Using an adjusting instrument, emphasis was placed on the upper cervical spine.

Presentation
A 72-year-old female who appeared to be in good physical condition for her age presented to my office. The patient’s chief complaint was mild neck pain that radiated into the right side of her head (hemi-cranial). The patient described her pain as a constant throbbing and reported her discomfort as 10/10 on a visual analog scale (VAS), with 0 being no pain. The patient had no reported traumas. The headache was insidious in nature with no known provocative factors, and she had not been without her constant throbbing for 8 weeks straight.

In truth, had it not been for the fact that she was already cotreating with a neurologist for some time, I don’t think I would have even begun to think about treating her without some advanced imaging of her head and neck. But the patient was carrying copies of her cervical x-rays and was feeling quite adamant about not undergoing any more tests.

Evaluation
I received pertinent information from looking at the x-rays and advanced diagnostic imaging results that were obtained from her neurologist’s office. X-rays revealed a reduced cervical curve measuring 26° (35–45° considered normal, in case some of you may forget), and mild discogenic spondyloarthrosis from C2–C6. CT of the brain with and without contrast revealed prominent enhancement of the right middle cerebral artery likely due to tortuosity. So the patient subsequently underwent an MR of the brain with and without contrast and an intracranial angiogram. These tests were reported by the radiologists as within normal limits.

My palpatory examination revealed spastic musculature in the suboccipital region and myofascial trigger points in the upper trapezius and levator scapulae (R>L); and subluxations in the cervical, thoracic, and lumbopelvic regions. Anterior head carriage noted. Range of motion (ROM) in the cervical spine decreased in all planes with the exception of flexion. Jackson’s test was (+) bilaterally in the cervical spine and cervical distraction “felt good,” as reported by the patient. ROM in the lumbar spine as well as orthopedic testing were essentially within normal limits (WNL). Motor reflex and sensory testing of the C5–T1 and L1–S1 were WNL.

At this point, my working diagnosis for the patient was cervicogenic headache; discogenic spondyloarthrosis; loss of the normal cervical curvature; upper crossed syndrome; and subluxations in the cervical, thoracic, and lumbopelvic spine. The patient remembered that she had a reported history of migrainous headaches in her mid 20s, but she failed to recall any problems since that time. Although the patient’s symptoms were typical of a common migraine with regard to location and sex (but not typical for duration), I strongly felt that some or all of her headaches were coming from the cervical zygapophyseal joints. Additionally, with any type of chronic pain, depression could easily become part of this situation if the patient did not get some help in the immediate future.

Treatment
Treatment frequency was determined to be three visits per week for the first three weeks followed by a re-examination. With the patient, I used diversified adjustments for the full spine, with other treatment adjuncts such as ultrasound combined with an electric-stimulation component, light manual cervical traction, and myofascial release (Active Release Technique) to help reduce trigger points and break fibrous adhesions in the cervico-thoracic and suboccipital region. A stretching program for the patient was prescribed. Amazingly, after two-and-a-half weeks, she could actually reproduce the stretches the way that I had first instructed them to her. The patient was very compliant with her treatment regimen. How could she not be, with all that she has been through?

After 1 month, the patient reported no change. May I remind you that this now makes 12 weeks with a constant headache graded a 10/10 on a VAS scale. The patient grew more frustrated and went back to her neurologist. I lost touch with the patient for 2 months until she called my office saying that she wanted to give chiropractic “one more shot.” This was apparently because she did not like her neurologist’s recommendation of injections in her neck and an increase in her medication (Neurontin), which made her feel, “groggy and unable to function like a human being.” With the break in treatment, this made her chief complaint now 20 weeks old. I was pleased to hear from the patient and explained to her that we would no longer be using the diversified type of adjustments that we had tried in the past and would try the activator for her case. The patient was placed in our office’s acute phase of care again.

The patient’s x-rays revealed a reduction of the natural cervical lordosis.

Using an adjusting instrument, emphasis was placed on the upper cervical spine, the second cervical vertebra in particular. Subluxations in the upper cervical spine and occiput often play big roles in the treatment of headache patients due to the anatomical relationship with the suboccipital musculature and their attachment to the dura matter, the upper trapezius muscle, and the occipital nerve entrapments. The most consistent subluxation that I felt was wreaking havoc in the patient was the second cervical vertebra. Once this subluxation began to “hold its adjustment,” the patient started to turn the corner and feel better. As my patient began to accept the adjustments she was receiving and healing in a better spinal alignment, with less nervous-system dysfunction, all that we can do as chiropractors is watch the body’s innate recuperative ability go to work.

After three visits, her pain rated 8/10. Even better, after the patient’s sixth visit, her VAS was down to a 5/10. The frequency was still reported as constant, however. Then, it happened. Our visit began as usual with the same questions: “How are you? Better? Worse? Or no change since your last visit?” When I heard the patient say she had no headaches since the last time she left the office, I nearly dropped my pen. She had a grin from ear to ear. You could just feel the change in her entire persona.

It was at this moment that I knew that she would be a chiropractic patient for life.

The patient’s treatments continued until eventually she was placed on a wellness plan, with her visits scheduled once per month. The patient moved to the East Coast and vowed to keep up with her maintenance care.

Three months after moving away, she stopped by my office for a quick tuneup and to let me know that she remains headache free and is no longer taking medication—by her own choice. I learned a lot from this patient. One of the biggest things that I took away from her was that no matter how dire a situation may seem, we must stay focused, continue to provide the best-known care for our patients, and never lose our faith that chiropractic works.

Scott Cicotte, DC, practices in N. Fort Myers, Fla. Contact him at (239) 997-7000.