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Saturday, March 27, 2010

Headaches related to rectus capitis posterior minor muscle and its atlanto-occipital membranes

A recent post of mine discussed the relationship between osteopathic (chiropractic) manipulation and TMD. That study showed that similar results were obtained with both types of treatment. A major consideration in treating headaches is the position of the head and neck. Neuromuscular dentistry tends to encourage healing or correction of abnormal head posture. This can have an enormous effect of the jaw muscles and jaw joints but also on the Atla-occipital joint and the Atlas-axis joint and surrounding tissues. These tissues (such as rectus capitus posterior minor) can create tension on the dura mater of the brain that can cause not just migraines, tension-type headaches, chronic daily headaches and neck pain but a wide variety of atonomic dysfunction.

The treatment of TMD with neuromuscular dentistry not only eliminates and/or alleviates migraines, tension-type headaches, TM Joint Pain and sinus headaches but it also creates an environment where long term healing of the upper cervical soft tissues and stabilization of atlas-axis joint and atlas-occipital joints occur. Successful treatment for many patients depends on judicious use of a neuromuscular orthotic in conjunction with manipulative therapies, by physical therapists, chiropracters, osteopaths, massage therapist or naprapaths.

These physical changes cannot be corrected with medications alone. I firmly believe that it would be in the best interest of patients if all chronic headache patients seen by neurologists were referred for neuromuscular dental evaluation and fitted with a diagnostic orthotic as well as being examined for myofascial trigger points and problems with the occipital-atlas-axis relations.

It has been shown that there is increased ability to correctly diagnose and treat migraines, tension headaches,cervicogenic headaches, Episodic tension-type headaches and chronic daily headaches when these therapies and evaluations are combined. Unfortunately most patients are never evaluated in this comprehensive manner. Dr Norman Thomas the leading expert on the anatomy, physiology and science of neuromuscular dentistry and its relation to cervical dysfunction says that if either the neuromuscular balance of the mandibular-maxillary relations or the atlas-occipital or atlas-axis joints are in improper alignment than the entire system will always be out of balance. He feels it is an all or none relation. Dr Norman Thomas is now in charge of neuromuscular dentistry research and education at the Las Vegas Institute (LVI)

I have included at the lower half of this posts several PUBMED abstracts concerning the Rectus Capitus Muscle and the attatchment to the dura-mater thru the atlantooccipital membrane.

Cephalalgia. 2007 Apr;27(4):355-62.
Magnetic resonance imaging study of the morphometry of cervical extensor muscles in chronic tension-type headache.
Fernández-de-Las-Peñas C, Bueno A, Ferrando J, Elliott JM, Cuadrado ML, Pareja JA.

Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation of Universidad Rey Juan Carlos, Spain. cesarfdlp@yahoo.es
This study analyses the differences in the relative cross-sectional area (rCSA) of several cervical extensor muscles, assessed by magnetic resonance imaging (MRI), between patients with chronic tension-type headache (CTTH) and healthy controls. MRI of the cervical spine was performed on 15 CTTH females and 15 matched controls. The rCSA values for the rectus capitis posterior minor (RCPmin), rectus capitis posterior major (RCPmaj), semispinalis capitis and splenius capitis muscles were measured from axial T1-weighted images using axial MR slices aligned parallel to the C2/3 intervertebral disc. A headache diary was kept for 4 weeks in order to substantiate the diagnosis and record the pain history. CTTH patients showed reduced rCSA for both RCPmin and RCPmaj muscles (P < 0.01), but not for semispinalis and splenius capitis muscles, compared with controls. Headache intensity, duration or frequency and rCSA in both RCPmin and RCPmaj muscles were negatively correlated (P < 0.05): the greater the headache intensity, duration or frequency, the smaller the rCSA in the RCPmin and RCPmaj muscles. CTTH patients demonstrate muscle atrophy of the rectus capitis posterior muscles. Whether this selective muscle atrophy is a primary or secondary phenomenon remains unclear. In any case, muscle atrophy could possibly account for a reduction of proprioceptive output from these muscles, and thus contribute to the perpetuation of pain.

PMID: 17376113 [PubMed - indexed for MEDLINE]

J Manipulative Physiol Ther. 1999 Oct;22(8):534-9.
A proposed etiology of cervicogenic headache: the neurophysiologic basis and anatomic relationship between the dura mater and the rectus posterior capitis minor muscle.
Alix ME, Bates DK.

Logan College of Chiropractic, Chesterfield, Missouri, USA. dralix@worldnet.att.net
OBJECTIVE: To examine the neurophysiologic basis and anatomic relationship between the dura mater and the rectus capitis posterior minor muscle in the etiologic proposition of cervicogenic headache. DATA SOURCES: On-line searches in MEDLINE and the Index to Chiropractic Literature, manual citation searches, and peer inquiries. RESULTS: Connective tissue bridges were noted at the atlanto-occipital junction between the rectus capitis posterior minor muscle and the dorsal spinal dura. The perpendicular arrangement of these fibers appears to restrict dural movement toward the spinal cord. The ligamentum nuchae was found to be continuous with the posterior cervical spinal dura and the lateral portion of the occipital bone. Anatomic structures innervated by cervical nerves C1-C3 have the potential to cause headache pain. Included are the joint complexes of the upper 3 cervical segments, the dura mater, and spinal cord. CONCLUSION: A sizable body of clinical studies note the effect of manipulation on headache. These results support its effectiveness. The dura-muscular, dura-ligamentous connections in the upper cervical spine and occipital areas may provide anatomic and physiologic answers to the cause of the cervicogenic headache. This proposal would further explain manipulation's efficacy in the treatment of cervicogenic headache. Further studies in this area are warranted to better define the mechanisms of this anatomic relationship.

PMID: 10543584 [PubMed - indexed for MEDLINE]

Clin Anat. 2006 Sep;19(6):522-7.
Soft tissue connection between rectus capitus posterior minor and the posterior atlanto-occipital membrane: a cadaveric study.

Zumpano MP, Hartwell S, Jagos CS.
Department of Basic Sciences, New York Chiropractic College, Seneca Falls, New York, USA. mzumpano@nycc.edu
This investigation determined the variation, prevalence, tissue-type, and sex bias in the soft-tissue bridge between rectus capitis posterior minor (RCPMi) and the posterior atlanto-occipital membrane (PAO). Seventy-five cadavers (27 females and 48 males) were surveyed. When RCPMi was revealed, its superior attachment was detached and the muscle was reflected inferiorly to determine if it was attached to the underlying PAO. If a soft-tissue bridge was identified, the fibers found within the bridge were classified by visual inspection into three categories: tendon-like, muscle-like, and fascia-like. A fourth category of no attachment was also noted. These results show that RCPMi was present bilaterally in 93% of all cadavers surveyed (89% of the female cadavers and 96% of the male cadavers). On the right side, a soft-tissue bridge was present in 67% of males and 78% of females. On the left side, the soft-tissue bridge was present in 69% of males and 82% of females. The number of male cadavers possessing tendon fibers in a soft-tissue bridge was 56% on the right side and 55% on the left side. In females, the number of cadavers possessing tendon fibers in a soft-tissue bridge was 44% on the right side and 64% on the left side. In males, muscle fibers were present in the soft-tissue bridge, 34% on the right side and 36% on the left. In females, muscle fibers were found in the soft-tissue bridge, 43% on the right side and 36% on the left. There were no significant associations of sex and the presence of the soft-tissue bridge and a fiber-type within a soft-tissue bridge.

Am J Phys Med Rehabil. 2008 Mar;87(3):197-203.
Association of cross-sectional area of the rectus capitis posterior minor muscle with active trigger points in chronic tension-type headache: a pilot study.
Fernández-de-Las-Peñas C, Cuadrado ML, Arendt-Nielsen L, Ge HY, Pareja JA.

Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation of Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.
OBJECTIVE: To investigate whether cross-sectional area (CSA) of the suboccipital muscles was associated with active trigger points (TrPs) in chronic tension-type headache (CTTH). DESIGN: Magnetic resonance imaging (MRI) of the cervical spine was performed in 11 females with CTTH aged from 26 to 50 yrs old. CSA for both rectus capitis posterior minor (RCPmin) and rectus capitis posterior major (RCPmaj) muscles were measured from axial T1-weighted images, using axial MRI slices aligned parallel to the C2/3 intervertebral disc. A headache diary was kept for 4 wks to record the pain history. TrPs in the suboccipital muscle were identified by eliciting referred pain to palpation, and increased referred pain with muscle contraction. TrPs were considered active if the elicited referred pain reproduced the head pain pattern and features of the pattern seen during spontaneous headache attacks. RESULTS: Active TrPs were found in six patients (55%), whereas the remaining five patients showed latent TrPs. CSA of the RCPmin was significantly smaller (F = 13.843; P = 0.002) in the patients with active TrPs (right side: 55.9 +/- 4.4 mm; left side: 61.1 +/-: 3.8 mm) than in patients with latent TrPs (right side: 96.9 +/- 14.4 mm; left side: 88.7 +/- 9.7 mm). No significant differences were found for CSA of the RCPmaj between the patients with either active or latent TrP (P > 0.5). CONCLUSIONS: It seems that muscle atrophy in the RCPmin, but not in the RCPmaj, was associated with suboccipital active TrPs in CTTH, although studies with larger sample sizes are now required. It may be that nociceptive inputs in active TrPs could lead to muscle atrophy of the involved muscles. Muscle disuse or avoidance behavior can also be involved in atrophy.

PMID: 18174844 [PubMed - indexed for MEDLINE]

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posted by Dr Shapira at 8:53 AM

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