Cluster headaches, neck instability and the trigeminal and vagus nerves

Ross Hauser, MD, Danielle R. Steilen-Matias, PA-C.

In this article, we will not examine which combination of medications, therapy, or neuromodulation techniques will work for you. If you are reading this article, it is unlikely you have had a long-term benefit from these treatments. What we will examine is something that may have been discussed with you briefly, that your headaches are coming from problems in your neck and possible compression of the vagus and trigeminal nerves.

Why so much confusion about getting treatment that can help my headaches?

A study from Harvard Medical School published in March 2019 in The Medical Clinics of North America (1) suggested that most headache patients seeking medical treatments for their headache symptoms will be diagnosed with a primary headache disorder, mostly migraine or tension-type headache. However, these patients may not be helped because there are other less commonly known primary headaches and secondary headaches that need to be considered in every patient presenting with a new onset or change in headache symptoms, and headache treatments are varied, one medication will not work for all headaches and giving the wrong medication will make the situation worse.

And this may be your history. A visit from specialist to specialist and the elimination of what you do not have to try to understand what you do have. And here you are, still looking for treatment for what you most certainly have: terrible headache-related pain.

Understanding “lesser-known” headache types

In the research above, a suggestion is made to start looking for less obvious or “lesser-known,” headaches. How can this help?

What are these “lesser-known” headaches? Have they been explained to you?

  • Lesser known headache group: Trigeminal autonomic cephalalgias, primarily cluster headache facial pain, primarily trigeminal neuralgia; and
  • Lesser known headache group: Miscellaneous headache syndromes, such as hemicrania continua and new daily persistent headache.

These headache types are explained below.

The research also notes that facial pain and neuralgias constitute a large and distinct group of head pains with separate evaluation and treatment approaches. This can cause confusion in treatment.

  • What the researchers point out is that the origins of your cluster headaches can be difficult to pinpoint. When causes are difficult to pinpoint, poor, inadequate, or sometimes hurtful treatments can follow.

Neovascular headache syndromes are collectively termed trigeminal autonomic cephalalgia

The start and symptoms of several types of headaches including cluster, paroxysmal hemicranias, and some types of migraines are felt in whole or in part to be due to trigeminal-induced vasodilation of cerebral blood vessels. These neovascular headache syndromes are collectively termed trigeminal autonomic cephalalgia. They often have common features including:

  • severe unilateral (one side) retro-orbital pain and autonomic symptom issues of lacrimation (tearing of the eye) or conjunctival injection (redness of the eye).

Chronic paroxysmal hemicrania

In a June 2023 update (2) to the online publication, STATPearls at the National Library of Medicine specialists write; “Chronic paroxysmal hemicrania is a primary headache syndrome characterized by recurrent unilateral (one-sided) episodes of headache associated with cranial autonomic symptoms. Headaches are sharp and stabbing in nature and occur more than five times per day, up to forty times per day in some cases. Associated cranial autonomic features include ipsilateral lacrimation one-sided eye-redness), conjunctival injection (inflammation around the eye), nasal congestion, rhinorrhea (thin nasal discharge), facial flushing, eyelid edema, miosis (excessive constriction of the pupil of the eye), or mydriasis (dilation of the pupil), diaphoresis (excessive sweating), or aural fullness. The mean duration of the attack is 26 minutes, with a range of two minutes to nearly two hours. Attacks occur both daytime and nighttime in most cases. Chronic paroxysmal hemicrania occurs on the same side in greater than 95% of patients. Chronic paroxysmal hemicrania differs from episodic paroxysmal hemicrania in that no remission or remission lasts less than three months. Paroxysmal hemicrania responds well to indomethacin (an NSAID), with complete resolution in most patients.”

A brief understanding of cluster headaches source: Trigeminal autonomic cephalgia

In your medical journey, you may have had it explained to you that your headaches fall under a diagnosis of Trigeminal autonomic cephalgia. Cephalgia means cluster headaches. Simply, and as you are well aware, your headaches typically seem to be generated on one side of your face, centralized behind your eye. That eyelid may droop, you may have tearing or redness in that eye, and/or your nose may clog. These symptoms occur on one side of your head and are caused by pressure on and traveling the path along the trigeminal nerve.

The key points in the illustration below are simple. As you know, your cluster headache can be a stabbing pain behind an eye or in the temple region.

  • Now follow the path of the Trigeminal ganglion, the nerve bundle that branches. One branch is the ophthalmic nerve or the V1. This nerve provides impulses and innervation into the eye and upper lid/face region. The region of cluster headaches.
  • Now follow the path of the maxillary nerve (V2) – it supplies nerve sensation from mouth to eye.

The illustration below points out that the “nuclei are situated within the CNS and the ganglia are outside of the CNS. What does this actually mean to you? This is a simple explanation:

  • Your nervous system is comprised mainly of the central nervous system and the peripheral nervous system.
  • The central nervous system or the CNS is your brain and spinal cord. When you have headache pain, the nerve impulses go to the spinal cord and brain so your body can assess what to do about this pain. As you well know, the brain and spinal cord do not have good answers most of the time.
  • The peripheral nervous system or PNS are the nerves, which branch out from the spinal cord such as the Maxillary (V2) and Ophthalmic (V1). What these nerves do is collect information about pain in the face and behind the eye and send it to the spinal cord and brain so they can figure out what to do about it.
  • Once the brain and spinal cord (the CNS) decide what to do, they send messages back to the peripheral nervous system (the Maxillary (V2) and Ophthalmic (V1))
  • Why it is important to note that the ganglia is outside of the Central Nervous System – it can be subjected to nerve compression on its own. Cervical spine instability can cause compression on these nerves that cause pain, loss of sensation, or cluster headaches among a large myriad of symptoms. This nerve compression can also cause confusing and conflicting messages from the Maxillary (V2) and Ophthalmic (V1) nerves. Your brain is not getting the right messages and it is responding to “bad information.” Your headaches are not only the result of this bad information but the cause as well.
Why it is important to note that the ganglia is outside of the Central Nervous System is because it can be subjected to nerve compression on its own. Cervical spine instability can cause compression on these nerves that cause pain, loss of sensation, or cluster headaches among a large myriad of symptoms. This nerve compression can also cause confusing and conflicting messages from the Maxillary (V2) and Ophalmic (V1) nerves. Your brain is not getting the right messages and it is responding to "bad information." Your headaches are not only the result of this bad information, but the cause as well.
Why it is important to note that the ganglia is outside of the Central Nervous System is because it can be subjected to nerve compression on its own. Cervical spine instability can cause compression on these nerves that cause pain, loss of sensation, or cluster headaches among a large myriad of symptoms. This nerve compression can also cause confusing and conflicting messages from the Maxillary (V2) and Ophthalmic (V1) nerves. Your brain is not getting the right messages and it is responding to “bad information.” Your headaches are not only the result of this bad information but the cause as well.

The start of the chase for the root cause of the problem. The connection between the vagus nerve and the trigeminal nerve and trigeminal ganglion.

What perhaps isn’t appreciated enough in pain management is the fact that structural abnormalities such as upper cervical instability can cause nerve stimulation to cranial nerves and even blood vessels, causing headaches. As discussed above, the parasympathetic nervous system is generally involved with the vasodilation of blood vessels, and the sympathetic nervous system is generally involved with vasoconstriction. It is now known from clinical and animal data that the observed vasodilation in headaches is, in part, an effect of a trigeminal parasympathetic reflex, which is part of the trigeminovascular system. There is evidence that there is direct trigeminal neural innervation of the cranial circulation.

The pathophysiology of several types of headaches including cluster, paroxysmal hemicranias, and some types of migraines are felt in whole or in part to be due to trigeminal-induced vasodilation of cerebral blood vessels. These neovascular headache syndromes are collectively termed trigeminal autonomic cephalalgia. They often have common features including severe unilateral, commonly retro-orbital pain accompanied by restlessness or agitation as well as cranial (parasympathetic) autonomic symptoms, such as lacrimation (tearing of the eye) or conjunctival injection (redness of the eye). The severe unilateral headaches generally last minutes and attack frequency can range from 5 to 40 attacks per day. The belief is that this reflex trigeminal-autonomic activation causes vasodilation of blood vessels. However, it also causes stimulation of several cranial nerves, including the facial and seventh cranial nerves, which causes autonomic symptoms in the face such as conjunctival injection and lacrimation.

The vagus nerve, as illustrated below, travels through the cervical spine. It travels especially close to the C1, C2, C3 vertebrae. Cervical spine instability in these regions can cause herniation or pinching of the vagus nerve, which can lead to a disruption of normal nerve communication between the vagus nerve, the trigeminal nerve, and the trigeminal ganglion. This disruption or herniation of the nerve can cause among the many symptoms of cluster headaches.

The vagus nerve, as illustrated here, travels through the cervical spine. It travels especially close to the C1, C2, C3 vertabrae. Cervical spine instability in this regions can cause herniation or pinching of the vagus nerve, which can lead to a disruption of normal nerve communication between the vagus nerve and the trigeminal nerve and trigeminal ganlia. This disruption or herniation of the nerve can cause among the many symptoms  cluster headaches.
The vagus nerve, as illustrated here, travels through the cervical spine. It travels especially close to the C1, C2, C3 vertebrae. Cervical spine instability in these regions can cause herniation or pinching of the vagus nerve, which can lead to a disruption of normal nerve communication between the vagus nerve, the trigeminal nerve, and the trigeminal ganglia. This disruption or herniation of the nerve can cause among the many symptoms of cluster headaches.

An understanding of the interplay between the vagus nerve and the trigeminal nerve

In the medical journal Cephalalgia, (3) February 2019, researchers at Radboud University Medical Center in the Netherlands focused their attention on the vagus nerve for non-invasive stimulation in headache relief. They noted that the vagus nerve is thought to modulate the headache pain pathways in the brain.

The study showed that non-invasive stimulation of the vagus nerve in primary headache disorders is moderately effective, safe, and well-tolerated.
The study also showed a deep and intricate entanglement between fibers of the vagus nerve and the trigeminal nerve.

Among their findings, the one that we want to illustrate is what the researchers suggest in their conclusion: “The moderate effectiveness of non-invasive stimulation of the vagus nerve in treating primary headache disorders can possibly be linked to the connections between the trigeminal and vagal systems.”

What we would like to point out here is that problems of cluster headaches as they relate to cervical neck instability, do not usually sit in isolation. It is usually a combination of problems that lead to difficult-to-treat or unresponsive cluster headaches. In this case the vagus and the trigeminal nerves.

In this illustration a close up view of the C1, C2, C3 proximity to the Trigeminal cervical nucleus and the Trigeminal nerve afferents, Maxillary (V2) and Ophalmic (V1). Cluster headache origins in the cervical spine make a lot more sense when you see the nerves of the cervical spine and their close interplay.
In this illustration a close-up view of the C1, C2, and C3 proximity to the Trigeminal cervical nucleus and the Trigeminal nerve afferents, Maxillary (V2) and Ophthalmic (V1). Cluster headache origins in the cervical spine make a lot more sense when you see the nerves of the cervical spine and their close interplay.

Chasing the Trigeminal autonomic cephalalgia diagnosis

According to the National Institute of Neurological Disorders and Stroke: Trigeminal autonomic cephalalgias are primary headaches that include cluster headaches, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing or cranial autonomic features.

Let’s briefly explain all of this.

  • Paroxysmal hemicrania-type headache
    • Pain on one side of the face, around or behind the eye can also radiate into the upper back and neck.
    • A clue that this headache is being generated by a problem in the neck is that patients suggest that these headaches begin when they make a certain movement of their head.
    • Another clue is that the patient is a woman. Women suffer from paroxysmal hemicrania more frequently than men.

Going back to the National Institute of Neurological Disorders and Stroke guidelines on treatment:

    • Indomethacin (a non-steroidal anti-inflammatory medicine or NSAIDs) often provides complete relief from symptoms. Other less effective NSAIDs, calcium-channel-blocking drugs (such as verapamil), and corticosteroids may be used to treat the disorder.
    • Patients with both paroxysmal hemicrania and trigeminal neuralgia should receive treatment for each disorder.

More clues that your problem may be caused by cervical neck instability

It is likely that if you are researching cluster headaches, Indomethacin did not offer you complete relief. The recommendation that paroxysmal hemicrania and trigeminal neuralgia should be treated independently of each other is another clue that the problem may be in the neck. How? Because the medications needed for each disorder will not be effective for the other disorder. Therefore the medications are not treating a “common source of pain origin.”  This may be the pressure on the nerves caused by cervical neck instability. This is something we see frequently in concurrent headache and head pain disorders where cervical neck instability is identified.

Chasing another diagnosis: Is it Trigeminal neuralgia (nerve pain) or hemicrania continua (cluster headaches)?

Trigeminal neuralgia or nerve pain centers on what is happening to the trigeminal nerve which carries pain, feeling, and sensation from the brain to the skin of the face. In the case of trigeminal neuralgia, most medical professionals cannot find the cause of why this pain started. This is borne out by the definition of trigeminal neuralgia.

Doctors are trying to treat a condition that they do not know what the cause is.

The missing or delayed diagnosis – why it took years to figure out what is causing your headaches and why it may still be the wrong diagnosis

A June 2019 study in the Journal of Headache Pain (4) led by King’s College London assessed headache disorders in patients coming into very specialized orofacial pain clinics after dental causes were ruled out. Of the one hundred and forty-two patients reviewed; there were 100 women (70%) and 42 men (30%).

  • The most common diagnoses were
    • possible trigeminal autonomic cephalalgia (44%),
    • possible migraine ( 27%) and
    • possible painful post-traumatic trigeminal neuropathy (12%).
    • The most common trigeminal autonomic cephalalgia diagnosis was hemicrania continua (9%), which is higher than the reported prevalence in neurology and headache clinics.

The researchers also noted these findings on diagnosis prior to coming to the clinic

  • Of the 142 patients, a previously suspected diagnosis was only reported in 17 patients, including six with trigeminal neuralgia, eight with, one with SUNCT (Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing), and two with painful trigeminal neuropathy
  • However, only 7 had a correct previous diagnosis and, interestingly, trigeminal neuralgia was the most commonly misdiagnosed (5/6 patients).
  • As with the previous comorbidity, temporomandibular dysfunction was present in 10 (7%) patients. (Note: Please see our Caring Medical research article on the connection between TMJ/TMD and cervical neck pain to include headache.)

Delay to diagnosis

  • The time to diagnosis for the whole study group was 5.6 years
  • In patients with confirmed trigeminal autonomic cephalalgia, the delay to diagnosis was 7 years.
  • The time to diagnosis in patients with hemicrania continua, the most common diagnosis among trigeminal autonomic cephalalgias, was 8.7 years.

More symptoms that may reveal a true diagnosis. 

A January 2022 paper in the Journal of Headache Pain (5) suggests “Voice change and throat swelling should be recognized as possible parasympathetically-mediated Cranial autonomic symptoms.”We will discuss this further below.

Vagus Nerve and trigeminal nerve stimulation with Non-invasive neuromodulation when medical treatment is contraindicated

In this section we will look at various treatment options we will look at:

  • Research on what may help you. Why didn’t medications help you? How did medications make your situation worse?

An August 2023 paper in the Cephalalgia: An International Journal of Headache (6) writes: “Acute treatments for cluster headache are primarily delivered via rapid, non-oral routes (such as inhalation, nasal, or subcutaneous) while preventives include a variety of unrelated treatments such as corticosteroids, verapamil, and galcanezumab.

Neuromodulation is becoming an increasingly popular option, both non-invasively such as vagus nerve stimulation when medical treatment is contraindicated or side effects are intolerable, and invasively such as occipital nerve stimulation when medical treatment is ineffective”

Below we will discuss vagus nerve stimulation especially when medical treatment is contraindicated.

Because of the limited effect of pharmacological medications on cluster headaches, researchers are exploring neuromodulation or direct electrical stimulation on the vagus and trigeminal nerves

Neuromodulation may have been offered to you for your headache pain. This is the use of electric current to alter or modulate pain impulses. Non-invasive neuromodulation is where the electric stimulus remains outside of the body and is not implanted in the body.

A June 2023 study in the journal Scientific Reports (7) “suggested that migraine patients without aura have altered brain connectivity patterns in several hub regions involving multisensory integration, pain perception, and cognitive function. More importantly, Transcutaneous auricular vagus nerve stimulation modulated the default mode network and the vestibular cortical network related to the dysfunctions in migraineurs.” The research further suggests “Transcutaneous auricular vagus nerve stimulation shows excellent effects on relieving clinical symptoms in migraine patients.”

A March 2019 study led by German researchers and published in the Journal of Neurology, Neurosurgery, and Psychiatry (8) wrote:

  • Non-invasive neuromodulation therapies for migraine and cluster headaches are a practical and safe alternative to pharmacologics but research is very limited and simply not that good.
  • Studies of all neuromodulation devices should strive to achieve the same high level of scientific rigor to allow for proper comparison across devices.

In other words, research is limited, but the treatment may help.

In December 2018 The FDA approved a twice-daily self-administered treatment that provides patients with 3 consecutive two-minute electrical stimulations through the skin of the neck that activates the vagus nerve to provide relief. In The Journal of Headache and Pain (9), in December 2017 migraine and headache specialists in Germany found that patients receiving stimulation to the Vagus nerve and standard-of-care medications reduced cluster headache attacks significantly more than with standard care alone in a four-week trial.

In June 2020, in the journal, Current Opinion in Neurology (10) researchers at King’s College London wrote: “Neuromodulation strategies aimed at anatomical structures involved in the pathophysiology of cluster headaches, such as the sphenopalatine ganglion (associated with the trigeminal nerve) and the vagus nerve, have proved effective in reducing the pain intensity and the number of attacks, and also to be safe and well-tolerated.”

While we do not use neuromodulation strategies, we do agree that addressing the pathophysiology of cluster headaches, such as the sphenopalatine ganglion (associated with the trigeminal nerve) and the vagus nerve is a path that needs to be explored.

A December 2023 paper in the journal Current Opinion in Neurology (11) looked at vagal nerve stimulation for headaches. The researchers write: “Vagal nerve stimulation (VNS) is emerging as a probable therapeutic option for headache. Several questions remain on the mechanism of action, device parameters, efficacy, duration of treatment, and long-term safety.”

Of course, vagal nerve stimulation is not without its controversies. In this study, the doctors reviewed recent findings for vagal nerve stimulation in alleviating headache symptoms in patients and offered their findings. Among the problems, the doctors wrote about that while potential biomarkers of headache (an example of a biomarker is the calcitonin gene-related peptide (CGRP), a 2014 paper wrote (12): “CGRP is a highly potent vasodilator and, partly as a consequence, possesses protective mechanisms that are important for physiological and pathological conditions involving the cardiovascular system and wound healing. CGRP is primarily released from sensory nerves and thus is implicated in pain pathways” These have been linked to acute migraine attacks).

The 2023 examined the biomarker effect and possible treatment effects. In support they noted was a “study on post-COVID-19 headache and its management with noninvasive cervical VNS adds to the body of original studies.” However, they also note: “The collection of these studies adds some data to mechanisms of VNS without adding much insight to differential effects of sub-types of VNS and possible device settings that could prove to be beneficial for headache management.” In other words, there are no standard protocols.

A September 2023 systematic review published in the Journal of Clinical Medicine (13) found moderate-to-high-quality evidence supporting that non-invasive neuromodulation of the vagus nerve and cervical neuromodulation of the vagus nerve may have some positive effects at the end of the treatment being effective to relieve the frequency and intensity of cluster headaches. The poor quantity of studies available and the lack of homogeneity in the study protocols did not allow the pooling of data for a meta-analysis. (In other words, comparisons and outcomes could not be accurately obtained.)

In June 2023, researchers writing in the Frontiers in Neuroscience (14) found “Some positive effects regarding the effect of non-invasive neuromodulation, auricular transcutaneous vagus nerve stimulation (at-VNS), and electro-ear acupuncture of the vagus nerve on migraine is reported in the current literature, but there are not enough data to obtain strong conclusions.”

Suprazygomatic pterygopalatine ganglion blocks and non-invasive vagus nerve stimulation

A November 2023 review of patient cases published in the Regional anesthesia and pain medicine (15) writes of nine patients with 11 longstanding treatment-refractory primary headache disorders and epidural blood patch (typically given to stop  cerebrospinal fluid leaks–resistant post-dural puncture headache (PDPH) received ultrasound-guided percutaneous suprazygomatic pterygopalatine ganglion blocks ((PPGB) from a 2022 study  (16) “Pterygopalatine fossa blocks have been demonstrated to be of value for multiple conditions, including migraines, post–dural puncture headaches, headaches associated with intracranial bleeding, and perioperative analgesia for operations in the mid-face, nose, paranasal sinuses, palate, and proximal pharynx, as well as multiple idiopathic and complex facial pain syndromes.”)). In this review of patients, seven also received non-invasive vagus nerve stimulation (nVNS). the rproting doctors wrote: “(The patients) experienced dramatic, immediate, satisfactory, and apparently lasting symptom resolution (at the time of the writing of this report).”

Surgical techniques include the implantation of deep brain or peripheral nerve electrodes

In March 2019, neurosurgeons in Italy offered a summary of surgical techniques in the journal Neurological Sciences (17) and what they may be offered to patients for:

  • “Craniofacial pain syndromes are comprised of multiple pathological entities resulting in pain referred to the scalp, face, or deeper cranial structures. In a small subset of patients affected by those syndromes, pharmacological and physical therapies fail to alleviate pain. In some of those refractory patients, surgical procedures aimed at relieving pain are indicated and have been adopted with variable results and safety profiles.”
  • Craniofacial pain syndromes that most commonly fail to respond to pharmacological therapies and may respond to surgical procedures include trigeminal, glossopharyngeal, and occipital neuralgias as well as some primary headache syndromes such as cluster headache, and the trigeminal autonomic cephalalgia type headaches short unilateral neuralgiform headache with conjunctival injection and tearing/short unilateral neuralgiform headache with autonomic symptoms, and migraine.
  • Surgical techniques include the implantation of deep brain or peripheral nerve electrodes with subsequent chronic stimulation, microvascular decompression of neurovascular conflicts, and percutaneous lesioning of neural structures.

Implantation of deep brain or peripheral nerve electrodes with subsequent chronic stimulation

Above we spoke about non-invasive neuromodulation. Here we will examine INVASIVE neuromodulation with the help of University of Minnesota researchers who published these observations in the journal Pain Research and Treatment. (18)

Here are the learning points:

  • There is little evidence regarding the long-term effectiveness of Peripheral nerve stimulation therapy in managing chronic pain. Case reports and retrospective reviews do support that Peripheral nerve stimulation may be helpful in chronic pain from peripheral nerve injuries.
  • However, in the context of the current opioid epidemic, when opioids kill nearly 42,000 people each year, it is important for healthcare providers to recognize potential non-drug therapies for treating chronic pain. Although randomized controlled studies are currently lacking, there is hope that neuromodulation devices may bring a new horizon for the treatment of chronic pain related to trauma, nerve injuries, and stroke.

Some people are helped by the surgical implant of stimulation devices. Some people are not.

A June 2022 paper from researchers at the Department of Neurosurgery, Humanitas Research Hospital in Italy, published in the Neurosurgical review (19) suggested that when cluster headache does not respond to medical treatment, it can be treated with Gamma Knife radiosurgery (GKRS). However, the outcomes of studies investigating Gamma Knife radiosurgery (GKRS) for cluster headaches in the literature are inconsistent, and the ideal target and treatment parameters remain unclear.

The researchers reviewed the data of five previously published studies describing outcomes of Gamma Knife radiosurgery for the treatment of cluster headaches for a total of 52 patients (48 included in the outcome analysis).

  • The individual studies demonstrated initial meaningful pain reduction in 60-100% of patients, with an aggregate initial meaningful pain reduction in 37 patients (77%).
  • This symptom relief persisted in 20 patients (42%) at the last follow-up.
  • Trigeminal sensory disturbances (typically transient symptoms of pain, numbness) were observed in 28 patients (58%), and deafferentation pain (hypersensitivity to pain from damaged sensory input (such as pain that is felt in a limb that is not there, that has been amputated) such as in 3 patients (6%).
  • In these findings, short-term pain reduction rates are high, whereas the long-term results are controversial. Gamma Knife radiosurgery (GKRS) targeted on the trigeminal nerve or sphenopalatine ganglion is associated to a frequent risk of trigeminal disturbances and possibly deafferentation pain.

Nerve compression surgery and non-surgical nerve compression options


Prolotherapy for headache

In 1993, Caring Medical opened its doors, and among our first patients were people who suffered from chronic headaches. Sixteen years later we were able to document our experience in treating patients with headaches with Prolotherapy injections:

In 2009, we published research in the journal Practical Pain Management (20) that showed weak or loose neck ligaments and/or tendons may act as headache triggers because of the instability they create in the neck. Instability leads to hyper vertebrae motion and compression of nerves and arteries that may restrict blood flow into the brain.

  • In our study, patients received Prolotherapy injections with a 15% dextrose and 0.2% lidocaine solution (as demonstrated in the video) No other therapies were used. The patients were asked to reduce or stop other pain medications and therapies they were using as much as the pain would allow.

Our findings strongly suggest that Prolotherapy injections can play a role in decreasing intensity level, frequency, duration, number of associated symptoms, and light sensitivity in patients with headache and migraine pain.

  • One hundred percent of patients reported they were at least somewhat better after receiving Prolotherapy, with
    • 39% of these patients reported 100% improvement.
    • 47% of patients stated the intensity of their pain was almost not noticeable after receiving treatment.
    • A notable improvement in the duration of time they suffered from headache pain was also experienced after treatment.
    • Seventy-three percent of patients reported a decreased sensitivity to light during a headache.
    • Symptoms associated with tension and migraine headaches decreased in 80% of the patients in this study.

Throughout this article, we have made references to cervical neck instability causing pressure on the vagus and trigeminal nerves and the various treatment options offered to help remedy this situation. Some treatments work, some do not. We have illustrated these points above.

In our examination, we too are looking for compression.

In this video, DMX displays Prolotherapy before and after treatments that resolved problems of a pinched nerve in the cervical spine

  • In this video, we are using a Digital Motion X-ray (DMX) to illustrate a complete resolution of a pinched nerve in the neck and accompanying symptoms.
  • A before digital motion x-ray at 0:11
  • At 0:18 the DMX reveals completely closed neural foramina and a partially closed neural foramina
  • At 0:34 DXM three months later after this patient had received two Prolotherapy treatments
  • At 0:46 the previously completely closed neural foramina are now opening more, releasing pressure on the nerve
  • At 1:00 another DMX two months later and after this patient received four Prolotherapy treatments
  • At 1:14 the previously completely closed neural foramina are now opening normally during motion


The head and neck, like all parts of the body, live in a complex relationship. Something in the neck can cause problems in the jaw, face, shoulders, fingers, etc. Problems in the jaw can cause problems in the neck. Any musculoskeletal problem can cause problems of headaches. Back to the keyword “compression.” We are looking for problems in the neck that can be influencing problems of the head and jaw.

Common characteristics of cervical neck instability causing headaches 

In our patient interviews at our first meeting, we find that people with cluster-type headaches:

  • Constantly self-manipulates or cracks their neck.
  • Constantly gets manipulation from chiropractors for neck pain.
  • Suffers from constant muscle spasms in the neck.
  • Had physical therapy with less than desired results.

In this video, a demonstration of treatment is given

Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.

This video jumps to 1:05 where the actual treatment begins.

This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.

Cluster headaches are an extremely challenging problem. We have presented our case that Prolotherapy injections can be a viable option in stabilizing cervical neck instability and its possible cause of pressure on the vagus and trigeminal nerve.

Summary

For the person with signs and symptoms of cervical instability including muscle tightness in the neck, crepitation sensations in the neck with rotatory motions, suboccipital headache, migraines who also have noticed changes in speech, voice quality, taste or swallowing, or symptoms such as tachycardia, whole body allodynia (sensitivity to touch), hyperalgesia (exaggerated pain response) or conditions such as dysautonomias, comprehensive prolotherapy may offer one solution to the resolution of symptoms.

Equally, in most cases of vagus nerve dysfunction seen at Caring Medical, there is obvious neck injury causing cervical instability so this is where treatment is addressed by comprehensive Prolotherapy. When motion x-ray demonstrates significant upper cervical instability, Comprehensive Prolotherapy is done to the C1-C2 region, often under fluoroscopic guidance. Generally, within a few visits, the person’s neck and headache symptoms are drastically improved, along with the systemic symptoms from vagus nerve dysfunction. There are times when despite improvement with Prolotherapy, the person still has some symptoms, and possibly nerve regeneration is needed.

If this article has helped you understand the problems of cluster headaches and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists

1 Vgontzas A, Rizzoli PB. Nonmigraine Headache and Facial Pain. The Medical clinics of North America. 2019 Mar 28;103(2):235-50. [Google Scholar]
2 Bodle J, Emmady PD. Chronic Paroxysmal Hemicrania. StatPearls [Internet]. 2020 Jun 12. [Google Scholar]
3 Jozef Hendrik Augustinus Henssen D, Derks B, van Doorn M, Verhoogt N, Van Cappellen van Walsum AM, Staats P, Vissers K. Vagus nerve stimulation for primary headache disorders: An anatomical review to explain a clinical phenomenon. Cephalalgia. 2019 Feb 20:0333102419833076. [Google Scholar]
4 Wei DY, Moreno-Ajona D, Renton T, Goadsby PJ. Trigeminal autonomic cephalalgias presenting in a multidisciplinary tertiary orofacial pain clinic. J Headache Pain. 2019 Jun 11;20(1):69. doi: 10.1186/s10194-019-1019-7. PMID: 31185885; PMCID: PMC6734481. [Google Scholar]
5 Karsan N, Nagaraj K, Goadsby PJ. Cranial autonomic symptoms: prevalence, phenotype and laterality in migraine and two potentially new symptoms. The Journal of Headache and Pain. 2022 Dec;23(1):1-8. [Google Scholar]
6 Peng KP, Burish MJ. Management of cluster headache: Treatments and their mechanisms. Cephalalgia. 2023 Aug;43(8):03331024231196808. [Google Scholar]
7 Rao Y, Liu W, Zhu Y, Lin Q, Kuang C, Huang H, Jiao B, Ma L, Lin J. Altered functional brain network patterns in patients with migraine without aura after transcutaneous auricular vagus nerve stimulation. Scientific Reports. 2023 Jun 13;13(1):9604. [Google Scholar]
8 Reuter U, McClure C, Liebler E, Pozo-Rosich P. Non-invasive neuromodulation for migraine and cluster headache: a systematic review of clinical trials. J Neurol Neurosurg Psychiatry. 2019 Mar 1:jnnp-2018. [Google Scholar]
9 Gaul C, Magis D, Liebler E, Straube A. Effects of non-invasive vagus nerve stimulation on attack frequency over time and expanded response rates in patients with chronic cluster headache: a post hoc analysis of the randomised, controlled PREVA study. The journal of headache and pain. 2017 Dec;18(1):22. [Google Scholar]
10 Villar-Martinez MD, Chan C, Goadsby PJ. Evolving options for the treatment of cluster headache. Current opinion in neurology. 2020 Mar 23. [Google Scholar]
11 Venkatakrishnan S, Thomas P. Vagal nerve stimulation for headache. Current Opinion in Neurology.:10-97. [Google Scholar]
12 Russell FA, King R, Smillie SJ, Kodji X, Brain SD. Calcitonin gene-related peptide: physiology and pathophysiology. Physiological reviews. 2014 Oct;94(4):1099-142. [Google Scholar]
13 Fernández-Hernando D, Justribó Manion C, Pareja JA, García-Esteo FJ, Mesa-Jiménez JA. Effects of Non-Invasive Neuromodulation of the Vagus Nerve for the Management of Cluster Headache: A Systematic Review. Journal of Clinical Medicine. 2023 Sep 30;12(19):6315. [Google Scholar]
14 Fernández-Hernando D, Fernández-de-las-Peñas C, Pareja-Grande JA, García-Esteo FJ, Mesa-Jiménez JA. Management of auricular transcutaneous neuromodulation and electro-acupuncture of the vagus nerve for chronic migraine: a systematic review. Frontiers in Neuroscience. 2023 Jun 15;17:1151892. [Google Scholar]
15 Boezaart AP, Smith CR, Zasimovich Y, Przkora R, Kumar S, Nin OC, Boezaart LC, Botha DA, Leonard A, Reina MA, Pareja JA. Refractory primary and secondary headache disorders that dramatically responded to combined treatment of ultrasound-guided percutaneous suprazygomatic pterygopalatine ganglion blocks and non-invasive vagus nerve stimulation: a case series. Regional Anesthesia & Pain Medicine. 2023 Nov 20. [Google Scholar]
16 Smith CR, Dickinson KJ, Carrazana G, Beyer A, Spana JC, Teixeira FJ, Zamajtuk K, Maciel CB, Busl KM. Ultrasound-guided Suprazygomatic nerve blocks to the Pterygopalatine fossa: a safe procedure. Pain Medicine. 2022 Aug 1;23(8):1366-75. [Google Scholar]
17 Franzini A, Moosa S, D’Ammando A, Bono B, Scheitler-Ring K, Ferroli P, Messina G, Prada F, Franzini A. The neurosurgical treatment of craniofacial pain syndromes: current surgical indications and techniques. Neurological Sciences. 2019 Mar 5:1-0. [Google Scholar]
18 Nayak R, Banik RK. Current Innovations in Peripheral Nerve Stimulation. Pain Res Treat. 2018;2018:9091216. Published 2018 Sep 13. doi:10.1155/2018/9091216 [Google Scholar]
Franzini A, Clerici E, Navarria P, Picozzi P. Gamma Knife radiosurgery for the treatment of cluster headache: a systematic review. Neurosurgical Review. 2022 Jun;45(3):1923-31. [Google Scholar]
20 Hauser R, McCullough H. Dextrose Prolotherapy for recurring headache and migraine pain. Practical Pain Management. 2009:58-65. [Google Scholar]

This article was update January 1, 2024

 

 

 

Get Help Now!

You deserve the best possible results from your treatment. Let’s make this happen! Talk to our team about your case to find out if you are a good candidate.