ATTENTION!!! The physician responsible for the patient’s treatment must be informed of the MEDICAL MASSAGE PROTOCOLs that will be used in manual therapy, and the practitioner must obtain the physician’s permission prior to the initiation of such therapy.
This video is a presentation of the MEDICAL MASSAGE PROTOCOL in cases of Non-Migraine Type Headache (Cranialgia), Greater Occipital Nerve Neuralgia. It is based on scientific publications reviewed in Medical Massage, Volume I (2nd Edition). Please refer to pp. 174-189 of the Medical Massage, Vol. I textbook to learn more about pathology, clinical symptoms and diagnostic evaluation of tissue in cases of Non-Migraine Type Headache (Cranialgia), Greater Occipital Nerve Neuralgia.
In the videos, we will repeat each technique and approach only two or three times to save time and space. Follow the time guidelines shown at the beginning of each step.
DIAGNOSTIC EVALUATION OF THE PATIENT WITH CHRONIC HEADACHES
DIAGNOSTIC EVALUATION OF THE SECONDARY SYMPTOMS ASSOCIATED WITH HEADACHES
MEDICAL MASSAGE PROTOCOL IN CASES OF NON-MIGRAINE TYPE HEADACHE (CRANIALGIA). GREATER OCCIPITAL NERVE NEURALGIA (GONN)
Duration: 45 min-1 hour
Step 1. Work on both sides of the neck and upper shoulders
Duration: 2 min
Pressure: below the pain threshold
Start with bi-manual effleurage strokes from the sternum along the anterior and posterior shoulders to the occipital ridge. Pay attention to the position of the elbows during the strokes.
End each stroke with short stretch of the neck. The white arrows indicate the direction of the passive stretch.
Next, apply ridged friction along the same area. While applying strokes, try to slightly flex and tighten your wrist joints while pressing your forearms against the table. This allows you to use your arms as leverage to slightly elevate the patient’s shoulders while applying the strokes.
End this step with the repetition of the effleurage strokes.
Step 2. Work on the unaffected side of upper shoulder and upper back
Duration: 2 min
Pressure: below the pain threshold
Apply intense kneading of the upper shoulder muscles on the unaffected side. Later, work along the insertion of the trapezius muscle into the spine of the scapula, the medial edge of the scapula, and line of the spinous processes.
Step 3. Work on the affected side of upper shoulder and upper back
a. Kneading of the trapezius muscle in the inhibitory regime
Duration: 2 min
Pressure: below the pain threshold
Begin on the distal part of the trapezius muscle employing kneading incorporating a stretching component.
Move to the middle of the belly of the horizontal portion of the trapezius muscle and employ kneading with a lifting component.
Finally apply kneading with a stretching component on the proximal part of the horizontal portion.
b. Relaxation of the cervical paravertebral muscles
Duration: 2 min
Pressure: below the pain threshold
Apply the technique for relaxation of the paravertebral muscles on the neck. To review the step-by-step application of this technique, click here.
c. Friction on the lateral surfaces of the spinous processes of the cervical vertebrae
Duration: 1 min
Pressure: below the pain threshold
Apply intense friction on the lateral surfaces of the cervical vertebrae which are painful duirng direct pressure application. To review the step-by-step application of this technique, click here.
Step 4. Work on the trapezius muscle
Duration: 2 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
Begin with friction strokes along the fibers of the trapezius muscle just along their insertion into the spine of the scapula. Later switch to cross-fiber friction.
Step 5. Work along the occipital ridge where the cervical muscles insert into the skull
a. Bi-manual friction BELOW the occipital ridge
Duration: 3 min
Pressure: below the pain threshold
Place the fingertips (brought together) of both hands below the occipital ridge on both sides, and apply circular and cross-fiber friction. Please notice in the video that the practitioner should bend his or her fingers such that the fingertips are positioned under the occipital ridge.
b. Intense friction and compression ON the occipital ridge
Duration: 4 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
First, the practitioner should determine the area to be treated. At the beginning of the video, the line of the spinous processes of the cervical vertebrae is shown. The practitioner should apply treatment at the insertion of the trapezius muscle into the occipital ridge.
This area is located where the paravertebral line meets the occipital ridge. This line is easier to find if the practitioner asks the patient to extend his or her head backwards against the practitioner’s resistance, rendering the insertions of the posterior cervical muscles into the occipital ridge visible and palpable. The tension in this area my irritate or compress the greater occipital nerve with the following development of the Greater Occipital Nerve Neuralgia (GONN).
Begin with cross-fiber friction employing pressure that is slightly above the pain threshold. Try to remain at the same spot while conducting the treatment.
The next step is the application of ischemic compression in the same area. Try to remain on the tendinous part of the posterior cervical muscles. Carefully control the position of the finger and do not slide it to either side of the tendon.
The pressure applied in this instance should in fact exceed the pain threshold. However, apply the pressure in stages using the “stop and go” technique (to review this technique, click here). Also, notice that the pressure is applied at a 40- to 45-degree angle. Do not employ vertical compression because it is less effective.
After releasing the pressure, apply several repetitive compressions during the patient’s prolonged exhalation. Repeat this sequence 2 to 3 times.
Step 6. Scalpotherapy
Before beginning scalpotherapy, examine the scalp for painful areas by applying vertical pressure to compress the scalp against the bones of the skull.
The duration of scalpotherapy will depend upon the number of painful areas detected in the scalp. The practitioner should spend about 2-3 minutes on each area of tension.
a. Raking effleurage
Pressure: below the pain threshold
Begin with raking effleurage along the scalp. The base of the hand provides the stability of the strokes and allows the freeing of the fingers for friction. All fingers are bent and spread out.
The fingertips are the main contact areas and they conduct circular friction while the hands are moving along the scalp. Try to access the scalp between the hairs without pulling on them.
b. Scalp stretching using the thumb
Pressure: at the level of the pain threshold (first sensation of discomfort)
Place the thumb in the previously detected sensitive areas of the scalp. Apply vertical pressure, compressing the scalp against the skull. Now, without releasing the vertical pressure, add a slow horizontal push, trying to form a fold of skin in front of the thumb.
The practitioner should apply these strokes in a ray-like pattern outward, from the center of the original painful spot. The practitioner may place the thumbs on top of each other to reinforce the strokes and to reduce pressure on the thumb.
c. Scalp stretching between two thumbs
Pressure: at the level of the pain threshold (first sensation of discomfort)
Place the thumbs on opposite sides of the painful spot in the scalp. Apply vertical pressure and stretch the scalp, pushing the thumbs in opposite directions.
d. Scalp stretching using crisscrossing thumbs
Pressure: at the level of the pain threshold (first sensation of discomfort)
The application of this stretching technique is similar to the previous one, except that the thumbs push the scalp in crossing direction.
e. Vertical compression and circular friction
Pressure: above the pain threshold
In the painful area, apply repetitive vertical compressions. Reinforce the thumb with the other thumb if needed.
Now combine the compression with a circular friction stroke of the widest possible radius allowable by the scalp at any given point, without sliding over the skin itself but rather displacing the skin over the underlying bone.
There are four special points in the scalp which should be examined and treated in every patient who suffers from headaches. These points are the upper and lower Grinstein’s points. They are located on both sides of the middle line of the skull, on the top of the head, in the areas shown in the video. Use the same combination of compression and circular friction in these areas.
Step 7. Passive stretching of the neck
a. Passive stretching of the neck along its axis
Duration: 3 to 5 repetitions (half a minute)
Pressure: below the pain threshold
Repeat the passive stretching of the neck along the axis of the neck.
b. Passive stretching incorporating rotation to the opposite side
Duration: 3 to 5 repetitions (half a minute)
Repeat the passive stretching of the neck using the rotation to the opposite side.
Cutaneous Reflex Zones
Duration: 3 min
Pressure: below the pain threshold
Cutaneous reflex zones are located in the paravertebral area on the upper middle back and posterior neck. Begin with skin kneading, and later add skin rolling.
End the treatment with the application of superficial friction. The white arrow in the video indicates the direction of skin tightening during the application of superficial friction.
Add this treatment at the end of Step 1 of the previously discussed protocol.
Connective Tissue Zones
There are four connective tissue zones associated with non-migraine type of headache (see also Fig. 148 in Medical Massage Vol. I textbook). Each of them should be addressed with a unique CTM protocol.
The duration of CTM will depend upon how many zones need to be treated. On average, it should take 2 to 3 minutes to complete CTM strokes in each area. Use CTM only if the connective tissue zones are present.
Pressure: below the pain threshold
a. CTM strokes for Zone #3 and Zone #4
CTM strokes on the upper back and posterior neck. This is the most common location of connective tissue zones associated with chronic headache.
b. CTM strokes for Zone #2
Video shows the CTM strokes on the middle back.
c. CTM strokes for Zone #1
Video shows CTM strokes in the lumbo-sacral area. Two solid lines indicate both iliac crests.
Reflex Zones in the Skeletal Muscles
a. Trigger Point Therapy on the posterior cervical muscles
Duration: approximately 2 minutes for the trigger point therapy on each point
Pressure: at the level of the pain threshold (first sensation of discomfort)
If the patient exhibits symptoms of reflex zones in the skeletal muscles, the practitioner should add this treatment at the end of Step 5 of the previously discussed protocol.
The video shows the location of the two most common trigger points in the upper portion of the trapezius muscle; the trigger points in the lower portion of the trapezius muscle; the trigger point in the levator scapulae muscle; and the trigger point in the semispinalis capitis muscle.
Give special attention to the trapezius muscle because tension there is the most common reason for the irritation of the greater occipital nerve and subsequent development of the non-margarine type headache.
The white arrows indicate the upper-medial angle of the scapula. Pay attention to the position of the thumb and the direction of the application of pressure. The practitioner should apply trigger point therapy only if trigger points are present.
b. Trigger Point Therapy on the obliquus capitis inferior muscle
The practitioner who works on the patient with GONN should always examine the obliquus capitis inferior muscle and if the tension is detected, use Trigger Point Therapy there. Tension in the obliquus capitis inferior muscle is the major undetected cause for the greater Occipital Nerve Neuralgia (GONN). Because of the deep anatomical location of the obliquus capitis inferior muscle the practitioner should use the special approach to this muscle.
Place the thumb under the transverse process of the first cervical vertebra (the black dot drawn on the skin in the video). Another landmark for the correct position of the thumb is the tendinous part of the trapezius muscle. In the video this part of the trapezius muscle is directly above the thumb. Thus the practitioner should place the thumb just below it. Please notice the angle of the application of pressure.
To review the applicable scientifically based trigger point therapy protocol, click here.
c. Postisometric Muscular Relaxation
PIR for the upper portion of the trapezius muscle
Head Rotation
Duration: 4 min (apply head rotation to both sides)
Pressure: below the pain threshold
On the first level of PIR, place your posterior arm on the anterior shoulder and the palm on the patient’s temple. Ask the patient to rotate his or her head while you resist this movement. The white arrows in video indicate the direction of the contraction.
Apply three passive stretches by passively rotating the patient’s head to the unaffected side during his or her prolonged exhalation. While rotating the head, be sure to keep the patient’s chin above his or her shoulder. The rotation should be conducted within the patient’s limits of comfort.
At the end of the third stretch, remain in this position and ask the patient to repeat the head rotation against your resistance. This is the PIR on the second level.
Apply three passive stretches during the patient’s prolonged exhalation after the application of PIR on the second level.
Lateral flexion and shoulder elevation
Duration: 3 min
Pressure: below the pain threshold
For the first level of PIR, place your posterior arm on top of the patient’s shoulder and the palm on the patient’s temple. Ask the patient to bend his or her head laterally, and simultaneously elevate the shoulder. Resist both movements. The white arrows in video indicate the direction of the contraction.
Passively stretch the cervical muscles during the patient’s prolonged exhalation as shown in the video.
At the end of the third stretch, remain in this position and ask the patient to repeat the head bending and shoulder elevation. This is PIR on the second level.
Apply three passive stretches during the patient’s prolonged exhalation after the application of PIR on the second level.
Head extension
Duration: 3 min
Pressure: below the pain threshold
On the first level of PIR, place both your elbows (medial surface) on the patient’s lateral shoulders and both your hands on the posterior head. Interlock the fingers of your hands.
Now, ask the patient to extend the head backward while you resist this movement. Use the shoulders as stabilization points for your resistance. The white arrows in the video indicate the direction of the contraction. To minimize body-to-body contact, place a soft pillow between the patient’s back and your chest.
Passively stretch the posterior neck muscles during the patient’s prolonged exhalation as shown in video.
At the end of the third stretch, remain in this position and ask the patient to repeat the head extension. This is the second level of PIR.
Apply three passive stretches during the patient’s prolonged exhalation after the application of PIR on the second level.
PIR for the lower portion of the trapezius muscle
Head and upper body extension
Duration: 3 min
Pressure: below the pain threshold
On the first level of PIR, ask the patient to place his or her hands behind the head and resist the patient’s head and upper back extension as shown in the video. The practitioner should resist the movement by holding the patient’s forearms just above the wrist joints. The white arrows in the video indicate the direction of the contraction.
To minimize body-to-body contact, place a soft pillow between the patient’s back and your chest.
Passively stretch the lower portion of the trapezius muscle by flexing the patient’s head and upper back forward during a prolonged exhalation.
At the end of the third stretch, remain in this position and now ask the patient to repeat the former head extension against your resistance. This is the PIR on the second level.
Apply three passive stretches during the patient’s prolonged exhalation after the application of PIR on the second level.
Full Protocol:
EYES TREATMENT
One of the areas where a headache or a migraine can greatly affect a patient is the eyeball and the tissue around the eyeball within the orbit. Frequently, this is the only area of headache which in this case called cluster headache. It is impossible to effectively control a cluster headache or reduce the intensity of a migraine without treating the eyes and releasing pressure in the extraocular muscles (the muscles which support and control movement of the eyeballs).
The eye is a very complex sense organ. Let’s review the extraocular apparatus of the eyeball support, as it has an important relation to headache and migraine. The eyeball is suspended inside the orbital cavity by a fibrous capsule which forms a sort of hammock supporting the eyeball. This capsule allows the great mobility of the eyeball, made possible by very complex interactions between seven small muscles constituting what is called the extraocular musculature: the superior rectus, inferior rectus, medial rectus, lateral rectus, superior oblique, inferior oblique, levator palpebrae superioris muscles (see Fig. 1). These muscles are able to quickly and precisely adjust the position of the eyeballs in the needed direction.
Fig. 1. Extraocular muscles of the right eye
1 – superior rectus muscle
2 – levator palpebrae superioris muscle
3 – lateral rectus muscle
4 – inferior rectus muscle
5 – inferior oblique muscle
The motor function of the extraocular musculature is provided by the oculomotor nerve (the third pair of the cranial nerves). The sensory function of the orbital area is provided by the ophthalmic division of the trigeminal nerve (the fifth pair of the cranial nerves).
Patients with chronic headaches and migraines experience pain and tension in the area of the forehead. These sensations frequently radiate to the area of the orbit, or have their origin in the orbital area itself, behind the eyeball.
Medical scientists commonly have associated cluster headaches with Trigeminal Nerve Neuralgia, but patients suffering from Greater Occipital Nerve Neuralgia very frequently exhibit cluster headaches as well.
The orbital part of the face is very richly innervated, especially the extraocular muscles, and their tension is an additional factor which greatly contributes to the intensity of the pain during a cluster headache.
We have developed the protocol of PIR for the extraocular muscles, and the results from its clinical application have shown that this is a great tool to control the intensity and duration of cluster headaches. The protocol of PIR for the extraocular muscles should not be used alone. If the cluster headache is a result of Greater Occipital Nerve Neuralgia, add treatment of the eyes at the end of the MEDICAL MASSAGE PROTOCOL presented above. If the cluster headache is a result of Trigeminal Nerve Neuralgia, add treatment of the eyes at the end of the MEDICAL MASSAGE PROTOCOL addressing Trigeminal Nerve Neuralgia (to review, click here).
Why is it that the protocol for treatment of the eyes is so effective in controlling a headache or a migraine implicating the eye area? As mentioned above, the orbital area is very richly innervated. Radiation of pain into, or pain having its origin in this area both greatly affect the orbital soft tissue, including the extraocular musculature. One of the first reactions of these muscles to chronic pain is protective tension which the patient feels as a very heavy, pulsating and ready-to-explode sensation within the orbit and behind the eyeball. Usually any movement of the eyes increases the intensity of the pain, which may also trigger nausea and vomiting.
There exists no other treatment to address the extraocular muscles except the protocol of Postisometric Muscular Relaxation discussed below. This PIR protocol, via its indirect impact on the extraocular muscles, allows the total reduction of tension in these muscles.
During this protocol, the practitioner must work around the patient’s eyes. Thus, the practitioner must explain to the patient the entire procedure in detail and must be certain that the patient is comfortable with this proposed treatment. Contact lenses must be removed before the treatment is begun. The treatment should be conducted within the patient’s comfort level, and he or she must keep the eyes closed. The PIR protocol to reduce tension in the extraorbital musculature is to be conducted on two levels.
Step 1.
Duration: 1 min
Pressure: below the pain threshold
Start with the bi-manual stretching effleurage strokes along the upper orbital edge. For the next part use small circular friction strokes along the upper orbital edge. Be sure to press the fingertips against the bone. For the last part of this step apply small circular friction below the upper orbital edge. Notice that, the practitioner carefully tries to get the fingertips below and behind the upper orbital edge, i.e., between the orbital edge and the eyeball itself.
Depending upon the size of the practitioner’s hands, he or she may choose to use the fingertips of the 5th finger, seeing as this maneuver calls for a very small contact area. The patient must inform the practitioner about any pain he or she experiences from this contact with the eyes. This is a main factor which defines the intensity of the applied pressure.
Step 2.
Pressure: below the pain threshold
The patient lies comfortably on the back with the eyes closed. Place your right index finger on the medial side of the right eyeball, and your left index finger on the lateral side of the left eyeball.
From the initial position of the eyes looking straight forward, ask the patient to roll the eyeballs to the left while both fingers resist this movement. Hold counterresistance for 10 to 15 seconds, and after this ask the patient to relax the extraocular muscles without opening eyes.
After this, ask the patient to inhale and, during the prolonged exhalation, to roll the eyeballs all the way to the opposite direction, i.e., to the right. The patient should return the eyes to the neutral position after each prolonged exhalation, inhale, and during the next prolonged exhalation should repeat the rolling of the eyes all the way to the right. This free (i.e., non-resisted) roll to the right is to be repeated by the patient 3 times.
After the last roll to the right, the practitioner asks the patient to keep the eyes to the right and places the same fingers as before on the medial (for the right eye) and lateral (for the left eye) surfaces of the eyeballs. From this new position (eyeballs looking to the right), the practitioner asks the patient to roll both eyeballs to the left while he or she resists the eyes’ movement for 10 to 15 seconds as before.
At the end of this second resistance, ask the patient to return the eyes to the neutral position again and to repeat 3 passive rolls of the eyeballs all the way to the right during the prolonged exhalation, as before.
White arrows indicate the direction of the eyes’ movement against the resistance elicited by the practitioner.
Step 3.
Pressure: below the pain threshold
This video repeats the same protocol of the eyes treatment, but in the opposite direction: rolling of the eyes to the right against the practitioner’s resistance on two levels, with 3 free rolls to the left after each level of the roll-against-resistance. Notice the position of the index fingers.
White arrows indicate the direction of the eyes’ movement against the resistance elicited by the practitioner.
Step 4.
Pressure: below the pain threshold
Start with the application of repetitive vertical compressions on the eyeballs during the patient’s prolonged exhalation. Notice that both fingers shape themselves to the contour of the eyeballs. Fit 3 to 4 vertical compressions into each patient’s prolonged exhalation.
The next part is the application of repetitive compression in the space between the eyeballs and upper orbital edge. Notice the change of the applied pressure compared to the first part of this step.
At the end of the video the vertical compressions on the eyeballs shown from the different camera angle.
Step 5.
Duration: 2 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
Repeat Step 1, but now the pressure applied should be made to reach the pain threshold.
Full Protocol: