Headache is one of the most prevalent of all complaints that might bring a patient to seek medical attention.
Diagnostic evaluation of the patient may be simple or comprehensive, dictated by the situation and presentation.
Statistically, the most common cause of headache is muscle tension.
While the diagnosis of muscle tension headache (MTH) might suffice for
most circumstances, unless the clinician locates the precise physical
site of the ‘pain generator,’ the chances of successful treatment are
slim. On the other hand, treatment is likely to be successful, if
diagnosis is refined from the generic ‘muscle tension headache,’ to the
more specific diagnosis.
The most common cause of MTH results from inflammatory changes at the
site of muscular attachment on the occipital ridge. As inflammation
develops, entrapment and irritation of greater occipital nerve results.
The typical symptom complex results from muscle spasm as well as from
Occipital neuralgia results in a distinct type of pain that is most
commonly characterized by piercing, throbbing, or lancinating pain in
the upper neck, back of the head, and behind the eyes. Most commonly
the problem is unilateral and because pain in the eye is typical, the
misdiagnosis of ‘migraine’ is made. The pain of Splenius Capitis
Syndrome (SCS) begins in the neck and then spreads to pain behind the
The pain is caused by inflammation, irritation, or injury to nerves. Muscular spasm results in a second pain constellation.
Interestingly, the pain of muscle spasm and the pain that results from
the neuralgia need not occur simultaneously and the nature of the pain
will, therefore, change from episode to episode, adding to clinical
Causes include trauma to the back of the head, pinching of the nerves
by overly tight neck muscles, and compression of the nerve as it leaves
the spine due to osteoarthritis. Localized inflammation or infection
can result in SCS, although this is quite rare. It can be caused by
diabetes and blood vessel inflammation. Clearly, the most frequent
cause is prolonged periods of keeping the head in a downward, rotated
and forward position. The muscle tension results in micro trauma to the
muscular attachment, swelling ensues, and myalgia/neuralgia result.
Symptoms: Occipital and shoulder pain; Pain behind the eyes; Awaken
with pain; Pain looking up or down particularly with rotation; Worse
with menses, ovulation, and salt load, Anticipate sleep disorder.
Causes of SCS: Trauma of a rotational nature; Blunt trauma, pugilism;
Flexion/extension injury; Vigorous cervical manipulation Surgery;
Dental chair; Mastoid surgery.
The causes of SCS can be quite distant from the site of pain.
That is, postural problems can result from foot pathology, ankle, knee
and hip problems that result in muscular dystony. Physical problems in
the lower extremity can cause physical changes in the axial skeleton.
Postural pathology can result from an arthritic toe or heel spur,
resulting in contralateral hip pain, and samesided headache.
Injection is performed in a short series, that is, once or twice, with
pain relief lasting from a few weeks to many months.Skillful injection
technique results in the most satisfactory results, and concurrent use
of common anti-inflammatories speed recovery, particularly when
combined with a low-dose diuretic. Muscle relaxant or anti-convulsants,
dosed at bedtime provide relief of the neuralgia and side effects are
minimized by the bedtime administration.
If exacerbation of pain is triggered by ovulation or dietary salt-load,
routine, or periodic administration of a mild diuretic is worthwhile.