Patient History
Jane came to this clinic for evaluation of chronic headache and chronic neck pain. 6 years earlier, she had suffered a laceration and fracture at the right occipital area of the skull. Over the next 2 years, complete numbness at the distribution of the greater occipital nerve (area of the scalp on one side) evolved into chronic headache. The old injury site was very sensitive to pressure. She developed daily headaches that wrapped around the entire head and often a shooting, knife-like pain from the back of the skull to just above the eye.

Over the years, she had several MRIs which were normal. She noted mild, transient improvement with chiropractic treatment, physical therapy (exercise and stretching), and massage.

Case Description
Palpation of the scar reproduced the knife-like headache and revealed restricted motion of the skin at the scalp (fascial restrictions). Palpation of the neck and upper back also revealed tenderness and restricted motion between several spine vertebrae.

Neurological examination did not indicate a problem with spinal nerve roots, spinal cord, or cranial nerves. Cardiovascular examination was also unremarkable.

Treatment Plan
She was suffering from chronic headache secondary to remote injury to the muscles and fascia adjacent to the greater occipital nerve. We discussed her options, began a course of cervical spine manipulation therapy and active release technique to improve the mobility of her scar and decrease suboccipital muscle tension at the base of the skull.

Outcome
Following the 1st treatment, she had only one more episode of knife-like, shooting head pain. After the 1st week of treatment (3 sessions), the patient had no more sharp head pain. At one month follow-up, she no longer head headaches.

Discussion
The generation of headache pain can come from multiple sources. A careful diagnosis is the 1st and most important step to treating any headache condition. This case demonstrated a confluence of two headache types. The daily headache that wrapped around this patient’s entire head, was most likely attributable to tension-type headache, originating from muscle and joint dysfunction of the cervical spine.

Additionally, the one-sided, shooting pain, reproduced by pressure at the old scar is more symptomatic of long-term, myofascial restrictions at the scar. (myo= muscle; fascial= the connective tissue the holds the muscles and skin together). Therefore a scar is simply an adhesion between the muscle, fascia, and skin. To apply active release technique (a specific form of myofascial release), I use my hands to evaluate the texture, tightness and movement of muscles, fascia, tendons, ligaments, and nerves. I then treat the abnormal tissues by combining precisely directed tension and specific movements by the patient.