Zhang Ying
Introduction
Migraine is a common and complex neurovascular headache. According to the World Health Organization (WHO), over a lifetime migraine will affect 10% to 15% of the population. The etiology of migraine is complex, involving genetic, environmental, endocrine, and neurovascular regulatory factors, and can be classified into various types based on clinical presentation and triggering factors, such as common migraine (without aura) and classic migraine (with aura). Among numerous etiological studies, the greater and lesser occipital nerves are closely related to certain types of migraine. Both clinical and anatomical studies have found that when the greater or lesser occipital nerve is subjected to pathological stimulation or compression, it can trigger or exacerbate ipsilateral migraine symptoms. The posterior occipital tendon arch formed by the sternocleidomastoid muscle and the trapezius tendon at the back of the occiput is the most common anatomical site for the compression and irritation of the nerves and blood vessels of the posterior head.
With the development of minimally invasive practices based on traditional Chinese medicines Pi Zhen cutting needle targeting migraine by releasing the posterior occipital tendon arch has gained widespread attention from clinical physicians due to its advantages of simplicity efficacy minimal trauma and rapid recovery This article elaborates on the release of the posterior occipital tendon arch as a treatment for migraine in conjunction with anatomical structure and clinical research in an effort to provide a reference for clinical diagnosis and treatment
Applied Anatomy
The occurrence of migraines is closely related to the compression and irritation of the greater and lesser occipital nerves by constrictive fascia or tendons within the fibrous canal on the occipital bone Therefore understanding the anatomy of the occipital tendon arch the greater and lesser occipital nerve and the occipital artery is important This section describes the key anatomical structures related to this treatment and suggests that clinical physicians carefully read and compare relevant anatomy before surgery and if necessary use imaging for localization
Occipital Arch
Location Located about cm below the superior nuchal line of the occipital bone in the deep fascia with fibers predominantly arranged transversely medially continuous with the tendon sheath of the trapezius muscle and laterally connected to the sternocleidomastoid tendon with a dense and tough texture
Relationship with surrounding structures The posterior atlantooccipital membrane and the occipital bone together form a flat bony fibrous canal known as the posterior bony fibrous canal The greater occipital nerve lesser occipital nerve and occipital artery are arranged from medial to lateral within this canal and may be compressed if it is constricted
Function and pathology Contraction of the occipital tendon arch can lead to increased local tension compressing the passing nerves and blood vessels thereby triggering or exacerbating migraine symptoms
Greater occipital nerve
Origin and course: The greater occipital nerve arises from the posterior branches of the second and third cervical nerves. It is the largest and longest branch among all spinal nerve posterior branches, traversing between the splenius capitis and semispinalis capitis muscles, adjacent to the ligamentum nuchae near the level of the spinous process of the second cervical vertebra, and then courses posteriorly and laterally, reaching the tendon sheath of the trapezius muscle, ultimately entering the superficial layer of the scalp through the fibrous canal of the occipital bone, innervating the skin of the occipital region and above the ear.
Possible compression The greater occipital nerve is prone to irritation and compression from the contracted nuchal ligament or thickened fascia as it passes through the fibrous canal at the occiput leading to pain or numbness in the nerve distribution area
Lesser occipital nerve
Source and course The lesser occipital nerve arises from the cervical plexus branches of the anterior rami of the second and third cervical nerves emerges at the midpoint of the posterior border of the sternocleidomastoid muscle and ascends along the posterior border to the occipital region innervating the skin of the lateral part of the head
Possible compression When the sternocleidomastoid or trapezius fascia is tense and contracted or when the ligamentous arch thickens the lesser occipital nerve may also be compressed or irritated as it passes through the posterior occipital region
Occipital Artery
Area Supplied The occipital artery is primarily responsible for the blood supply to the skin and muscles of the posterior head and neck region
Pathway The occipital artery along with the greater occipital nerve and lesser occipital nerve passes through the fibrous canal of the posterior occipital bone adjacent to the nerve pathway Compression or traction of the blood vessels may also induce localized ischemic pain
Upper Trapezius Muscle
Attachments: Origin is from the superior nuchal line, external occipital protuberance, nuchal ligament, and all thoracic spinous processes, inserting on the acromial end of the clavicle, scapular spine, and acromion.
Nerve supply: accessory nerve and cervical plexus branches (C2-4).
Function: The upper fibers can elevate the scapula, and simultaneous contraction on both sides can cause the head and neck to tilt backward. When the intersection of the trapezius fascia and the posterior nuchal ligament becomes contracted, it increases pressure on the occipital nerve.
Sternocleidomastoid muscle
Origin and Insertion: The sternal head originates from the anterior surface of the manubrium, the clavicular head originates from the superior surface and outer edge of the sternal end of the clavicle, and the muscle belly spirals upward to insert on the external surface of the mastoid process and the lateral aspect of the superior nuchal line.
Nerve supply: accessory nerve and anterior branches of cervical nerves C2-C4.
Function Bilateral contraction can cause flexion of the head and neck while unilateral contraction can cause the head to tilt to the same side and turn to the opposite side Muscle contraction can easily affect the tension of the nuchal ligament
1. Occipital artery 2. Posterior lymph nodes of the occipital tendon arch 3. Lesser occipital nerve 4. Greater occipital nerve. 5. Treatment area. 6. Posterior insertion points of the sternocleidomastoid muscle 7. Spinous process of the second cervical vertebra 8. Posterior insertion point of the trapezius muscle.
Clinical manifestations
The clinical manifestations of migraines are diverse ranging from episodic severe pain to persistent dull or throbbing pain According to clinical experience migraines caused by stimulation of the greater or lesser occipital nerve often have the following characteristics
Pain location and extent
Headaches often occur in the occipital region and may radiate to the same side of the vertex and temporal region. Some patients may also experience tension and stiffness in the neck.Patients with a long course of illness may experience a pulsating sensation in the occipital region, and even discomfort that radiates to the periorbital and retroauricular areas.
Duration and frequency of episodes
Pain can be persistent or intermittent, with greater intensity during the acute phase, affecting daily activities; in the chronic phase, it is characterized by recurrent episodes lasting from several hours to several days each time.
Accompanying symptoms
Patients may experience nausea photophobia a feeling of eye pressure tinnitus and decreased attention In severe cases it can affect sleep and quality of life and may even lead to memory decline and mood swings
Tender point
Significant pain and swelling at the back of the head with notable tenderness often found about cm below the line connecting the mastoid process and the external occipital protuberance deep pressure may provoke or exacerbate headaches
Diagnostic Key Points
Medical History and Symptom Characteristics
There is a history of recurrent migraine and the headache often occurs in the occipital or cervical region with pain characteristics consistent with the distribution area of the occipital nerve
Physical examination
Pain and swelling at the back of the head with obvious tenderness found within a cm range between the external occipital protuberance and the mastoid process upon palpation which can exacerbate headaches
Imaging examination
XMRI
Xrays often show no significant abnormalities and cervical spine MRI can exclude other possible diseases that may cause headaches such as intervertebral disc herniation spinal canal compression and structural abnormalities of the atlas and axis
Ultrasound examination of the local soft tissue condition can be performed if necessary to assess the thickness or inflammatory changes of the posterior tendon arch
Differential Diagnosis
It is necessary to differentiate from cervical spondylosis tensiontype headache intracranial organic diseases etc
For those with obvious symptoms of nerve compression or local muscle and ligament lesions a comprehensive judgment should be made based on clinical manifestations and imaging
Treatment methods
Pi Needle Release Therapy Traditional Chinese Medicine Minimally Invasive Treatment
Indications
Patients with migraine due to dense contraction of the occipital tendon arch leading to repeated stimulation or compression of the greater occipital nerve or lesser occipital nerve Patients who have not responded well to conservative treatment oral analgesics physical therapies etc or those with recurrence after conservative treatment
Operating Steps
Position
The patient sits upright next to the treatment table with both hands overlapping on the surface and the forehead gently resting on the backs of the hands keeping the neck at an approximately forward tilt
Preoperative Preparation
Routine disinfection of the surgical area skin the operator wears sterile gloves prepares a beryllium needle commonly used specification
Needle positioning
At the most prominent point of tenderness the needle is perpendicular to the cranial surface and forms a angle with the skin
Decompression Method
The needle blade is perpendicular to the fiber orientation of the occipital tendon arch cutting or releasing the tense deep fascial fibersDuring the procedure it is necessary to maintain stability and proceed slowly avoiding excessive force to prevent damage to the greater occipital nerve and occipital vessels
Postoperative management
Generally only one treatment is required if symptoms persist treatment can be repeated after one week
After local tenderness and other symptoms from the procedure improve functional exercises can be performed such as neck extension and relaxation exercises
Postoperative local physiotherapy such as infrared irradiation can reduce inflammation and benefit tissue repair
Analysis of Advantages and Disadvantages
Advantages Minimally invasive small trauma quick results significant effect on fascial compression has a definite therapeutic effect on difficulttorelieve migraines
Disadvantages Requires a specialist physician very accurate anatomical location is necessary and the skills for the procedure are demanding
Other treatment methods
Medication Therapy
Conventional analgesics such as NSAIDs or tricyclic antidepressants can alleviate acute symptoms to some extent but they are prone to relapse or the development of tolerance
Specific medications for migraine attacks such as triptans can relieve symptoms but they do not fundamentally improve the pathological mechanism of nerve compression
Physical Therapies
Tuina massage acupuncture ultrasound and infrared etc can all improve the root cause of muscular and fascial tension and assist in alleviating symptomsHowever if the fascia is severely contracted and thickened due to prolonged contracture relying solely on conventional physical therapy often has limited effectiveness
Surgical treatment
For severe occipital nerve compression and fascial narrowing, microsurgical decompression may be considered, but the trauma is relatively significant, and the postoperative recovery time is longer. Compared to this more minimally invasive procedure, surgical costs are higher, and the indications are stricter.
Precautions
Anatomical positioning is accurate
Careful preoperative palpation combined with imaging should accurately determine the tension points of the posterior occipital tendon arch and the positions of the occipital nerve and blood vessels
Clear hierarchy of operations
The penetrating dissection procedure should be performed in layers to avoid injuring the deep nerves and blood vessels
Strict sterility concept
Preoperative skin disinfection and intraoperative procedures must comply with sterile requirements to avoid infection.
Postoperative Observation and Rehabilitation
Postoperatively, local swelling and pain should be monitored, and they should be instructed to perform gentle functional exercises of the neck and shoulder, and avoid prolonged postural stress on the affected area, such as sitting at the computer.
Summary
Minimally invasive treatment of migraines based on the release of the posterior neck tendon arch in traditional Chinese medicine combined with precise release using a beryllium needle at the fibrous areas of the tense and contracted posterior neck tendon arch can significantly alleviate the compression of the greater occipital nerve lesser occipital nerve and occipital artery with clear clinical efficacy This method is easy to perform and has a quick recovery time When combined with overall rehabilitation and functional exercises it can effectively reduce the recurrence rate of migraines With the continuous improvement of minimally invasive techniques in traditional Chinese medicine and a deeper understanding of the anatomical mechanisms of the posterior neck tendon arch this therapy has broader application prospects in clinical practice
About the author
Professor Zhang Ying，Postdoctoral fellow in orthopedics at China Academy of Chinese Medical Sciences and integrated Chinese and Western medicine at Xiangya Hospital of Central South University; former leader of soft tissue minimally invasive surgery at the First Affiliated Hospital of Guangzhou Medical University; China’s first doctor and postdoctoral fellow engaged in acupuncture research; The first professional doctor to introduce visceral and craniosacral manipulation to China; Won 2 national invention patents and 10 utility model patents; Proponent and promoter of structural medicine.
References
Zhou Jincai Zhang Ying Luo Yiwen et al Clinical and Mechanism Analysis of Release Needle Therapy for Myogenic Migraine Journal of Hunan University of Traditional Chinese Medicine
Zhang Ying Li Jiabang Zhou Jiangnan et al Release of the posterior cervical tendon arch in the treatment of cervicogenic headache and its relationship with serum Creactive protein Journal of Modern Chinese Medicine
Zhang Ying Zhou Jiangnan Zhou Jincai et al The Pathogenic Mechanism of the Occipital Tendon Bow in Cervicogenic Headache Journal of Neck and Low Back Pain
Zhang Ying Li Jiabang Zhou Zhonghuan et al Release therapy for cervicogenic headache and its relationship with nitric oxide and endothelin in the blood Journal of Traditional Chinese Medicine and Orthopedics
Dong Fuhui Peripheral Nerve Compression Syndrome MM Beijing Peoples Health Publishing House
Chen Desong Peripheral Nerve Compression Diseases MM Shanghai Shanghai Scientific and Technical Publishers
The Global Burden of Headache: A Documentation of Migraine Prevalence and Disability JJ. Lancet Neurology, 2017, 16(8): 635-637.
Editor’s note: Because the clinical experts are in different regions and countries, the treatment methods introduced in this article are new therapies that have appeared in the acupuncture community in mainland China in recent years. It may not be in line with your medical practice standards. Please make your decision according to local laws and regulations.
