I could say there is not one Rolfing perspective around this but one of the interesting promises of Ida Rolf's perspective was that it wasn't about motor control, it wasn't about remembering to hold yourself in the right posture. That when you were actually able to build support in the body, and build adaptability, that that was self-perpetuating.

There is something really fascinating about that premise, and then the results of the work too. When you get people in their body, you get them adaptable, you get them so that they can find a sense of support to rest into, it becomes less about control, and less about holding.

Whitney Lowe:

Yes.

Til Luchau:

The promise there is even less about remembering. Now of course, we run into the problem that people then expect to be simply placed into a correct posture, and then that's going to stick and stay there, and that doesn't happen either. There is a role of our own responsibility for our, you could say, posture, or movement, or getting up and moving, that no manual therapist can provide really.

Whitney Lowe:

Yeah. Unfortunately, I think too many of the people who come to us want us to do something to them to make this change. That's not always a feasible outcome there, because so much of it does involve the participation as opposed to us doing something to them.

Til Luchau:

That's a topic I do want to talk to you about, participation. And how do we inspire our clients to own that process from their side as well? Then also really interesting is what gets in the way of that. I'm not quite sure which order these episodes are going to come out. So it's possible this conversation we have now , I will have talked you into that episode before this comes out. But I want to have an episode around what gets in the way of us doing the things we want to do.

Whitney Lowe:

Okay. That's good.

Til Luchau:

One more self-care before we move toward the close here. That's the Mulligan SNAG for cervicogenic headache. If you just have a strap, a dog leash, or I just took my belt off to show you here on the video, just could say a belt, or a yoga strap around your, say C1 area, that is the top of your neck, just into your skull. If you pull forward say with one hand, that helps you rotate to the opposite direction.

Then if I pull down with the other hand, that helps anchor that strap in place such that I can really from the outside in, help the turning of that C1 vertebrae with the strap. In my case I'm pulling forward on the right with my belt strapped under base of my skull, pulling down with my left and that's rotating my head to the left.

That simple exercise, and then breathing, and relaxing there for three seconds or so, coming out and repeating that. That's been shown to really help people with cervicogenic headache, you do it both ways, especially focusing on the painful direction, and just repeating that, and in Toby Hall's study it was sustained for three seconds, twice times a day for 12 weeks, significant changes in people's cervicogenic headaches just from doing that simple exercise, the Mulligan SNAG.

Whitney Lowe:

Is that self-administered or was that done with somebody doing that for them?

Til Luchau:

That was self-administered. That's homework we taught the client is to just get to your strap, pull your C1 around in the sensitive direction, breath relaxed for three seconds, do that twice a day for 12 weeks. The important considerations there, it's staying within the pain-free range. It's not pushing it into something that hurts. And it shouldn't provoke any other symptoms. Besides, you come up to the edge you could say of the headache range. You're not getting any numbness or tingling, none of that. That's not allowed.

Staying in the pain free range. Doing that a couple of times a day for up to 12 weeks really has helped people quite a bit.

Whitney Lowe:

Yeah. There may be multiple mechanisms of effect there, doing things both with movement of the vertebral structures themselves, but especially the way that you demonstrated that, with a belt or strap on your neck, a lot of the people who are advocates of the dermoneuromodulation theories, and the skin pulling, and myofascial application say, "Hey, we're doing all this stuff with the superficial skin and neural receptors in there as well."

Til Luchau:

Absolutely. Mulligan straps are a little bit tacky. They have almost like a yoga slippery mat surface on them. So, you really are pulling on the skin. You're getting some of that drag on the skin. Maybe it is cutaneous nerve glide that we're affecting, or maybe it's the brain getting recolored, or maybe we're turning C1, that's the traditional explanation. Or maybe it's that in combination with something I do to myself that brings me to some sensation, that I sustain or relax into that I do that a couple of times a day, maybe that makes a big effect.

Whitney Lowe:

Yeah. And it's probably some of the all of the above.

Til Luchau:

Some of all of the above. That's right.

Whitney Lowe:

We're getting close to wrapping up here. We were going to just touch base a little bit on some red flags, and things to watch out for.

Til Luchau:

Yeah. We should for sure mention those. Should I go through those Whitney? You think we should do those?

Whitney Lowe:

Let's do it. You've got a nice little acronym for those there, so let's...

Til Luchau:

Any time we talk about headaches, I make sure to talk about these. The acronym is SNOOP, S-N-O-O-P, because they're headaches are a symptom often. They're a symptom of something else. That something else could be serious, and by diminishing someone's symptoms, we could actually delay them getting treatment inadvertently.

They could go, "Oh, it's better. I'm not going to go check this out." There are some serious things that people should have checked out that the headaches are a sign of. Some of those red flags to watch out for is systemic symptoms, that's the S in SNOOP, such as fever, or weight loss, or if they have other systemic risk factors like HIV, or cancer, and they have a headache, they want to be checked out for that.

The N is neurologic symptoms, or abnormal neurological signs, such as confusion, impaired alertness, weakness, a stiffening of the neck. It seems like the neck muscles are tense, visual disturbances, nystagmus of the eyes wiggling, things like that. Those are neurological symptoms that are saying, "They need to see a primary care physician or a specialist, that is for sure."

Whitney Lowe:

All right.

Til Luchau:

The double O, the first O is the onset, was it sudden? Was it abrupt? Did it happen in seconds as opposed to minutes? Is it rapid? That's a red flag if it comes on quickly, the headache. The second O is the older patients, the older person. Whitney, I'm over 50, in fact, I'm almost 60, so I qualify. I don't know about you.

Whitney Lowe:

Great.

Til Luchau:

A new headache in an older patient, or a progressively worsening headache in a middle-aged patient, that's over 50, we're more middle-aged, Whitney, you got to admit.

Whitney Lowe:

Yeah. We are. For those of you who don't know we're pretty close in age here, but he's in his sixties, and I'm still in my fifties.

Til Luchau:

In a few weeks I will be coming up to that milestone.

Whitney Lowe:

When is your birthday? We shouldn't say that on air probably.

Til Luchau:

It's in January.

Whitney Lowe:

I think we talked about this before because mine's in December.

Til Luchau:

Right. Anyway, Happy Birthday for you coming up, and me too.

Whitney Lowe:

Yeah, right.

Til Luchau:

The P in SNOOP, the progression pattern of a previous history of headache. If they have a previous history, has it changed or progressed? Is there a change in the frequency? The severity, the clinical features that come with that? Or is their first headache unlike any headache they've heard or experienced before? Again, those are all red flags to say, "Let's get this checked out."

I just can't underline that enough. I know you all know this, I know you hear it on every technique instruction you get, but with headaches in particular, there is some stuff that people want to be under the care of a physician about, and headaches might be the only sign.

Whitney Lowe:

Yeah. Absolutely. Don't hesitate with those red flags to say, it's a good idea for somebody else to be looking at this as well. It doesn't mean necessarily you can't do things with them, but certainly if any of those things are present there, those would be indicators for having somebody else be involved.

Til Luchau:

Yeah. And it's like with great power comes great responsibility. Our power here is we can make most headaches better just with our hands, because of all those mechanisms we mentioned. That doesn't mean we've ruled them out as still needing to be evaluated perhaps.

Whitney Lowe:

Yeah.

Til Luchau:

As we wrap up here I should mention that handout again. It's a-t.tv/ttp-cgh, we'll put that in the show notes. Anything else you want to make sure we mention Whitney on our way out?

Whitney Lowe:

Yeah. I think we've covered a nice introduction to this overall topic here, and we will probably revisit this I'm sure somewhere down the road as we look at some other things like maybe creative treatment strategies, and delve into some of our favorite manual interventions as well. Some really good places to get started looking at the role of cervicogenic headaches here today.

That sounds good. I think we're going to wrap up here. We've got a message from also one of our other sponsors for the podcast to wrap up here.

Til Luchau:

Yeah. Handspring, and the story there is when I was wanting to publish a book myself, The Advanced Myofascial Techniques series, I got two offers. One was from a large international media conglomerate, which I was flattered about, and then the other was from Handspring, a small publisher in Scotland run by four great people. And I'm glad I chose them. I chose the small guy, because not only did they really help me make the books I wanted to make, but their catalog has emerged as one of the leading collections of professional level books, written especially for body workers, movement teachers and all professionals they say who use movement or touch to help patients achieve wellness.

Whitney Lowe:

And Handspring has a new webinar series called Moved To Learn, which are free 45-minute segments featuring some of their amazing authors, including one from Til on there. Head on over to their website at handspringpublishing.com to check those out, and be sure to use the code TTP, like The Thinking Practitioner, at check out for a discount.

Whitney Lowe:

So, we thanks Handspring very much for sponsoring the podcast. And always thank our other sponsors that we have for the podcast. You help us get this show out to everybody. So, we certainly do appreciate that. You can stop by our sites for show notes, that handout Til mentioned earlier to you as well. Transcripts and extras over there, we'll have that stuff posted through our sites. Mine is that academyofclinicalmassage.com. Til, where can people find that over on your site?

Til Luchau:

advanced-trainings.com, the blog or podcast link right up at the top. If you have questions that you would like to hear us talk about, or just comments you want to make, I'd love hearing from you. It's really great always to get your questions or comments. You can email us at info@thethinkingpractitioner.com, or look for us on social media. I'm @TilLuchau, T-I-L L-U-C-H-A-U. How about you Whitney?

Whitney Lowe:

Also under my name on social media, Whitney Lowe. You can also follow us on Spotify, Stitcher, or wherever your podcasts are that you listen to, rate us on Apple Podcast, or wherever else you listen in, do share the news, tell a friend. Again, we do thank you for being a listener of the podcast, and helping to get the news around everywhere.

Thanks everybody, we'll be back here in another couple of weeks with another adventure down the manual therapy hole somewhere.

Til Luchau:

Thanks Whitney.

Whitney Lowe:

Okay, sounds good. We'll see you then.