Case Study
14-Year-Old presented with Severe Headaches

Reuben C is a 14 year-old boy who was an A- student from a very supportive family.  He has little social pressure, but is very bright and excels in most areas.  He came to us with constant debilitating headaches.  He was diagnosed with a slight overbite and braces were put on his teeth approximately one year ago.   About two months later the headaches began and within three months he had to be taken out of school and home schooled because the headaches only increased in intensity and duration.  The pediatrician basically put the headaches down to stress.  They then sent him to two TMJ specialists who said he should be splinted and medicated for pain.  One made him a night splint because they felt he was clenching his teeth. None of these things gave the child any relief.

The doctor then wanted to send him to physical therapy but they did not have a reason for doing that. He was next tested by a neurologist, who again diagnosed stress and prescribed muscle relaxants and heavy pain medication.  None of the doctors ever asked what other medications had been prescribed by the other doctors.  Another doctor said it was not TMJ, but did not look anywhere else for the cause of the headaches.  He was sent to a massage therapist for relaxation treatment.  On a scale of 0 to 10 where 0 is pain-free and 10 is emergency room pain; he rated his headaches as 7.

His mother began searching for answers on her own.  She found a book about alternative methods to treat headaches.  It mentioned CranioSacral Therapy and listed references in the back.  She got on the Internet and went to www.alternativemedicine.com where she found our listing.  She looked in her local area of New Mexico for someone who knew something about CST. She went to our website and was very impressed by what she read.  She called for information and since Reuben had never had neck or jaw pain and I was able to describe the type of pain her son was having just from how she answered my questions, she set up an intensive at our clinic.

We saw Reuben in our office for a two-hour evaluation and for 6 hours of treatment, two hours a day for four days.  Upon initial evaluation I saw a typical 14 year-old boy, slender build, with marked forward head, upper cervical extension, and fascial restrictions throughout his body.    His headaches would come and go and were mainly "cranial cap" headaches.  He had no neck pain, minimal TMJ pain on the right, with popping at the joint only on opening the jaw.  I did a full assessment of his body to determine any additional imbalances.  I found increased weight bearing on the left lower extremity.  His right iliac crest was higher.  His left ASIS was forward and rotated down.  The nipple line was asymmetrical; the right side was lower approximately one inch.  His right shoulder was lower than his left.  The right clavicle at the sterno clavicular joint was more forward.  His right ear was higher.  The left PSIS was also up.  The left scapula was up and forward, versus the right, which was lower and retracted.  In a supine position both shoulders were significantly up off the mat but the right was more than the left.  He had no other pain, besides the headaches.

Upon assessment of the intraoral cavity, I found marked tightening of the pterygoids, right greater than left.  The vomer was very high up and immobile.  It looked like his head had been placed in a vise.  It was as though the sides had been compressed and everything was trying to come out the top of his head.  His sphenoid was stuck and not moving.  He had almost no cranial rhythm because of the immobility.

Reuben did very well with treatment.  After the first session, the headache, which had been constant for the previous six months, was gone.  The clicking and popping in the right side of his jaw had stopped and he said he felt he could breathe better out of both sides of his nose.

I worked to balance the whole body and restore the CranioSacral rhythm in order to assure that the other CranioSacral adjustments would hold.

We achieved our goals. On his last visit, everything was balanced and aligned in a more neutral position.  We had restored his CranioSacral rhythm.  We gave him some home exercises and posture and body mechanics training so he may continue to progress.  We instructed the parents that a growth spurt might cause some additional symptoms but that I could do more adjustments at that time.  He was entirely pain-free after the second visit and when he left he was standing in a more upright balanced posture with significant improvement in his forward head posturing.  He stopped using the night splint after our second visit because he was no longer clenching his teeth at night.  When he left, he had a great big grin on his face because he was finally pain-free.

Since Reuben lives out of state, we called to follow-up with him two weeks later.  He reported that he was still pain free and it was now easier for him to move in space.  He will be returning to school to finish the semester with his friends, like a normal 14 year-old boy.  We will see him periodically during school breaks for maintenance.

This website last updated on 31 July 2010

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