Cervicogenic headache (CEH) is caused by dysfunction in the cervical spine and surrounding muscles. It is typically characterized by unilateral or sometimes bilateral head pain, often accompanied by limited neck movement.  Postural and neuromuscular dysfunction in the cervical spine may contribute to the onset of headache-related pain. This study aims to address headache-related pain using the C2 evaluation and treatment protocol from the MyoKinesthetic System, a manual therapy method focused on evaluating and treating postural imbalances.  A female patient with self-reported chronic headache-related pain and neck discomfort underwent six treatments using the C2 cervical nerve root protocol over a two-week period, with 48-72 hours between each session. Each treatment lasted approximately 8 minutes. Subjective and objective outcome measures were collected throughout the treatment period, including clinician-assessed cervical range of motion, the Numerical Pain Rating Scale (NPRS), the Neck Disability Index (NDI), and the Headache Impact Test-6 (HIT-6). At the initial assessment, the patient reported an NPRS score of 4/10, an NDI score of 14/50, and a HIT-6 score of 58.  After the final treatment, the patient’s NPRS pain score was 5/10, with NDI and HIT-6 scores of 15/50 and 54, respectively. Cervical extension range of motion improved by 7 degrees post-treatment. However, the average NPRS pain reduction over the two weeks was only 0.25 points and not clinically significant. At the 30-day follow-up, NPRS results met the minimally clinically important difference (MCID), with a score of 0. Headache frequency decreased from daily to once every three days, with the duration reduced to around 15 minutes. The patient reported improved tolerance for physical activities and fewer work disruptions. Lasting improvements were observed in neck function, headache impact, pain, and range of motion.  These findings are promising, but more research is needed to confirm the MyoKinesthetic System’s effectiveness for CEH. Targeting the C2 cervical nerve root helped reduce the patient’s chronic headache frequency and neck discomfort, suggesting potential for addressing neuromuscular imbalances. However, since this is a single case study, further research with larger samples and comparisons to other treatments is needed to assess its broader efficacy and long-term effects.

Key Words: MyoKinesthetic System; cervical nerve root; head-related discomfort

INTRODUCTION

Cervicogenic headache (CEH) is characterized by pain in the head associated with the cervical spine and cervical musculature (Bogduk, 2001; Bogduk & Govind, 2009; Haldeman & Dagenais, 2001). Sjaastad et al. (1998), along with the International Headache Society (The International Classification of Headache Disorders, 2018), define CEH as a unilateral headache that may also present bilaterally, associated with the cervical spine and muscles. Identifying signs and symptoms, including a reduced active and passive range of motion in the cervical spine leading to mechanical dysfunction, is critical in diagnosing CEH (Sjaastad et al., 1998). Accompanying symptoms may include nausea, vomiting, flushing, dizziness, phonophobia, photophobia, blurred vision, and dysphagia (Sjaastad et al., 1998). The burden of a headache is measured by the degree of pain and suffering experienced by the patient.

Treatment options are available across multiple healthcare specialties (Yang et al., 2010), including athletic training, and treatment choice appears to depend on the specialty of the healthcare provider treating the patient (Smith & Bolton, 2013). Various treatment methods have been studied, both invasive (e.g., surgery and injections) and non-invasive (e.g., massage, cervical mobilizations, trigger point therapy, and acupressure) in nature (Bogduk & Govind, 2009; Haldeman & Dagenais, 2001; Quinn et al., 2002; Schoensee et al., 1995). The goal of clinicians using non-invasive manual therapy techniques is to resolve patient complaints by treating the cervical spine as the primary source of CEH symptoms (Bogduk, 2004).

Non-invasive therapeutic techniques for CEH include cervical spine mobilization, massage, trigger point therapy, and acupressure (Bogduk & Govind, 2009; Haldeman & Dagenais, 2001; Quinn et al., 2002; Schoensee et al., 1995; Youdas et al., 1992). Researchers have demonstrated clinically significant reductions in headache intensity, frequency, and duration among patients treated with non-invasive techniques over at least a six-week treatment protocol (Bogduk & Govind, 2009; Haldeman & Dagenais, 2001; Quinn et al., 2002; Schoensee et al., 1995; Youdas et al., 1992). Although manual therapy techniques have been reviewed as effective management tools for CEH (Bogduk & Govind, 2009; Haldeman & Dagenais, 2001; Quinn et al., 2002; Youdas et al., 1992), no studies have specifically evaluated the effects of pain intensity changes and cervical range of motion after shorter treatment durations, such as a two-week treatment protocol. Conservative treatments that require extended durations to achieve significant results may motivate patients to seek faster remedies (e.g., medication) that perpetuate their condition by altering symptoms without addressing the underlying cause.

The MyoKinesthetic (MYK) System is an evaluation and treatment paradigm used to restore the central nervous system’s (CNS) communication with the musculoskeletal system to achieve allostasis. The MYK evaluation is designed to identify abnormalities in a patient’s static posture and connect those abnormalities to specific nerve root(s) via the associated myotome(s). The clinician then treats at the level of the identified myotome by using active and passive patient movements with a simultaneous external stimulus, similar to massage, to stimulate the communication pathways of the CNS.

The MYK System is theorized to decrease nociceptive firing that may cause or occur due to joint and tissue movement restriction (Smith & Bolton, 2013). The MYK system aims to create postural balance by treating the bilateral neuromuscular system along a specific nerve root. Specifically, for headaches, the MYK System utilizes additional classification beyond postural evaluation, including assessing headache pain and location. The MYK system, which helps the clinician determine the nerve root to be treated, offers a headache assessment table designed by Dr. Mike Uriarte (Uriarte, 2004). The location of headache-related symptoms in one or multiple areas (e.g., top of the head, sides of the head, front or back of the head, front of the head above the eyes, and back of the head no lower than the occiput) is used to determine which cervical nerve root may be affected. Currently, limited published research examines the effectiveness of the MYK headache treatment on headache-related pain (Moy, 2015).

The purpose of this case study was to examine the effects of the MYK system over two weeks when treating a patient classified with chronic CEH (i.e., occurring 15 days or more per month for longer than three months).

TABLE 1

The ‘Yes/No’ Cervical Nerve Root Assessment Chart

Nerve Root	Location of Pain	Special Characteristics
C1	Anywhere on the head, this is determined when we do the ‘yes/no’ test.	If their head is ‘rotated only,’ it is C1.
C2	Top of the head, sides of the head, front and back of the head.	No lower than the occiput.
C3	In the eyes, between the eyes, behind the eyes, into the jaw or cheek area, top of the neck.

Case Report

The patient, a thirty-three-year-old female, reported her main complaints were headache pain and neck discomfort off and on for over ten years, starting while she was in middle school.  A signed HIPAA and informed consent form were obtained before the initial evaluation and treatment. The patient’s prior history of significant injury included rotator cuff lesion and finger, foot, and toe fractures. The patient underwent shoulder arthroscopy to repair the rotator cuff three years prior. Still, since the headaches were present before and after the surgery, it was not believed to be a primary contributing factor. The patient’s contributing factors that coincided with her headache symptoms included sinusitis and bilateral numbness in her hands.  The patient also reported that she had missed significant events in her life because of her chronic headache pain. Her work-life was frequently disturbed; she required breaks often and was unable to stay focused on her tasks. In her own words, her ‘everyday active lifestyle was disrupted frequently’. 

The patient pursued multiple treatments and techniques over several years to relieve her headaches and neck discomfort but found little to no success. Some treatments positively impacted her condition for a short period but had not changed her condition long-term. These treatments and techniques included chiropractic care, medication, injections, essential oils, and physical therapy. Prescription pain medication and muscle relaxers were used as a last resort.  Over-the-counter medicines were used by the patient weekly as needed.

METHODS

Assessment

After obtaining a complete history and satisfying the inclusion/exclusion criteria (see Table 2), a physical examination was performed, consisting of cranial nerve and vertebral artery insufficiency testing, before the MYK ‘yes/no’ test and the MyoKinesthetic (MYK) full-body postural assessment.  Cranial nerve function tested normal, as did the vertebral artery performance.

Table 2

 Inclusion and Exclusion Criteria.

Inclusion Criteria	Exclusion Criteria
-Pain projected to the forehead, orbital region, temples, ears, neck, or occipital region; -Pain with specific neck movements or sustained postures; -Complaints of palpable pain or discomfort/limitation of active or passive ROM.	-Participants > 50 years old; -Positive Vertebral Artery Test; if positive, refer out  -If any analgesic or non-steroidal anti-inflammatory drugs (NSAIDs) were taken within the last 24 hours; -If the participant has an acute diagnosis of concussion or has not been released by a physician for full activity with no restriction from a concussion diagnosis

The MYK ‘yes/no’ test is used within the MYK System to determine resting head position. The patient stands with eyes closed and nods and shakes his/her head several times before coming to a comfortable resting position. The position of the head at rest is noted. Assessing cervical posture/imbalance with eyes closed may help to remove the visual input that the body uses to level itself with the horizon. In conjunction with the location of symptoms as outlined in Table 1, the ‘Yes/No’ Test is used to determine the cervical nerve root associated with the patient’s posture and symptoms. In this case, the patient’s cervical posture was visibly laterally flexed to the right. 

The MYK full-body postural assessment consists of the clinician evaluating the patient’s posture and stance, noting any imbalances when compared bilaterally and against postural norms (e.g., neutral).  In this case, clinical evaluation utilizing the MYK full-body postural assessment (Table 3) and clinician expertise demonstrated a C1-T1 dysfunction, with considerable postural imbalances associated with C6. The patient’s primary complaint was headache pain on the top of the head and temples with general neck discomfort. As outlined in Table 1, the C2 nerve root was identified as the affected nerve root using the headache treatment guidelines.

Pain-free active cervical ranges of motion (extension, flexion, and right/left rotation) were assessed using a goniometer with the patient’s eyes closed. At the initial examination, the patient had 53 degrees of pain-free active cervical extension and 45 degrees of pain-free active cervical flexion.  Pain-free active cervical rotation to the left and right was 60 degrees and 67 degrees, respectively.

Instrumentation

For patient-reported instruments to be most helpful in clinical practice and research, those with good psychometric properties and clinical applicability were utilized (Houts et al., 2020; Farrar et al., 2001). Instruments that were well-established in the literature and validated were selected to measure the impact of headaches in this case study.

The Headache Impact Test Questionnaire

The Headache Impact Test (HIT-6) is designed to assess the global impact of headaches on patients, measuring content areas such as pain, social-role limitations, cognitive functioning, psychological distress, and vitality (Houts et al., 2020). Nachit-Ouinekh et al. (2005) evaluated the global impact of episodic headaches in patients consulting general practitioners using the HIT-6 questionnaire and compared headache severity and quality of life. A comparison of the HIT-6 scores was conducted for each of the four sub-scores (i.e., functional, psychological, social, and therapeutic indices) against the French Qualité de Vie et Migraine (QVM) questionnaire (Nachit-Ouinekh et al., 2005). Scores range from “60 or more—headache has a severe impact on your life” to “49 or less—headache has little to no impact on your life” (Nachit-Ouinekh et al., 2005).

The Numerical Pain Rating Scale

The Numerical Pain Rating Scale (NPRS) is an 11-point numerical scale in which the clinician asks the patient to rate their pain verbally on a scale from 0 (no pain) to 10 (worst pain imaginable) (Farrar et al., 2001). In this study, average scores were calculated using the patient’s “current,” “best,” and “worst” pain scores, which were then compared to the post-treatment “current” pain score.

The Neck Disability Index

The Neck Disability Index (NDI) is a patient-reported, condition-specific functional status questionnaire that includes items related to pain, personal care, lifting, reading, headaches, concentration, work, driving, sleeping, and recreation. Out of a possible 50 points, a higher score indicates greater patient-perceived neck disability. A 5-point change on the index is considered a clinically important difference (Chan Ci En et al., 2009).

At the initial assessment, the patient reported an NPRS of 4/10, a HIT-6 score of 58, and an NDI score of 14/50. Measurements and outcomes were also collected at 30- and 60-day follow-ups.

The treatment of the C2 nerve root was determined based on the MyoKinesthetic (MYK) System’s “yes/no” test results. Treatment was performed following MYK System guidelines with the patient in a seated position. The clinician administered treatment using the MYK System parameters: passive movements were completed first, with the clinician passively moving the participant through each muscle’s range of motion (five times) while applying manual stimulus similar to massage to the muscles of the C2 myotome. Then, the participant actively moved (seven times) through the same range of motion while the clinician applied the same stimulus to the muscles. Once all muscles innervated by the C2 nerve root were treated bilaterally, treatment was complete. Treatments lasted approximately eight minutes on average and were conducted six times over two weeks, with 48 to 72 hours between each treatment.

RESULTS

After the final treatment, the pain reported on the NPRS was 5/10. The patient also completed the NDI and HIT-6, with scores of 15/50 and 54 points, respectively (see Table 4). Cervical range of motion (ROM) measurements were recorded in degrees and evaluated pre- and post-treatment. There were significant improvements in cervical extension ROM, with an increase of 7 degrees post-final treatment. A summary of ROM measurements is presented in Table 5.

The mean pain scores across the two weeks of treatment were not clinically significant compared to the NPRS minimally clinically important difference (MCID), which is defined as an average decrease of 2 points. In this case, the average decrease was only 0.25 points (Chan Ci En et al., 2009). However, daily NPRS results met the minimally clinically significant difference at the 30-day follow-up, with an average of 0 (Chan Ci En et al., 2009). Lastly, the patient’s postural examination changed between intake and discharge, as many imbalances were corrected within normal limits (see Table 3; Uriarte, 2004).

The patient reported a dramatic decrease in headache frequency over the two-week period, from experiencing a headache daily to only one every three days. By the end of the two-week treatment period, the patient noted that headache duration significantly decreased, lasting approximately 15 minutes compared to several hours or days before treatment. The patient also reported improved tolerance for physical activities she had previously been unable to perform, such as walking for extended periods, lifting weights, completing household tasks, and playing with her child. Disruptions at work were also greatly diminished, and the patient reported improved ability to focus on tasks with greater ease.

While the patient reported notable improvements, it is essential to analyze the raw data to form a proper conclusion. When evaluating follow-up scores, the findings suggest lasting improvements in multiple aspects of the patient’s life, including but not limited to neck function, perceived headache impact, pain levels, and range of motion. The follow-up scores are illustrated in Table 4.

DISCUSSION

The MyoKinesthetic (MYK) System elicited positive and lasting changes in this patient with frequent and intense cervicogenic headaches (CEH) over just two weeks of treatment. By the 60-day follow-up, the patient’s pain was nearly eliminated, and headache frequency had become rare. The patient also reported no headache-related pain or discomfort between treatments, which were spaced 48 to 72 hours apart. Improvements were observed in cervical flexion and right rotation, and the patient reported a significant enhancement in functional activities, allowing her to enjoy a more comfortable home life and a less painful work environment. The MYK System may be beneficial for other patients with CEH; however, research on its effectiveness remains limited, as is the case with other manual therapy techniques. Further studies are needed to determine why MYK may have been effective in treating this patient.

Manual therapy has been shown to decrease pain, improve function, and enhance quality of life in patients with musculoskeletal conditions, though its effectiveness varies among individuals (Uriarte, 2004). For example, massage therapy is commonly used to treat general pain complaints, yet some patients experience substantial relief while others show little to no improvement. Similarly, alternative treatment approaches, such as mobilizations with movement, may have been more or less effective in addressing the patient’s primary complaint. Treating patients with pain is inherently subjective, as each patient’s response is influenced by a combination of mental, physical, and emotional factors.

The MYK technique may extend its effects beyond conventional treatment boundaries. Patients may perceive MyoKinesthetic treatment as similar to joint mobilization and massage (e.g., pressure, squeezing, trigger point therapy). Neural mobilization may also occur as all tissues move through various ranges of motion. Some patients report a stretching or traction effect, while others describe experiencing a “pop” sensation, suggesting a possible manipulative effect. The MYK System is designed to be quick and efficient, requiring minimal space and exertion from the clinician (Moy, 2015).

Although limited research has explored manual therapy as a viable treatment for headaches, Smith and Bolton (2013) provided a compelling argument supporting its use. While acknowledging study limitations, their evaluation considered both postural and pain-related factors. Headaches related to stress, nerve irritation, or muscle spasms were subjectively identified, and chronic pain in the neck and upper trapezius region was also noted. MYK was used in this case to address the patient’s symptoms, and the treatment was beneficial. The systematic evaluation process within the MYK System highlighted neuromuscular imbalances, targeted their treatment, and raised the question of whether MYK could serve as an effective intervention for headaches (Uriarte, 2004).

A study by Moy (2015) applied the MYK System to a patient with complaints of neck pain, shoulder pain, hip pain, and headaches. Through a comprehensive assessment, the C8 nerve root was identified as the source of the patient’s symptoms. Following targeted MYK treatment, the patient experienced a significant reduction in pain, improved cervical range of motion, and enhanced quality of life after nine treatment sessions.

At the conception of the MYK System, a review of research addressing neuromuscular function and dysfunction was conducted. Understanding the neuromuscular system was fundamental to its development. Dr. Uriarte (2004) conceptualized the neuromuscular system as a “two-sided story,” emphasizing the necessity of bilateral treatment to address the root cause of pain rather than merely targeting the symptomatic area.

Furthermore, during MYK treatment, the body may perceive movement as normal and recognize the applied stimulus as non-threatening. This process allows patients to transition from painful to non-painful motion. A unique aspect of the MYK System is how treatment concludes. According to Dr. Uriarte (2004), posture serves as an external reflection of the neurological system. Before treatment, compensatory patterns may develop due to dysfunction and gravitational forces. Following treatment, the body and neurological system are expected to feel more balanced and better equipped to adapt to movement and gravity naturally.

Limitations

As with any attempted case study, limitations were present. Limitations included the following: 1) The treatment pressure may vary among treatments over the two weeks.  While the type of stimulus (stroking, tapping, massaging) may not matter, varying pressure has not been studied; therefore, the effects of pressure have not been determined.  This may be viewed as a limitation of the technique rather than a limitation of this study.  2) Reliability of goniometric measurement was not established before data collection, which may have created a limitation on reporting significant cervical ROM changes.  However, all measurements were taken in the same setting, patient position, and by the same clinician.  Validity and reliability of goniometric measures are usually established amongst clinicians, with multiple ROM measurements collected blindly over some time with the same subjects.  With there only being one patient and one clinician in this study, inter- and intra-reliability are lacking.  3) Although the patient was instructed not to take medication or have other treatments for headaches, the clinician cannot control what happens outside the clinic.  The patient did not report any other treatments or taking medication during the time of the study.

Further research should be conducted, exploring whether the muscles’ stimulation affects multiple participants with suspected cervicogenic headache during the acute stages of a CEH.  Other research should be conducted utilizing the MYK manual therapy treatment technique on different body regions to determine treatment effectiveness.  Another viable research topic would be comparing the specific nerve root treatment based on the location of headache pain (C1, C2, C3) compared to the location of dysfunction according to the MYK Upper Body assessment findings (C1-T1).    

CONCLUSIONS

MYK manual therapy helped this patient improve in their complaint of headache pain and frequency.  This study demonstrates that the MYK System headache treatment may be a practical treatment choice to reduce the intensity of patient-reported pain in patients with suspected cervicogenic headaches.  The treatment of cervical nerve root C2 from the MYK System created a clinically significant change in the participant’s perceived pain, including some results found after the 30-day and 60-day follow-ups.   

The question arises: Is MYK the most viable option for patients suffering from headache-related pain?  MYK is quick, easy, and presents as effective.  The treatment needs more research and discussion to support the idea that MYK is effective and helps validate more manual therapy techniques.  While MYK is not the only manual therapy technique available, it appears viable when assessing and treating patients. Overall, the changes in pain, intensity, and frequency observed in this study support the MyoKinesthetic System headache treatment along cervical nerve root C2 as a successful form of a non-invasive technique when treating cervicogenic headaches.

APPLICATIONS IN SPORT

For coaches, athletic trainers, and parents, understanding cervicogenic headaches (CEH) and their potential impact on athletes is crucial. Athletes, especially those involved in contact sports or repetitive motions, are at a higher risk for neck injuries that could lead to headaches. These headaches can affect an athlete’s performance and overall well-being, causing discomfort, limiting movement, and sometimes sidelining them from practice or competition.

As a coach or athletic trainer, recognizing the signs of CEH and addressing them early can make a significant difference in an athlete’s recovery and performance. Techniques such as cervical mobilizations, myofascial release, and other manual therapies can relieve, improve range of motion, and prevent long-term issues. By being proactive and incorporating strategies to address CEH, you can help athletes stay on track, reduce downtime, and support their physical function, ultimately enhancing their athletic experience and success. Parents, too, can play an important role by being aware of the symptoms and encouraging their athletes to seek timely treatment.

Acknowledgments

The authors declare no conflict of interest and did not receive payment for this study.

Table 4

Patient Reported Outcomes

	NDI		HIT-6		NPRS
ASSESSMENT	Score	Ranking	Score	Ranking	Pre- Score	Post- Score	Mean of  Raw
Initial	14/50	Mild	58	Substantial	4	3	3.75
Discharge	15/50	Moderate	54	Some	7	5	4
Mean	_	_	57.6	Substantial	–	–	–
30-Day	8	Mild	46	Little to no impact	–	–	0
60-Day	5	Mild	38	Little to  no impact	–	–	.666

Table 5

Goniometric measurement mean normative data for cervical range of motion taken from Norkin et al.

Cervical Range of Motion
Movement	Normative Data	Pre-treatment	Post-treatment (change)	30-Day Follow Up	60-Day Follow Up
Flexion	40° ± 12	45°	40° (-5°)	47.3°	46°
Extension	50° ± 14	53°	60° (7°)	41.6°	37°
Left Rotation	49° ± 9	53°	54.6° (1.6°)	55.6°	51°
Right Rotation	51° ± 11	60°	61.6° (1.6°)	58.6°	62°