I recently saw a woman in my clinic complaining that the left side of her head hurt. Not just a headache but also the muscles throughout her face, around her ear, eye socket, teeth, palate, jaw and the back of her head too. She complained that it felt as if a large hook were in the left side of her mouth painfully pulling her lips and cheek to her left ear. She also complained of the feeling of broken glass in her nose. Her sense of taste had been altered. She was very sensitive to light and sound too and complained of dizziness and nausea. This had been going on relentlessly for several months after a yoga session she attended. The pain was constant in her jaw and face and spread to the other areas of her head when it became worse. She had a very difficult time sleeping and had to lie “just so” in order to finally fall asleep. She said that sometimes she would have to wear a mask to keep breezes from touching her face as it would send her into waves of pain.
She had been to several neurologists and other doctors who agreed it was trigeminalgia—basically an irritation of her trigeminal nerve which fed different parts of her face (See the great image above from the guardian). The trigeminal nerve is mostly a sensory nerve which carries information from her face to her brain. She had been given a series of medications to control the pain and irritation but she didn’t want to control it, she wanted to fix it. She didn’t want to take medications.
Her past history involved several car accidents when she was little which left her with chronic migraine headaches and general neck stiffness and pain. She told me that since those accidents, she never liked having both arms over her head. No doubt, she neglected to tell this to her poor yoga instructor!
Several years ago she had a traumatic blow to her left shoulder which dislocated it and was repositioned in the ER with no further treatment. Earlier in the year, I was working with her knee, she was feeling so good she decided to try yoga again. It just so happened that I told her on her last visit that I thought I could help with her chronic migraines if she wanted to give it a go. After that I hadn’t seen her for months until recently. I had thought that somehow I had made things worse but instead she had developed this condition for which she had been trying to find answers. Because I worked with her knee, she thought I was a “knee guy” and never thought I could also help with her latest issue too (she saw this recent issue as unrelated to her migraines). Physical therapists help with conditions from head to toe.
Her doctor finally sent her my way in desperation. After going through her history, I believed I knew what was happening. I then evaluated her, which confirmed my suspicions. During our evaluation, I found I could press anywhere on her left arm or hand and elicit different patterns of pain in her face and head. This was news to her as no one had ever looked at this before. This is due to the fascial connections between the arms and neck/head area (See image below: Fascial Arm Line–posterior). I also found that the right side had a similar finding as the left, although she reported no symptoms on the right side (this also was news to her). I found several other issues, many of which are outlined in my neck pain & headaches book.
One detail that shone through her history and tipped me off to the root cause was that this occurred after a yoga session during which her arms were raised over her head. While it’s easy to dismiss this detail if you believe there are no significant anatomical connections between the shoulder and the neck or skull, I see daily evidence these connections exist and are very impactful in terms of pain generation and so it wasn’t a big leap to suspect shoulder girdle dysfunction as a root cause of the irritation. I can certainly understand how most doctors would not suspect this as a irritant to the trigeminal nerve as there is no anatomical text that describes it. Yet I see it frequently as evidenced by the successes I have with difficult headaches and neck pain and now perhaps two trigeminalgia cases (see the very first unsolicited testimonial I received just three weeks after I released my neck pain book from someone who I think had trigeminalgia. It’s the first testimonial on the page).
After her first treatment session three things happened that were new to her since this began several months ago: 1. the pain had decreased significantly and had leveled off. 2. that night she slept through the night with no pain. 3. she had forgotten to take her pain meds for an hour and a half—something she never missed for months because the pain would be screaming back if she didn’t take her meds every 30 minutes. These were all good signs.
Our second treatment reproduced our first and she was feeling more relief during the session. “It’s like when you have a sand castle and pour water on it and see it melt away” she said of the pain. These are the descriptions I like to hear. They confirm we’re on the right track. I’m definitely not a “No Pain, No Gain” physical therapist. I taped her shoulder blades in place which I had also done the first treatment (I’ve just added a video of this technique to both my shoulder and neck pain book videos to help people recover faster from their issues. They can be found in the “Bonus Videos” portion of the videos for those books).
I saw her for 10 sessions before her insurance visits ran out. Overall she eliminated almost all of her pain including the hook in the face and broken glass feelings, the sensitivity to light and sound were nearly gone, there was no more dizziness or nausea, she was sleeping much better and now understands why it all happened in the first place. I wish I could’ve seen her to the end but that happens sometimes in physical therapy when you work with insurance. That’s why it’s crucial that we educate our patients as much as possible about their condition and how to think about it. She can now use her body in a way that feeds her rather than breaks her down.
I thought this was an interesting case because the trigeminal nerve is a cranial nerve–meaning it originates in the brainstem. How would working with her shoulder affect this nerve? I’m not sure, however I wonder if there are fascial attachments from the cervical spine that somehow travel through the foramen magnum (the hole where the spinal cord exits the skull) and interacts with the cranial nerves either directly or indirectly. Or possibly it affects where the cranial nerves exit the skull to feed the face. Either way, it gives hope that other similar cranial nerve issues may be impacted via treating the shoulder girdle. I’d love to experiment more and visit a cadaver lab to explore these potential connections!
I hope this gives some hope to those of you with perplexing pain conditions. My premise in working with every patient is that there is a solution. We just need to uncover it–even if I’m not the person with the answer.