Finding the missing cause of headaches, dizziness, and facial pain

Ross Hauser, MD

Many patients with cervical spine instability have been chasing a diagnosis for years. At some point these people, probably you or your loved one, start to realize that their chase is nowhere near the endpoint because they continue to have worsening symptoms and continue to receive ineffective treatment with the addition of possibly unneeded medications that do not help. In our office, one of our diagnostic tools is a Digital Motion X-ray. We use tools because they can help reveal a missing diagnosis.

A case history of a decade of chasing headache pain

This is an email example, to illustrate the idea of how pervasive mismanagement of cervical instability is when it comes to understanding headaches. Some of the personal information has been changed.

Dear Dr. Hauser, let me first say that your videos made perfect sense as to what I’m experiencing every day. I live with a chronic headache that will not go away. It started back in 2008 when I was rear-ended and suffered severe whiplash. The pain in my neck was the first symptom I experienced and then the headaches came on. The headaches would start at the base of my skull with a burning sensation. Within minutes the pain was more intense on the right side of my neck. I also had sharp pain shoot down my right arm with tingling and numbness in my hand.

The MRI results didn’t show any significant problems that would cause headaches.

After several months of chiropractic treatment, it was decided that I needed an MRI because I was “not getting anywhere.” The MRI results didn’t show any significant problems that would cause headaches.

I suffered from pain for about a year and decided to see a neurosurgeon. After several years of different medication protocols, steroid injections, physical therapy, nerve blocks, and facet blocks, the pain wasn’t getting any better, I was not responding to treatment.

In 2012 (four years into this health challenge) the headache was stubborn, called difficult to treat, and non-responsive to any remedies. It decided not to go away. I wake up every day with a headache and go to bed with a headache. Depending on what I did physically determined how bad the pain would get. When I look up or lift something heavy the pain gets so severe. My doctor then decided to put in a cervical spine stimulator to hopefully help with the pain. In the beginning, it seemed to ease the pain a little. I believe that I was wanting relief so bad that I made myself believe it was helping when it really wasn’t.

I was referred to a pain management doctor and he tried more and different nerve blocks and stronger and more frequent medications with little to no help.

With no other help, the doctor put me on antidepressants. I didn’t know I was addicted to my pain medications until they took me off of them

By now it’s 2014 (six years into this health challenge) and I suffer from severe depression. This wreck from 2008 has changed my life in so many ways and I’m very upset that no one can help me. My husband could see the change in my state of mind and had the doctor put me on antidepressants. I was so mentally and physically exhausted. My doctors agreed to send me to a Headache Clinic in Chicago where I was immediately admitted into their hospital.

I didn’t know I was addicted to my pain medications until they took me off of them. I went through a terrible detox. All I ever wanted was for the headache to stop but I didn’t realize how I was causing rebound headaches. I went years suffering before I started taking painkillers because of that reason. My hospital stays there were two weeks. I attended group meetings with others who also suffer from headaches.

It’s not a migraine, stop telling me it is

I’ve known all along that my headache was not a migraine headache. I’ve never experienced nausea or sensitivity to light. I was in a group of patients where 99% of them suffered from migraines. I had C2 & C3 nerve cauterization before I was sent home. This seemed to have helped temporarily relieve my headaches for a short period.

I’ve seen probably over twenty plus doctors over the past 8 years

After traveling back to Chicago from Mississippi several times I decided to look for another doctor. I’ve seen probably over twenty-plus doctors over the past 8 years. In 2016 My husband set up an appointment with a doctor at a major medical center in Florida. My visit with this doctor made more sense to me than any other doctor’s visit. He explained to me after a full examination and going over all my records that my problem was upper cervical instability at C1  and C2. He said, when a person has had a severe whiplash trauma, sometimes the damage it causes will not show up on film. After all these years I finally had some sort of answer to why all the other doctors were not able to help me. He then referred me to a doctor in Philadelphia who began treating my pain with nerve blocks at all upper cervical discs. Over the past 6 months, I’ve made 4 trips there for all sorts of treatment. I believe every nerve in my neck has been cauterized.

Two out of three surgeons feel that I would benefit from fusion surgery.

This doctor has been the most caring and optimistic doctor I’ve ever seen. He performed a discogram on me and during the procedure, my pain was intensified when he hit certain spots. His diagnosis is that my pain is coming from C2 and C3 and C3 and C4. He believes that I would benefit from a fusion at those levels. I’ve already met with three different surgeons and two out of three feel that I would benefit from the surgery.

I know the risks involved and also know that the surgery may not help end my headache. I’m so scared to get this surgery done and it does not help at all and then I may have created another problem.

How we may help a person like this is explained below.

MRI accuracy in upper cervical instability

In the story above we revealed a woman who had a long journey into discovery. The discovery she wanted was what could be causing her terrible headaches. As you are reading this article, she may have a very similar story to yours. Years of searching and two dozen doctors later the discovery that she has upper cervical instability and the recommendation that she have neck fusion from at least C1 through C4 with no guarantees the surgery will work and certainly no going back if the surgery failed. To be clear, many people have successful cervical fusion surgeries, the people we see at our center are mostly trying to avoid fusion because of a poor prognosis for success.

But how did this person get to the point of multi-segment fusion? Why wasn’t upper cervical instability revealed to her long before?

The reasons why this condition goes undiagnosed by  medical doctors and health care professionals are manifold including:

  • Headaches, even suboccipital and occipital ones, are common innocuous. In other words, the headaches themselves are not considered harmful and are just one of many complaints.
  • Many doctors are not trained to evaluate the upper cervical spine.
  • Static x-ray and MRI analyses often do not show upper cervical pathology.
  • Radiologists who read the x-rays and MRIs emphasize the lower cervical vertebrae and discs in their readings, often not even commenting on the upper two cervical vertebrae.
  • There are invasive procedures to decrease nerve impulses for the occipital and trigeminal nerve such as radiofrequency ablation and microvascular decompression, so these techniques are emphasized for treatment; however, occipital and trigeminal neuralgia are both typically from upper cervical instability.
  • Other common symptoms of upper cervical instability include reduced neck range of motion, neck pain, insomnia, dizziness, lightheadedness, neck pain with movement, preauricular (ear) region pain, ringing in the ear, and vertigo. Again, these are common symptoms for which there are drugs to control the symptoms so upper cervical instability is not in the differential diagnosis.

The challenges of diagnosing upper cervical instability are documented in the medical research

The challenges of diagnosing upper cervical instability with MRI or standard physical testing are documented in medical research. BUT, the research is very limited. This is not a frequent area of study for doctors and radiologists. So let’s explore what we have.

In December 2013, a paper in the journal Physical Therapy (1) Offered these observations:

“Patients with neck pain, headache, torticollis, or neurological signs should be screened carefully for upper cervical spine instability, as these conditions are “red flags” for applying physical therapy interventions. However, little is known about the diagnostic accuracy of upper cervical spine instability tests.”

To try to answer this problem the research team examined the diagnostic accuracy of upper cervical instability screening tests in patients or people who are healthy and in which sensitivity (the probability that these tests could correctly identify upper cervical instability and specificity (no test is 100%, the specificity is the percentage of tests that are likely accurate) were reported or could be calculated. So in essence, could the tests correctly identify upper cervical instability (percentage of sensitivity), how accurate would these tests be specifically? So specificity would be the percentage of tests that would be considered accurate diagnosis.

What were the tests?

  • Sharp-Purser Test (SPT) to assess for atlantoaxial instability. Mostly in patients with rheumatoid arthritis. This is a controversial test as its safety and reliability is often questioned. This was discussed in a May 2020 study in The Journal of Manual & Manipulative Therapy (2) where researchers noted: “The Sharp-Purser Test may be inappropriate to use due to inconsistent validity, poor inter-rater reliability, and potential to cause harm.”
  • Clunking test – does the patient make a clicking or clunking sound when they move their head.
  • Palate sign – deviation of dysfunction in the palate.
  • Alar ligament test
  • Transverse ligament test
  • Tectorial membrane test. You had your head pulled on and if symptoms worsen or are relieved. If they are worsened upper cervical ligament weakness or instability is suspected with a focus on the tectorial membrane, the continuation of the posterior longitudinal ligament that covers the Odontoid process.
  • and posterior atlanto-occipital membrane test.

The researchers then assessed five previously reported studies. Problems developed.

  • Statistical pooling was not possible due to clinical and statistical heterogeneity. (A general opinion could not be given because there was insufficient common data).
  • The specificity of 7 tests in the five studies was sufficient, but sensitivity varied. (The outcomes specific that people had cervical instability had enough data to examine BUT the sensitivity did not).
  • The Predictive values were variable. Likelihood ratios also were variable, and, in most cases, the confidence intervals were large. (Confidence intervals mean a predetermined set of values that would help confirm the accuracy of the tests. The researchers said it was too large. What does this mean? For example, say there was a test that tried to determine the likelihood that a certain shoe size caused toe pain. If the confidence intervals were size 2 to size 15 would cause toe pain, that is really not helpful as it could be suggested that all shoe sizes cause toe pain, and the test to see if size 7 causes more pain than size 9 would be difficult to determine or even peruse as a valid finding in this example.

The general conclusion was these tests may be accurate they may not be, it is difficult to tell based on the data examined.

Video discussion

In this first video a patient shares his experience with dizziness and light sensitivity coming from neck instability, and treatment with Prolotherapy here at the Hauser Neck Center. His story is similar to many people who we speak to and see here for care. **DISCLAIMER: As with any medical treatment, no guarantees or claims of cures are made as to the extent of the response to treatment that every person experiences. Every therapy/treatment has patients who experience varying levels of success and failure. Results may not be the same from patient to patient, even with a similar diagnosis, as the body’s internal status is unique to each individual.

The search for the missing diagnosis

For many people, a digital motion x-ray can reveal a series of missing diagnoses and possibly end your chase for that elusive diagnosis that finally responds well to treatment. A digital motion x-ray is exactly what it sounds like. It is a moving picture x-ray.

Head, neck, jaw, and face pain

In our 30+ years helping people with chronic pain of the head, neck, jaw, and face we have seen many people with a diagnosis of Trigeminal neuralgia. For some of these people, possibly including yourself, it was not easy getting this diagnosis as this problem can be confusing and frustrating to understand. Not only for the patient but the doctor alike. The problems of diagnosis to determine where your source of facial, head, and jaw pain is coming from is covered in our article: The evidence for Trigeminal Neuralgia non-surgical treatments.

Painful, involuntary muscle spasms in the neck 

  • Lateral head tilting is linked to Torticollis, painful, involuntary muscle spasms in the neck with a resulting head rotation and tilting to one side. In the 2020 medical publication STAT Pearls, the authors noted, “There may be several presenting positions, including flexion, extension, right or left tilt (in Torticollis.) (3) See our article Cervical dystonia and spasmodic torticollis treatment.

Dizziness, loss of balance, sometimes nausea, sometimes vomiting

  • Lateral head tilting is linked to Benign paroxysmal positional vertigo or BPPV. Some of you reading this article may have been offered this diagnosis with a somewhat reassuring tone that your dizziness, loss of balance, sometimes nausea, sometimes vomiting is something that can be managed, may go away on itself, and this will be more of a nuisance than anything. That is why it is called “Benign.” For some people indeed, this does happen, for many patients we see, the dizziness did not go away and it continues on. Please see our article Cervical Vertigo and Cervicogenic Dizziness.

The problem of the posterior ponticulus revealed

At 1:45 of the video:

The next thing that we see, that may not be discovered by conventional x-ray is that the patient, this mother of three, has a unilateral posterior ponticulus and what that is it’s a fancy word for a little bone formation at the C1 that sits by her vertebral artery. The vertebral artery is one of the major supplies of blood between the brain and the spine. So when you have posterior ponticulus,  any injury to that upper cervical spine is going to leave the patient more prone to headaches, dizziness, lightheadedness, or simply a feeling of being a little bit off-balance, and neck pain. This problem can also be causing our patient’s vertebral blood supply loss.

In this image from the video and article Understanding Ponticulus Posticous, Ross Hauser, MD explains that in advancing cervical spine instability and neck problems, and with seemingly no alternative, the posterior atlantooccipital ligament transforms itself into a bony structure to “bridge” over the foramen in a last attempt to prevent vertebral artery and suboccipital nerve compression. The last chance to fight off cervical instability.

In this snap shot from the video belwop, Dr. Hauser shows the development of Ponticulus Posticus in a Digital Motion X-Ray of a patient. Dr. Hauser explains that with seemingly no alternative, the posterior atlantooccipital ligament has transformed itself into a bony structure to "bridge" over the foramen in a last attempt to prevent vertebral artery and the suboccipital nerve compression.
In this snapshot from the video below, Dr. Hauser shows the development of Ponticulus Posticus in a Digital Motion X-Ray of a patient. Dr. Hauser explains that with seemingly no alternative, the posterior atlantooccipital ligament has transformed itself into a bony structure to “bridge” over the foramen in a last attempt to prevent vertebral artery and suboccipital nerve compression.

C1-C2 – the anterior-posterior open mouth view reveals cervical dysfunction in motion and more clues to the cause of the patient’s symptoms.

If you went to the hospital or your doctor and they suspected a problem in your upper cervical spine, they may recommend an anterior-posterior open mouth (APOM)  x-ray view. This again would be a “snapshot,” or an image of a single moment. The difference with digital motion x-ray is that we are able to watch your neck move in real-time and see how in real-time motion how your C1-C2 interact and work, or not work together.

The involvement of DMX in discovering a difficult to find diagnosis is covered in these articles on specific symptoms:

Treating and repairing cervical instability with Prolotherapy: research papers

References

1 Hutting N, Scholten-Peeters GG, Vijverman V, Keesenberg MD, Verhagen AP. Diagnostic accuracy of upper cervical spine instability tests: a systematic review. Physical therapy. 2013 Dec 1;93(12):1686-95. [Google Scholar]
2 Mansfield CJ, Domnisch C, Iglar L, Boucher L, Onate J, Briggs M. Systematic review of the diagnostic accuracy, reliability, and safety of the sharp-purser test. Journal of Manual & Manipulative Therapy. 2020 Mar 14;28(2):72-81. [Google Scholar]
3 Cunha B, Tadi P, Bragg BN. Torticollis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; April 13, 2020. [Google Scholar]

This article was updated July 31, 2021

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