Combination of TENS, Lidocaine Injections and Muscle Manipulations as a Therapeutic Method for Cervicogenic Headache – Pilot Study

Abstract

Objectives:Cervicogenic headache is a chronic cause of pain with a symptomatology varying between neck pain, instability while walking, dizziness, vertigo, ear pain, eye pain, and unilateral tinnitus, which is leading to increased morbidity and use of analgesics. Currently, the contribution of the local infusion of lidocaine in the treatment of cervicogenic headache is very significant.

Material and methods:In this pilot study, eight patients with cervicogenic headache were examined between February 2017 and August 2017 and treated with a three-scale method combining: 1) transcutaneous electric nerve stimulation (TENS); 2) minimally invasive methods of lidocaine injections and nerve blocks; and 3) stretching of the cervical and trapezoidal muscles.

Results:The results show that the combined three-step therapy decreases both pain intensity based on VAS score and constant use of analgesics.

Conclusion:Three-step therapy can be conducted in one session or multiple sessions and appear to constitute a minimally invasive technique that decreases analgesic use, reducing not only their adverse effects and interactions with other pharmaceutics but also the cost of their use.

Keywords:cervicogenic headache, lidocaine, TENS, muscular stretch technique.

INTRODUCTION

Headache is the most common cause of pain. From the 14 types of headaches, cervicogenic headache is in the range of 2.5 to 4.1% (1). Cervicogenic headache is common with regard to cervical syndrome, myofascial head-neck pain syndrome, and neck injury (2). The most frequent symptomatology is the reduced mobility of the neck, particularly regarding neck rotation, neck pain in the upper third of the neck, the bilateral path of pain from the occipital to the parietal region, instability during walking, visual disturbances, unilateral high frequency tinnitus, ear pain, dizziness and occasionally brief episodic vertigo (3).

The treatment of cervicogenic headache can be pharmaceutical, non-pharmaceutical (physiotherapy, for example), invasive or surgical (4). Local injection of lidocaine via the technique of muscular injections/infiltrations, or, if necessary, nerve block of occipital nerves is a method belonging to invasive techniques. Few minutes after the application of TENS, the muscular injections are performed. At the end of infiltrations, muscular stretch technique and cervical muscular movements are applied. This three-step technique contributes either to the complete elimination of the pain or to its reduction, working not only via the local action of lidocaine as a local anesthetic on the sodium channels membranes lidocaine but also on the local improvement of microcirculation in the corresponding anatomical region (5). Direct relief of the pain and the concomitant symptoms usually occur over a period of time ranging from 10 minutes to 20 minutes after the last infiltration. The questions that are raised here are whether the three-step treatment is sufficient to improve cervicogenic headache symptoms and if the administered pain medication could be reduced after a certain period of time.

METHODS

For this reason, an investigation on the outcome of three-step treatment for cervicogenic headache at the outpatient clinic of an otolaryngologist (P. G.) in cooperation with a neurosurgeon (Th. B.) was initiated.

The first results concern 28 outpatients who presented to the clinic between February 2017 and August 2017. Patients came to the doctor with the symptomatology of dizziness, pain, unstable walking and occasionally, tinnitus. (Table 1). A detailed medical history was obtained from each patient, followed by clinical examination; then each patient was sent for a magnetic resonance imaging (MRI scan) to confirm/exclude medical conditions such as intervertebral disc, myelopathy, vertebral stenosis and tumors.

Of the 28 patients, 20 were rejected: 12 were referred to a neurosurgeon due to spinal pathology that required treatment, seven had another type of headache and one patient had headache caused by arterial hypertension. Only eight patients with a mean age of 56.75 years were examined: six women aged 43 to 80 (median age 57) and two males aged 42 and 72. During their visit, a visual analogous scale (VAS) was applied before administering the three-step therapy and 20 minutes after (Table 2). Prior to their appointment to the outpatient clinic, four out of eight patients had visited other doctors (two patients went to orthopedists, one patient to a neurologist and another one to an otorhinolaryngologist). The confirmed etiological factors are shown in Table 3.

From their individual history, there were no other comorbidities causing chronic pain. All eight patients received a questionnaire about how they take painkillers (frequency and daily dose). Later on, we observed each of them for a three-month period of treatment for cervicogenic headache. Patients with cervicogenic headache indicated a pain intensity from 5 to 9 based on the VAS pain scale (1-10), with associated symptoms and causative factors shown in Table 3. In case of tinnitus, and/or earache, there was an additional ENT (Ear Nose Throat) assessment and an audiogram.

Technique

In all eight cases, a three-step treatment was applied in a single session (except for two cases requiring repetitive sessions) as follows: a) transcutaneous electric nerve stimulation (TENS); b) local intramuscular injection of lidocaine 2%; and c) muscle manipulations in the region of the trapezoid muscle, in the upper cervical region and in the occipitovertebral region. The therapeutic steps were performed exactly in the listed order.

Neurostimulation (Figure 1) using an automatically- changing rate lasts 15 minutes, then the pads and TENS device are removed.

This is followed by disc application with all that is necessary for infiltration: needles, syringes, gauze, cooling sprays, 2% and 1% lidocaine solution, and antiseptic solutions. The disc is placed on the right site of the patient, who is sitting on the bed, and at the same time on the right of the doctor, who is standing behind the patient.

After skin antisepsis with alcohol, 2% (sometimes 1%) lidocaine in 5 cc and 3 cc syringes is administered and three types of needles (27 G, 0.4 mm x 19 mm; 25 G, 0.5 mm x 1 inch; and 25 G, 0.5 mm x 40 mm) are used. The access points for the infiltration are three on the right side and three on the left side, in a symmetrical configuration calculated based on an imaginary vertical line connecting the spinous processes of the cervical vertebrae, marked in Figure 2.

Injections were started from the bottom to the top, as follows:

- The first point was determined at 3 cm from the free rim of the trapezoid (6), about 10-11 cm from the predisposed on the skin vertical line of the spinous processes; 0.5 cc at a depth of about 1 cm was injected with the 5 cc syringe and a 27 G, 0.4 mm x 19 mm needle, which was then lowered and guided to two points on either side of the central predisposed point without exceeding the depth of one centimeter per point, 0.3 cc; the same procedure was repeated on the opposite side, with a total amount of lidocaine at 2 cc.

- The second access point was 3–3.5 cm of the middle of the A6-A7 distance; a 3 cc syringe was needed, preferably with a screwtype safety nozzle, because a longer needle 25 G, 0.4 mm X 40 mm (orange) would be used; 1 cc is administered in depth about 3.5 cm and as the syringe is being retracted backwards, but not completely retracted, to a depth of 1 cm, a further injection of 0.5 cc was applied. Aspiration is necessary before the infusion, in any case.

- The third point is located in the upper cervical region, at the level of A3 and 3 cm laterally of the vertical line (spinous processes line), with a depth of application of less than 1.5 cm at the central point of entry and about 1 cm in the satellite filtrations without needle withdrawal; therefore, a 5 cc syringe with a 25 G, 0.5 mm x 1 inch needle was used, with the same doses being administered.

Prohylaxes – Contraindications

The maximum allowable dose of lidocaine is 2.9 mg/kg (without vasoconstrictor addition) and should not be exceeded (7), but it can be reduced in elderly and chronic patients. A good history of possible allergic reactions to local anesthetics should be obtained, while in patients under anticoagulation therapy, the dose of anticoagulant is temporarily discontinued and adjusted after a proper consultation with their physician. In intramuscular infiltrations, vasospasm is not used, so no side effects are discussed. It is useful to test for coagulation prior to treatment if the conditions allow it.

Patients stay for at least 20 minutes in the clinic after the last local infusion for follow-up (8). The clinic is equipped with the necessary means for patient revival, including first aid equipment. Excellent knowledge of anatomy is undoubtedly indispensable, and aspiration is always performed, even at new injection locations without retraction and of course in the place of first entry.

RESULTS

The use of painkillers per os prior to treatment was observed for the eight patients in the study group (Table 4). After the treatment session, the results after 20 minutes, two weeks, one month and three months are also shown in Table 4.

In two separate cases of cervicogenic headache with neck pain, there was a feeling of instant rotational vertigo referring to the known vertigo of position, bedding and head turning during sleep, along with walking instability during the day. In both cases, the imaging test revealed cervical spine alignment especially in the lateral reception. In both cases, three additional sessions were performed, since after the first one there was a slight improvement in the frequency and intensity of brief vertigo and a large regression of the walking instability sensation, with a much improved sense of stability in the upright position. The final outcome of the tinnitus, after four sessions, was that they decreased to about one third of the intensity in one case and showed moderate improvement in the second case.

In one case of cervicogenic headache, deep orbital pain was reported on the right side, which was not documented by an ophthalmological history, nor by an eye injury. Here, the third upper cervical snap point was about one centimeter lateral to the original design, because the active firing point was located there.

DISCUSSION

Cervicogenic headache is a type of chronic headache which starts from the neck and extends to one or more points either in the facial area or in the area of the neurocranium or both.

The cervical spine consists of seven vertebrae and eight pairs of peripheral nerves. The first three pairs of neurons have centrifugal aesthetic fibers to the spinal nucleus of the trigeminal nerve. The cationic aesthetic fibers from the semilunar ganglion of the trigeminal nerve are also connected to the same nucleus.

These sensory fibers carry information about pain, pressure and temperature. Regardless of this, the somatosensory and motor fibers of the 11th cerebral cranial nerve (XI) pass through the area and interact with the cervical and trigeminal fibers. From the spinal nucleus of the trigeminal nerve, another bundle (neuron) begins, which transfers information to the ventral posterior nucleus of the thalamus. Cervicogenic pain starts due to irritation in the region of A1-A2-A3 cervical neurons (9, 10). It is believed that this interaction with the trigeminal nucleus in the spine is responsible for the pain sensation in the occipital region and around the eyes (11).

Any damage to the area of the neck can cause a cervicogenic headache. It is believed that in cases of intervertebral disc herniation, an asymptomatic inflammation irritates the area and causes the cervicogenic headache (12). Neck injury in an upper cervical spine syndrome originating from the spinal articular surfaces and that of the lower type of cervical spine syndrome derived primarily from the nerve root (13) may trigger cervicogenic headache, even facial pain, despite the fact that it is not known how the neck is linked to the maxillofacial region (14). In cases of chronic musculoskeletal disorders, in repeated minor injuries, in poor posture and in situations of stress, favorable conditions for the formation of Trigger Points (15) are developed, especially in muscle groups that contribute to the maintenance of the standing posture. As a result, tension headache, back pain, better sensation of plantar attachment to the ground, tinnitus (usually contralateral), perinatal pain or numbness, and pain in the areas of the muscle masseter may occur.

In the cervicogenic headache, the differential diagnosis from migraine, Arnold-Chiari syndrome, temporal arteritis, intracranial ailments, and especially simple tension headache (16) is required.

Treatment of cervicogenic headache is multifactorial. The first time of treatment, given that CGH is a secondary disease, is the removal of the primary cause. Many methods are available, each of them working at different levels. One of these methods is the injection of lidocaine, which is increasingly used in clinical practice. The mechanism of cervical headache obstruction using this minimally invasive technique is not fully known. It appears to be related to the “closure” between the sensory fibers of the trigeminal and the aesthetic fibers of the upper cervical roots at the level of the trigeminal nucleus in the medulla oblongata. An important role in pain relief is also played by the inhibitory path with serotonin and catecholaminergic interactions where the gray matter of the aqueduct and the core of the middle seam are involved (17). Electrophysiological investigation methods of the nociceptors of the trigemino-cervical complex and the adduct fibers provide useful information on the interaction of the trigeminal system with the cervical one (18).

Another method that evolves on a daily basis is transdermal electric nerve stimulation, which is classified as a non-invasive technique. It uses the stimulation of the nerves with different intensity and frequency to provide analgesia (19). It is believed that TENS stimulates the inhibition of interneurons in the substantia gelatinosa in the posterior horn of the spinal cord, in particular large diameter fibers (A-beta) which inhibit the transmission of stimuli by small diameter fibers (20). The other theory states that nerve stimulation produces endorphins, which is known to have an analgesic effect. A non-invasive technique of muscle manipulations has a similar basis. With muscle manipulations, inhibitory neurons are induced, as well as inhibitory areas in the grey matter of the mesenchephal, thus reducing the sensation of pain.

Cervical strains in which pain firing points are identified can be treated by injection, in one or more consecutive sessions, in the more palpable sensitive area that gives the Trigger Point. It usually occurs in splenius and semispinalis muscles, in the upper or lower cervical region, and in the sternocleidomastoid. Infiltration in the anatomical space between A1 and A2 should be avoided due to the vertebral artery superficial pathway, while infusion of the splenius muscle may be useful in a slightly vertical direction (21). When an active Trigger Point is detected, the third injection point will be on the trigger point and not in the predicted third plane at level A3 of Figure 2. It would also be possible to inject an adjacent trigger point in the trapezius muscle as an alternative first infusion site instead of the initially defined point on Figure 2, an exclusion that we performed in three cases. In this case, the potency of the effect increases after the disturbed muscle metabolism is restored in the area of the firing point and the trigger point is deactivated. An inactive (latent) firing point does not cause any referred pain (22).

The use of lidocaine is being recently applied to the treatment of cervicogenic headache. However, there is global evidence of its results. In a single blind randomized controlled clinical trial, Lugo et al. (23) show that lidocaine infusion has the same effect as physiotherapy after one month when applied separately, and when applied together leads to a significant improvement of symptoms. In another study with 47 patients, Naja et al. (24) show that lidocaine infusion leads to an improvement in symptoms; however, the longer the problem, the more injections will be needed for the same effect. In a double blind randomized controlled clinical trial also authored by Naja et al. (25), anesthesia infusion appears to improve not only the symptoms but also the everyday use of analgesics.

On the other hand, TENS alone leads to symptom improvement by 60% (26, 27). In the study of Haspeslagh et al. (28), 10/14 patients treated with anesthetic and TENS were considered to have a successful outcome. In the same study, it was found that radiofrequency treatment was not different from the combined therapy of lidocaine with TENS. On the other hand, Li et al. (29) compares TENS with the muscular manipulations and it appears that TENS improves the degree of headache rather than pain intensity and frequency, while muscular manipulations seem to improve all three parameters. The same result has been published by many authors and appears to have good long-term results (30, 31).

In eight cases, the associated symptoms improved shortly after the three-step session and patients reported immediate remission of the pain (VAS scale), feeling of stability during the 15 minute trial walk in the examination room, tinnitus reduction, feeling of lightness in the eyes, forehead and back, as well as a better rotation mobility of the head. We noted the length of time between the last infiltration and the onset of symptom decline, ranging from 5 to 10 minutes. Lidocaine hydrochloride has an onset of action in a few seconds and is shorter than other local anesthetics (32). In two cases, there was a feeling of an instant rotary vertigo where the exams revealed cervical alignment. The latter is caused by muscle contraction due to injury or as a normal anatomical variation. However, a cervical spine alignment may temporarily cover a ligamental injury due to posttraumatic muscle spasm (33).

In one case of cervicogenic headache, deep orbital pain was reported and the third upper cervical point of injection was done about one centimeter lateral to the original design because the active firing point was detected there. Several papers show the great importance of having a Trigger Point, usually in the occipital region, which when injected, relieves patient’s pain. This is trigemino-cervical referred pain, which even if presented as a single symptom, without headache, is a disease entity independent of the known ophthalmic spectrum of symptoms. It disappears as soon as the interaction of the trigeminal with the cervical limb is interrupted (34).

In neuralgia of the occipital nerves when there is pressure of the A2 and/or A3 roots, the pain is usually located in the one half of the craniocervical junction region and neck (8), and not in both sides, as it occurs in case of cervical spine syndrome (3). For these reasons, we did not have to use a technique of blocking the occipital nerves in the incidents of this study. In cases of neck injury, when we find that there is an active Trigger Point, we always infuse the point. We inject the point around the middle of the trapezoid muscle (Figure 2) even when no trigger point is found because we target the zone with the richer growth of “s” like dendrites. This can eliminate neck pain for a prolonged period, even up to six months, as reported in the literature (36).

CONCLUSIONS

Cervicogenic headache may occur with headache accompanied by neck pain but also by walking instability, ear pain, ocular pain and unilateral tinnitus. It is caused by lesions of the cervical spine, injuries and myopathogenic pain with the presence of Trigger Points. The invasive three-step regimen, including local injections of lidocaine presented with any variations per case, is a minimally invasive treatment, resulting in a reduction of the incidence and intensity of the episodes. This may result in multiple benefits for the patient, including the reduction in the use of painkillers.

However, this is a pilot study and, for a peer-to-peer outcome; hence, a multicenter study over a longer period of time would be useful.

Conflict of interests: none declared

Financial support: none declared.

TABLE 1.

Symptomatology

TABLE 2.

Visual analogue scale (V.A.S.) before and after the application of three-scale therapy

TABLE 3.

Etiology

FIGURE 1.

Neurostimulation using a TENS device

FIGURE 2.

Marked access points for lidocaine injections

TABLE 4.

Use of analgesics before and after three-scale therapy