Question
Hi,  This is not an injury, or at least I do not recall any injury that might have
caused it. I have been having some weird headaches for the last month. I flew
in to the U.S. from overseas and had jetlag and have had some stress from
work and was really tired and at first just thought I had really over exerted
myself and needed some rest.    

It first occurred on July 1.  I was involved in some physical exertion and I
could feel
it start in my lower neck and come up the nerves on the right and left side of
my spine up into 2 little depressions that are at the top of the back of your
neck right where the neck and the cranium come together.  It felt like a rush
of blood coming up there and really intense pain began and it almost
knocked me out.  I had to lay down
for a couple of hours and Tylenol did nothing for it.  

This happened a couple of times over the next week.  I went to the doctor
and they took a cat scan and did the normal physical checkup.  I am 44, 5'8"
and 300lbs. They said my vision was good at 20/13, but I have noticed over
the last 6 months though that I am having to hold a book further away to
read it though.  From the CAT scan, they said
there were no tumors and no possible aneurysms.  They basically said they
could not identify anything wrong.  They gave me some pain medicine and
referred me to a Neurologist.  I went to the Neurologist and she did a normal
check up, looked inside my eyes, had me touching my fingers to my nose and
then touching her hand in rapid motion, checked my reflexes etc. and she
told me also that there was nothing wrong and the problem would probably
go away
in a few weeks.  It has been 2 or 3 weeks since then.  The severity of the
headaches has reduced a lot, but the frequency has increased.  In the
beginning it was once every 2 or 3 days under physical exertion.  Now it is
much less severe pain but once or twice a day.  The other difference now also
is that the pain reliever I received and Tylenol both now work where as in the
beginning they did not at all.  

As an example, yesterday it did not bother me most of the day, but when we
went out to eat
dinner, I was chewing and I started to notice it beginning to hurt and throb a
little.  I stood up to go get a drink refill and I could feel the back of my neck
start to pulsate. I could feel the blood flowing and I could distinctly feel my
pulse in the back of my neck.  And then the pain came.  Again, the pain is not
debilitating
like previously, but there was no physical exertion.  It hurts enough that I
hold
the back of my head when it happens and my wife notices.  I came home,
took some tylenol, waited the normal 15 minutes and it was mostly gone.

Interestingly enough, physical exertion does not bring it on now.  Chewing
something that is tough or long concentration working on the computer, etc.
brings it on sometimes.

I am trying to find out what kind of doctor I should be going to see or any
ideas on specifically what could be causing this or what to do.

Thanks for any advice in advance.

Answer
Dear John,

At first I thought this was a vascular headache, but it doesn't follow the vascular related symptoms, and the more I read your descriptions, it seems musculoskeletal in nature.  Anytime exertion brings on a headache, there are actually a few options: vascular/inflammatory/hypertensive, tumor, musculoskeletal, and cluster headache can mimic these as well.   Since the CT has ruled out any pathology, we are left with musculoskeletal and cluster...you are not experiencing migraine symptoms (migraines are vascular anyway).

Cluster headaches are usually precipitated by alcohol consumption, smoking, occur mostly in men and in the twenties or later, but the pain patterns are unilateral and on the side of the head and face, not the back of the head, so musculoskelatal is the likely culprit.

When the nerves or muscles in the back of the neck are under chronic tension from work, stress, poor ergonomics or altered biomechanics of the neck the result is often headache pain that is localized to the back of the neck, skull and the top of the head, which may or may not be resistant to over the counter medication.  The fact that you headaches are worse after working at the computer, and after increased jaw motion reinforces the musculoskeletal origin of the problem.  I would opine that you likely are deconditioned with poor posture (rounded shoulders, slightly humping back, and forward head posture).  This is a common representation of someone with musculoskeletal headaches originating from the upper back and neck. Basically you are creating so much tension in the muscular system that the spine has reduced function and position, and the neurological system is in a state of chronic firing and inflammation. Sound familiar?

I would suggest a few options, intense massage therapy to the upper back, neck and shoulders to reduce the immediate tension, and an evaluation of your posture, ergonomics, and spine to look for biomechanical dysfunction and underlying degenerative changes.  A chiropractic physician is the perfect health care professional to perform this examination, as we have been highly trained in the relevant form, function and structure of the relevant anatomy along with diagnosis and treatment. I would also suggest that you additionally do a bit of research on a technique called chiropractic biophysics before you choose a local chiropractor so that you can better understand the structure of the spine and how it relates to your current issues- www.idealspine.com.

It is likely that your treatment approach will need to be multifaceted to include chiropractic adjustments, stretching, exercises, traction and massage...this has likely been an ongoing problem for years that is just now starting to cause pain. Moreover, I would suggest that you take a serious look at your diet and nutrition as they are contributory to the problem...obesity and inflammtion go hand in hand in pain generation all over the body...weight reduction and proper nutritional status will likely reduce overall pain although they might not specifically address the headaches.

John, for a better understanding of what I have described, and some simple techniques that you can start to employ right now, I am going to attach below an article I have written on this problem.  Please read over it, find a good chiropractor, and feel free to write back if you need to.

Respectfully,
Dr. J. Shawn Leatherman
www.suncoasthealthcare.net

Training for Stability of the Neck and Back匩ot What You Think!
  
A brief look around any boardroom, construction site, grocery store etc?will provide any observer an insight into poor posture and de-conditioning syndrome. A deconditioned individual has only one option for lasting pain relief which is increasing their functional capacity. The average teenager and adult have pronounced spinal displacements due to chronic poor ergonomics of basic living, poor posture, and constrained working environments.  Back or neck pain is the number one reason for a visit to the chiropractic physician and medical doctor!  Shouldn抰 you work to prevent injury and strain?  The obvious answer is yes!

The most common reasons for back and neck pains are poor lifting techniques, abnormal posture, and repetitive micro-strain coupled with the lack of stability within the muscular system, and trauma.  It is sometimes difficult to avoid trauma, but if you eliminate poor technique, improve the ergonomics of your work station, and train your spine for stability, you significantly reduce your risk of injury.  Remember that we live in a gravity controlled environment and all muscular actions are in direct opposition to gravity.  We stabilize bridges and buildings so they won抰 buckle or break, you need to do the same for your spine.  

That being said, conventional strength training with free weights and isolation machines will give general overall gains in muscular strength if utilized properly, but won抰 necessarily target stability of the core or the spine.  Muscles to target are the multifidus, rotatores, intertransversales, transverse abdominis, and the pelvic floor.  Moreover, it is important to train for balance and symmetry thereby reducing abnormal weight bearing on all joints of the body.  

Lifting technique is important for optimal health and the reduction of injury.  To execute a lift properly, the back should be fairly straight while maintaining the normal lordosis (forward arch of the low back).  This position will activate the musculature properly for stability while not recruiting the ligaments for support.  Squatting is optimal, due to its neutral spinal position and the ability to use the muscles of the legs to accomplish the lift.   Stooping should be avoided, especially with repetitive movements.  Stooping creates an unstable configuration for the disk with increased tensile pressure on the posterior portion of the disk due to increased compression on the anterior portion of the disk.  This can easily result in a rupture of the disk.  In addition, objects should not be lifted if they are placed awkwardly which may require twisting and or bending, weights should be held close to the body, and jerky movements are only appropriate for highly trained individuals such as advanced athletes under the supervision of a trainer.  The last key is to create contraction of the abdominal musculature before the lift. This provides greater stabilization the spine, and your entire core.  You can easily accomplish this by sucking the belly button in toward the spine.  This activates the transverse abdominus muscle which is key for all movements.

One of the most deleterious activities people engage in is sitting. Sitting increases disk pressure more than standing and encourages abnormal flexion (forward bending) of the neck and upper back in addition to slumping in the chair.  These postures chronically load the disks, ligaments and musculature of the spine creating micro-injury and dysfunctional movement patterns.  

Many of us spend the majority of our days at a desk, computer or workstation.  We need to consider and modify our workspace carefully.  Adding a support for the lumbar spine reduces disk pressures.  A seatback angle of 5-15 degrees from vertical will reduce low back muscle activity and disk pressure.  Proper desk height is approximately 30 centimeters from the seat of the chair.  Arm rests are important in limiting strain on the upper muscular complex of the back and neck to include the trapezius, rhomboids, and levator scapulae.  The shoulders should be able to relax with the elbows bent at 90 degrees while the hands rest on the desk surface.  

Forward movement of the head on the neck is extremely problematic. For every inch forward the head moves in relation to the neck and shoulders, the compressive forces on the lower neck increase by the entire weight of the head, 10-16 lbs. Think about the difference in holding a bowling ball close to the body, or away from the body. This illustrates the differences in muscular work needed to support the weight and the ligamentous strain.  Computer monitors should be elevated so that the center of the screen is at eye level while looking straight ahead.  This will reduce eye strain; further reduce muscular tension of the neck while limiting the forward flexion of the head, therefore reducing the abnormal loading of the ligamentous complex.  This will also help reduce those 搘ork headaches?  Placing the monitor higher to induce a slight extension of the head is permissible.

Now that you have proper technique, and your workstation is optimal, structural and functional training of the musculature on the back of your body and your core is the key.  You must have a balanced and relaxed spinal cord for optimal function.  That being said, specific training is the way to achieve spinal balance and stability, and you don抰 have to go to the gym to achieve it.  If you can appreciate that we spend most of our days in a flexed position, the way to relieve that cumulative stress is to train the small stability muscles in an extended position.  

Most people are flexed forward at the hips/pelvis, have rounded shoulders, and a forward head and neck, this is called Global Flexion.  Extending the head backwards, opening up the chest by turning the palms of your hands outward and stretching your arms backwards relieves this global flexion.  The last step is to stand up and bend backwards at the waist approximately 20 degrees. You have just accomplished the task of Global Extension.  If you flex or tighten up all you muscles while in this position it further accentuates the value of the exercise and also promotes increased blood flow and oxygen delivery to the body.  This is a relief position that everyone should use frequently throughout the day to abate cumulative postural stresses.

Moving on, posture is the next consideration.  Your posture should not be a conscious task, but with the level of deconditioning in the population, conscious postural improvements are necessary.  This is mostly common sense, and your mother has telling you to do this since you were a child.  Exercise your postural muscles while walking.  Stand up straight, hold your head up high and walk with confidence looking ahead of yourself, not at the ground.  Pull your shoulders back, breathe deeply, and take confident long strides.  This alone will bring more oxygen to your body by fully opening up the lungs, increasing blood flow, and reducing abnormal stress on spinal structures.  You can also practice this position on a physio-ball or thera-ball to improve your seated posture and balance.  Complex postural issues and stability issues need to be addressed by a professional.

Remember that weight training, aerobic activity, and general fitness types of activities are only good for you if done with proper form, balance, control and stability.  If you don抰 have good posture and spinal symmetry, a traditional workout program will only make those problems worse.  It is essential to incorporate stability into your spine and your life before starting any exercise program.  You should see a medical or chiropractic physician before starting a fitness regime to make sure you are in good health and able to handle the rigors of increased physical activity.  If you have any cardiovascular issues, a stress test should be performed.  Many subsequent doctor visits are caused by improper fitness activities; it is better to see you doctor before rather than after.

All chiropractic physicians will be able to teach you about postural imbalances and how to improve your own posture, but many chiropractors have additional post-doctoral training in advanced postural biomechanics and structural correction to help you attain improved spinal dynamics.  Ask your chiropractic physician to tell you about their training, and provide written documentation about their qualifications.  To learn more about postural correction check out www.idealspine.com. In addition, a Certified Pilates instructor, www.nypilates.info, www.pilates-trainning.com or Certified Personal Trainer www.nsca-lift.org, www.ncsf.org  can have great benefit.  Remember to check their qualifications as well.