Cervicogenic headache secondary to overactive SCM + VBI secondary to elevated pleural dome and tight scalenes

Subjective (TBC)

Miss L, 22 years old, Female, R hand dominant

Pa - Tension headaches over posterior occiput region on exertion, comes with nauseousness sometimes

Pb - Cramping feeling over R eye, occasional on exertion

Pc - Occasional weakness over R arm

MOI: insidious onset, Pa long standing problem, Pa diagnosed as Migraine although MRI scan NAD.

Pb, Pc onset few months ago.

Aggravating factors(all): exertion - climbing stairs, jog/run

Easing factors: Rest, Epilim for migrane during runs only.

24hr - activity dependent

Patient reported feels breathless easily and is VBI positive on R side.

Objective findings
Observation
Forward head posture
Palpation:

• R SCM, Scalenes tender on palpation(trigger points radiate pain to Pa, Pb)
• R 1st Rib elevated
• Increased tone in abdominal muscles
• Diaphragm tender on palpation bilaterally, Right worse than Left
• Increased tension over R PleuroCervical ligaments

ROM
Cx
-Flexion FROM, Left opening pattern FROM, no pain on overpressure
-Extension FROM, dull ache at end range
-R rotation feels discomfort and mild nauseousness
-L lateral flexion feels tight, firm end feel.
-Closing Pattern/VBI test positive, onset immediately(reports nauseous, dizziness, drop attack sensation, discomfort)

PAIVM
-R 1st rib caudal glide hypomobile, Pb and Pc provocated
-C0-C2 hypomobile on R only
-C2-C7 hypomobile in all segments, R worse than L
-T1-T2 hypomobile
-Costotransverse Joint 2 hypomobile

Breathing
-Increased scalenes activity on R
-Decreased rib expansion over R upper ribs

Muscle Length Test
SCM both tight, R worse than L
Anterior and middle scalenes tight on R side
Upper trapezius, levator scapulae R=L

Treatment
Linea Albea release
R SCM, Scalenes soft tissue release + MET
1st rib caudal glide
Costotransverse Joint 2 manipulation
//patient able to breathe better, increased L lateral flexion range
PleuroCervical Ligament release
Subclavian-Brachial artery traction
//VBI symptoms onset after 20 seconds with marked decreased severity of symptoms.
MET C0-C1, C1-C2
C3,C4 upslope manipulation
// R rotation FROM, no pain on overpressure