#PTonICE Daily Show – Thursday, December 21st, 2023 – Needling for the suboccipital headache

In today’s episode of the PT on ICE Daily Show, Dry Needling lead faculty member Ellison Melrose discusses how to dry needle the occiput to address headache complaints. Elli orients listeners to the anatomy of the occiput as well as muscles to target when needling. She also discusses what stim parameters to use when treating headaches.

Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog

If you’re looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling, Lower Body Dry Needling, and Advanced Dry Needling.


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All right, good morning, Instagram and YouTube. Welcome to the PT on ICE Daily Show. My name is Dr. Ellison Melrose. I am lead faculty with the dry needling division. We’re gonna dive right into things today. I am here to bring you dry needling for the suboccipital headache. And why I say that in quotations is because oftentimes when people are complaining of headaches at the base of the occiput, If we actually take time to palpate those tissues, it’s not the true suboccipitals, okay? So we are thinking about the occipital insertion of things like upper trap and semispinalis. Those are our two main culprits when we have patients that complain of the headaches that start at the base of their occiput. So before we dive in, first of all, I have already cleaned the tissue of my patient here. but let’s orient ourself to the anatomy of this occipital area.

So in order to do so, we are gonna start by palpating for the external occipital protuberance, which is the protuberance, which is the nice bump on the back of our head here. So that’s going to give us that orientation of where that superior nuchal line is, okay? Superior nuchal line is going to be the superior border of those occipital insertion of upper trap and semispinalis. We can follow that superior nuchal line down towards the mastoid process here. That’s going to give us our, again, superior border of where those needles live. If we follow the mastoid process medially, it dives deep, but the inferior nuchal line is going to be the inferior most border of where we’re needling today. What I want to do is I wanna take some time to find where the true suboccipitals live as to avoid needling in this area. So in order for us to do that, we’re going to, there’s a couple ways to find this region. First, we can palpate that EOP, external occipital protuberance, and drop down. The first spinous process we come in contact with is going to actually be spinous process of C2, as C1 does not have a spinous process. So that is going to be the inferior aspect of where the true suboccipitals live. Let’s come back towards the mastoid process. From there, if we drop just distal, feeling the lateral like pillars of the neck, that is going to be the transverse, the first thing we palpate there is a transverse process of C1. So the true suboccipitals live between the spinous process of C2, transverse process of C1 and that inferior nuchal line. So we do not want to be needling in that area today, as it’s a little bit more of an advanced technique. And I think when we’re talking about the headaches that present at the base of the occiput, it’s actually not the true suboccipitals. So for orienting ourself to where the muscles are, we have two main muscles, but we have bilateral tissue. So we’re going to be treating bilaterally for this headache presentation. We are going to find that external occipital protuberance. If we step just about a finger breadth lateral to that, we can palpate a tootsie roll shaped tissue, and that is going to be your upper trap insertion on the occiput. When we’re needling this area, we want to be mindful of some sensitive structures around this tissue. For example, what kind of is around the upper trap insertion is going to be greater occipital nerve. Essential anatomy is going to make it really seem very easy to find and it’s not necessarily easy to find. One way that we can avoid too much interacting with this nervous tissue is going to be limiting our pistoning in this area.

So for treating these occipital insertion musculature, we want to be using our E-STIM with pain modulating parameters. Okay, so EOP, first step lateral, is going to be that tootsie roll of upper trap. From there, we can take another finger breath lateral to that and we can find semi spinalis muscle belly as well as it inserts on the occiput. So let me do that on the other side. EOP, upper trap, we got a good old tootsie roll here. And then just stepping just lateral to that, we have semi spinalis. There is an area we want to avoid in this area, region as well. And it’s going to be, if we find the mastoid process, about one finger breadth medial to that, there’s a little sulcus. That sulcus is where the occipital artery lives. And if we go too deep there, we can interact with things like the vertebral artery and such. So we don’t wanna be interacting with that tissue there. So we are gonna be keeping, it’s pretty small territory here, but keeping our needles about, you know, two finger breaths away from that EOP is where those needles are going to be living. Let’s talk about needle application. So in this area, the occiput is kind of diving anteriorly, right? So we want to have a bony backdrop for these muscles, and that’s going to be on that occiput. We want to be using a firm palpation to mitigate the sensation of the needle inserting into the tissue. There’s a lot of tendinous tissue here, so sometimes it can be a little bit more sensitive of an area to needle. So we can mitigate that sensation with increasing our palpation and our compression there. Our needle angle, let me just grab a guide tube out and we can kind of go over that. Our needle angle is going to be almost perpendicular to that occiput. So if we’re thinking about the needle angle is like so. So for upper trap, we’re thinking about angling that needle almost towards the eyeball or on that ipsilateral side of that muscle. For the semispinellas, it’s a little bit more lateral. The occiput is diving, again, anterior. So there’s some 3D anatomy here. We wanna be inserting, again, perpendicular to that occiput. So our needle angle, may look a little bit more flared towards midline, or that needle angle is going towards the contralateral eyeball, okay? So, again, let’s orient ourself, and we’ll then start placing some needles, because that’s why we’re here, right? So, palpating external occipital protuberance, stepping just distal to that and lateral, so we’re underneath that superior nuchal line. If we are at the level of the EOP, we’re going to be in more tendons. We wanna be a little bit more distal between superior and inferior nuchal line. Finding that tootsie roll, that’s going to be upper trap. We are using a firm two finger digital compression to rock climber grip that upper trap against the occiput. We’re using some short needles here. So I have 30 millimeter needles, and that should be sufficient enough to access this tissue. My needle angle for upper trap is going to be, compress, create a small treatment window between my fingertips, and I’m letting that needle settle. My needle angle is directly towards the eyeball on the ipsilateral side. Firm tap, and then we’re going to advance our needle towards a bony backdrop on that occiput. So there we have upper trap on the patient’s right side, And then our semi-spinalis is going to look very similar to that. We’re just thinking just lateral to that insertion of upper trap, okay? So this is a petite anatomy here, so we don’t have a ton of space between that kind of mastoid process and the upper trap needle that we just placed, right? So what we’re going to be doing is the same sort of thing, hook, rock climber grip, Now my needle angle’s a little bit more flared towards the midline, towards the opposite eyeball. Firm tap needle towards occiput. So now we have placed both upper trap and semi spinalis needle on the patient’s right side. For treatment purposes, I would be doing bilaterally. And we can walk through that if, let’s do it. Why not? Let’s do it again. So, again, we’re gonna find EOP, drop just distal to that, just distal to that superior nuchal line, stepping one finger breadth laterally, that’s gonna be our upper trap insertion. Needle direction is towards the eyeball, perpendicular with the occiput here. Two finger digital compression, firm compression, creating a small window between our two fingers, firm tap, advancing the needle to a bony backdrop on the occiput. Again, we’re limiting the pistoning in this area because we have some sensitive structures like that greater occipital nerve, really close to the upper trap insertion there. We are then going to step just lateral to that to interact with the semispinalis insertion at the occiput. So again, one finger breath lateral to that, avoiding that sulcus between the mastoid process and this muscle tissue, compressing tissue. Now my needle angle is a little bit more towards the contralateral eyeball. And we’re again, looking for a bony backdrop here, maintaining that depth as we let that tissue recoil. So again, optimal treatment for these muscles is going to be setting up a circuit for pain modulation, and treating that tissue there. We want to limit pistoning in order to mitigate interaction with some more sensitive structures, including the greater occipital nerve. Again, for these suboccipital headaches, we are not treating the true suboccipitals. We are a little bit more proximal to that. We are thinking we are at the occipital insertion of upper trap and semispinellis. We want to orient ourself to this anatomy by finding the EOP mastoid process, and the region of the true suboccipitals as to avoid that area. We’re using a firm compression to mitigate the sensation of the needle insertion. Upper trap is going to be perpendicular to the occiput. Needle direction is towards the eyeball, ipsilateral eyeball. Semispinalis is just about a finger breadth lateral to that, and we are angling the needle towards the contralateral eyeball. So there we have the needling technique for treating the suboccipital headaches. Um, there’s actually the occipital insertion of upper trap and semi spinatus So that’s all I have for you guys today. If you guys can catch us out on the road next spring We have some upcoming live courses in january. We’re kicking off the the new year strong I will be teaching in rochester, minnesota the second weekend of january. I believe that’s the 12 through the 14th, and Paul will be up in Bellingham, Washington for our first advanced course that same weekend. Then you can find me teaching the upper quarter in Longmont, Colorado two weeks later, so the last weekend in January. And Paul will be continuing some courses out in Seattle. So feel free to hop onto PTOnIce.com to check out where we are on the road. Again, this is We’re starting the new year off really strong with some upcoming courses and our first advanced concepts course that Paul will be leading in Washington. So hope you guys have a great rest of your Thursday and I am signing off. See ya.

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