Male Having Headaches

MALE HAVING HEADACHES

A twenty-six year old male appeared in my office with complaints of headaches of one year duration. The patient describes his headaches as starting in his neck, creating a tightness that runs to the top of his head then behind his right eye. The patient relates some relief when he "pops" his neck. The patient has been to six medical physicians in the last year. He has had multiple examinations and tests including MRI and CT. All the examinations were negative. He has been on numerous medications including steroids without relief. The patient gives a past history of being involved in an automobile accident approximately six years ago.

Examination of this patient showed his reflexes to be +2 in the upper extremities. Cervical range of motion was restricted and painful. Palpable tenderness at C1, C2, and C6-T2. Cervical compression tests were positive on the left and right. Cervical distraction tests were positive.

X-rays were taken of this patient’s neck. The x-rays were reviewed with the patient. The intervertebral foramina were open. There were no thin discs and no signs of significant degeneration. The vertebral bodies were rotated to the right with a misalignment noted at C2.

I explained my findings with the patient including the x-rays. I discussed his options. He realized that he had tried almost everything before coming here. I suggested a series of spinal manipulations to try to restore normal function to the vertebrae of the neck. The patient agreed. The patient was given his first spinal manipulation. I advised the patient to return the next day.

The patient stated that his headache felt a little better. However, he slept much better. The patient was treated again. He was told to return the next day.

The patient comes in saying that his headaches are a lot better. I suggested a course of treatment of six weeks and then I would do a re-evaluation. The patient agreed.

During the course of treatment the patient had good days and bad days. The bad days involved headaches however, never as bad as the original complaint. The patient continued to sleep and rest better.

At the end of the six weeks the patient was re-evaluated. His original findings had improved however; there remained a restriction in the cervical range of motion. The patient was advised he needed two to three more weeks of care. The patient agreed.

At the end of three weeks the patient appeared to have fully recovered.