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.

基於枕後腱弓鬆解的中醫微創治療偏頭痛章瑛

章 瑛

引言

偏頭痛（migraine）是一種常見而複雜的神經血管性頭痛，全球發病率較高。據世界衛生組織（WHO）統計，約有10%～15%的人群在其一生中會遭受不同程度的偏頭痛困擾。偏頭痛的病因複雜，涉及遺傳、環境、內分泌、神經血管調控等多方面因素，可按臨床表現和觸發因素進行多種不同類型的分類，如普通型偏頭痛（無先兆偏頭痛）、典型偏頭痛（有先兆偏頭痛）等。

在眾多病因學研究中，枕大神經和枕小神經與部分類型的偏頭痛關係密切，臨床與解剖學研究均發現，當枕大神經或枕小神經遭受病變刺激或卡壓時，可引發或加重同側的偏頭痛症狀。枕部胸鎖乳突肌與斜方肌腱在枕後形成的枕後腱弓，是最常見的壓迫與刺激枕後神經及血管的關鍵解剖部位。

隨著中醫微創理念的不斷發展基於枕後腱弓鬆解而針對性治療偏頭痛的鉍針鬆解術因其具有操作簡便療效確切創傷小康復快等優勢受到臨床醫師的廣泛關注本文結合解剖結構及臨床研究對枕後腱弓鬆解的中醫微創治療偏頭痛進行系統闡述以期為臨床診療提供參考

應用解剖

偏頭痛的發生與枕大神經枕小神經在枕後骨纖維管內受到攣縮性筋膜或肌腱壓迫刺激關係密切故對枕後腱弓枕大神經枕小神經枕動脈等局部精細解剖的理解尤為重要本節著重對與本治療相關的關鍵解剖結構進行描述並建議臨床醫師在術前仔細閱讀對照相關解剖圖譜必要時可結合影像學進行定位

枕後腱弓

位置位於枕骨上項線向下約處的深筋膜纖維多呈橫向排列內復於斜方肌腱膜外連胸鎖乳突肌腱質地致密而堅韌

與周圍結構的關係枕後腱弓與枕骨共同形成扁平狀骨纖維管稱為枕後骨纖維管枕大神經枕小神經及枕動脈在此管道內由內向外排列通過時易受到攣縮纖維的壓迫

功能與病理枕後腱弓攣縮可導致局部張力增大對穿行的神經血管形成卡壓從而誘發或加重偏頭痛症狀

枕大神經

來源及走行：枕大神經由第2、3頸神經後支發出，是所有脊神經後支中最大、最長的一支。穿行於頭下斜肌與頭半棘肌之間，於第2頸椎棘突平面附近與項韌帶相鄰，後向外、上方向穿行至斜方肌腱膜，最終通過枕後骨纖維管進入頭皮淺層，支配枕項及耳上方皮膚。

可能受到的壓迫枕大神經在穿過枕後骨纖維管時易受到攣縮的枕後腱弓或增厚筋膜的刺激和壓迫引發神經分佈區的疼痛或麻木症狀

枕小神經

來源及走行枕小神經由第頸神經前支的頸叢分支經胸鎖乳突肌後緣中點穿出沿肌後緣上行至枕部支配頭外側部皮膚

可能受到的壓迫當胸鎖乳突肌或斜方肌腱膜緊張攣縮枕後腱弓增厚時枕小神經在行經枕後區域同樣存在受壓或刺激的可能

枕動脈

供應範圍枕動脈主要負責頭頸後側部及枕部皮膚肌肉的血液供應

走行特點枕動脈與枕大神經及枕小神經同樣穿過枕後骨纖維管毗鄰神經走行血管受壓或牽拉也可能誘發局部缺血性疼痛

斜方肌

起止點：起自上項線、枕外隆凸、項韌帶及全部胸椎棘突，止於鎖骨肩峰端、肩胛岡及肩峰。

神經支配副神經及頸叢肌

功能：上部纖維可上提肩胛骨，兩側共同收縮可使頭頸後仰。當斜方肌腱膜與枕後腱弓交匯部位攣縮時，加劇對枕神經的壓迫。

胸锁乳突肌

起點與止點：胸骨頭起自胸骨柄前方，鎖骨頭起自鎖骨胸骨端上方及外緣，肌腹螺旋向上止於乳突外側面及上項線外側面

神經支配：副神經和頸神經 C2-C4 的前支。

功能雙側收縮時使頭頸屈曲單側收縮時使頭偏向同側並轉向對側抽去收縮易影響枕後腱弓的張力

枕動脈枕後頸弓內視鏡枕小神經枕大神經治療部位胸鎖乳突肌枕後止點第頸椎棘突斜方肌枕後止點

臨床表現

偏頭痛的臨床表現多種多樣既可呈發作性劇痛也可表現為持續性鈍痛或脹痛根據臨床經驗枕大神經或枕小神經受刺激所致的偏頭痛常有以下特徵

疼痛部位與範圍

頭痛多起於枕部，可向同側頭頂及顳側放射，部分患者可伴隨頸項部緊張、發僵感。病程久者可出現枕部搏動感，甚至牽拉至眶周、耳後部位的不適。

持續時間與發作頻率

疼痛可為持續性或間歇性發作，急性期疼痛強度較大，影響日常活動；慢性期則表現為反覆發作，每次持續數小時至數天不等。

伴隨症狀

患者可出現噁心畏光眼脹感耳鳴注意力下降等嚴重時影響睡眠和生活品質甚至出現記憶力減退情緒波動等

壓痛點

枕後脹痛明顯乳突與枕外粗隆連線中下方約公分處常有顯著壓痛深壓可誘發或加重頭痛

診斷要點

病史與症狀特點有反覆偏頭痛病史且頭痛多起於枕部或頸項部疼痛特點與枕神經分佈區域相吻合

体格检查

枕后胀痛触诊可于枕外粗隆与乳突间下范围找到明显压痛点并可诱发头痛加重

影像學檢查

光常無明顯異常可透過頸椎固定椎間盤突出頸椎椎管佔位寰樞椎結構異常等其他可能導致頭痛的疾病

必要時可行超聲檢測局部軟組織情況評估枕後腱弓厚度或炎症改變

鑑別診斷

需與頸椎病肌緊張性頭痛顱內器質性疾病等相鑑別

對於有明顯神經卡壓症狀或局部肌肉韌帶病變者應結合臨床表現及影像學綜合判斷

治療方法

鈹針松解術中醫微創治療

適應證

枕後腱弓緻密閉收縮導致枕大神經或枕小神經反覆受刺激或卡住的偏頭痛患者經保守治療口服止痛藥物理治療等效果不佳或癱瘓者

操作步驟

體位

病人端坐在治療台前兩臂重疊位於工作站上前額輕放於腹背上使頸部保持約前傾

術前準備

常規術消毒區皮膚術者戴標準手套準備鈹針常用規格

進針定位

在壓痛點最明顯處針體與顱骨面垂直與皮膚呈夾角

松解方法

針刃與枕後腱弓纖維方向垂直透過切開或鬆解緊張休縮的深筋膜纖維操作時需保持穩定緩慢不宜用力過度避免損傷枕大神經及枕血管

手術後處理

一般治療次若症狀殘留可在週後再次治療

待局部壓痛及症狀消失後可進行功能性鍛煉如頸項部伸展及放鬆練習

手術後輔以局部物理治療如紅外線紅外線可促進電網吸收和組織修復

優缺點分析

優點創微創傷小見效快針對筋膜卡壓效果明顯難以緩解的偏頭痛有有意治療

缺點需專業醫師進行操作解剖定位要求準確且對術中技術掌握要求較高

其他治療方法

藥物治療

常規止痛藥如非類固醇抗發炎藥或三環抗憂鬱藥能一定程度緩解急性期症狀但易於插入或更換針對偏頭痛的藥物如曲坦類雖然能緩解症狀但對神經卡壓的病理機轉無根本改善

物理治療

按摩針灸超音波物理治療紅外線照射等可改善手術與筋膜的緊張狀態並輔助減輕症狀但若筋膜嚴重攣縮僅依靠常規物理治療往往治療有限

手術治療

對於嚴重的枕大神經卡壓、筋膜狹窄者，可考慮顯微手術鬆解，但創傷相對較大幅度，不一定恢復時間較短。與鈹針微創相比，手術費用更高，適應證更嚴格。

注意事項

解剖定位準確

術前應仔細觸診並結合影像檢查精確判斷枕後弓形張力與枕神經血管的位置

操作層次要點

滲透式松解操作需分層進行避免誤傷深部神經血管

嚴格無菌概念

術前皮膚消毒與中術操作均須符合嚴格要求，避免感染。

術後觀察者與康復

手術後應及時觀察患者局部腹部、疼痛情況，指導其進行頸項部功能鍛煉，並避免長時間單一體位。

小結

基於枕後頸弓松解的中醫微創治療偏頭痛結合鈹針在緊張康復的枕後腱弓纖維處行精準松解可顯著著醒枕大枕小神經及枕動脈受壓狀況臨床危及此方法操作不得快速恢復配合整體復健與功能鍛煉能有效降低偏頭痛的痊癒率隨著中醫微創技術的不斷改進及對張力枕後機制認識的深入此治療弓在臨床上具有更穩定的應用前景

作者簡介

章 瑛教授,中國中醫科學院骨傷專業、中南大學湘雅醫院中西醫結合專業兩站博士後；原廣州醫科大學第一附屬醫院軟組織微創外科學科帶頭人；中國第一位從事針刀專業研究的博士及博士後；首次將內臟及顱骶骨手法調理引進國內的專業醫師；獲國家發明專利2項，實用新型專利10項；結構醫學的提出者及推廣者。

参考文献

周锦财章瑛罗毅文等松解针治疗肌源性偏头痛的临床及机理分析湖南中医学院学报

章瑛李家邦周江南等枕后腱弓松解治疗颈源性头痛及与血清反应蛋白的关系中国现代医学杂志

章瑛周江南周锦财等枕后腱弓在颈源性头痛中的发病机制颈腰痛杂志

章瑛李家邦周中焕等松解治疗颈源性头痛及与血中一氧化氮内皮素的关系中国中医骨伤科杂志

董福慧皮神经卡压综合征北京人民卫生出版社

陈德松周围神经卡压性疾病上海上海科学技术出版社

編者註：因各位臨床專家所在地區和國家不同，本文介紹的治療方法，是近年來出現在中國大陸針灸界的新療法。不一定符合您的行醫規範，請您根據當地的法律法規決定取捨