Takeaway: To protect the head when falling forward, one massively contracts the posterior muscles of the neck, which could lead to strain or injury in other areas.

“Face-first! When I tripped, my body shot forward and I was heading face-first into the pavement,” Ms. R. explained. “I don’t know how I managed not to smash my face! I remember very little, except that I ended up in the hospital for a couple days. Everything else is healing, but these headaches are just debilitating. Certain positions trigger them.”

“Like what?” I asked.

“The strangest thing is that I can’t lie on my back,” she replied. “When I was in the hospital, I had to position the hospital bed up as far forward as possible so there wasn’t any pressure on the back of my head. If I lie back, the pressure of the pillow gives me a headache. It’s frustrating since I’m a back sleeper, but now that’s out of the question. I also think my neck is involved, because I can’t turn my head as far as I used to.”

“Where do you typically feel the headache symptoms?” I asked. 

“All throughout the back of my head and sometimes at the very top of my head as well,” she answered. 

As I listened to her symptoms, a clearer explanation formed. When people are hypersensitive to even the pressure of a pillow, it’s likely an issue involving the greater occipital nerve. There was likely a preexisting sensitivity, but the fall was the last straw. To protect the head when falling forward, one massively contracts the posterior muscles of the neck. Since the greater occipital nerve courses through muscles like the semispinalis capitis, this was a likely explanation. 

Having her lie supine, I gently examined the occipital area. I could tell by her immediate reaction that this area was very sensitive. More work directly in that area seemed far too risky. 

Since the occipital area was overly sensitive, I decided to address the lower attachments of the semispinalis capitis. She was surprised at the sensitivity, but also recognized that this area was a source of tension. As the semispinalis quieted, I moved to the upper trapezius—the greater occipital nerve courses through that muscle in about half the population. As I carefully examined the anterior fibers, I could see Ms. R.’s facial expression change. 

“I can feel that into my face!” she said. “It goes right to the area that I have been feeling pain. I was really hoping the root canal would help, but it didn’t.”

“You had a root canal?” I asked.

“Yes, about two weeks ago. This one didn’t help either.”

“Either?” I asked again, incredulously. 

“That was my second, but the pain hasn’t really changed. The doctor thinks there are still parts of the nerve not yet addressed, so I’m scheduled for one more. It’s been an ordeal. Is it possible that I feel it in my jaw when you press on that muscle?”

“You know what you feel,” I replied. “Since this muscle is involved, it has a few friends we should also examine.” 

Leaving the upper trapezius, I next addressed her sternocleidomastoid muscle. This muscle can affect the spinal accessory nerve, which innervates the upper trapezius. If I could downregulate the upper trapezius via the sternocleidomastoid, I would have an inroad into the nervous system. Returning to the upper trapezius, it was less sensitive. 

Knowing the relationship of the spinal accessory nerve and its ability to communicate with the trigeminal nerve, I decided to explore the temporalis muscle. I landed on a nodular area that elicited
a reaction. 

“Wow, that’s tender!” she exclaimed. “And you know what? That place perfectly reproduces the pain I feel in my tooth, where I had the root canal. That’s so weird!” 

After the temporalis point quieted down, I returned to where we started, in the suboccipital area. Instead of treating the rectus capitis muscles like before, I explored the obliquus capitis inferior, which can be key in restricting the cervical range of motion and is a common site for greater occipital nerve entrapment. My goal was to release restrictions around the nerve, without pressing directly on the nerve. Since I could do this without eliciting symptoms, I was satisfied the goal was accomplished. 

To finish, I returned to each of the areas previously treated, discovering that each of them had reduced in intensity. Before she left, I explained the muscular anatomy and the neural relationships that were the basis of my treatment.   

After two more visits, her headaches went away for the first time in two months, which was really good news. The better news? Since her symptoms have abated, the additional root canal was canceled!