title: Reduction in high blood tumor necrosis factor-alpha levels after manipulative therapy in 2 cervicogenic headache patients.
abstract: OBJECTIVE
  This case report discusses the treatment of 2 patients with cervicogenic headache (CHA) attending the Outpatient Clinic of the Hungarian National Institute for Rheumatology and Physiotherapy (Budapest, Hungary) and reviews the pathophysiology, therapeutic strategy, and problems associated with the treatment of CHA.
  
  
  METHODS
  Patient 1 was a 27-year-old female who sustained a whiplash injury. A sharp, shooting headache developed, readily induced, and aggravated by just bending the neck backward or by turning her head. Magnetic resonance imaging revealed a disk protrusion at C4-C5 pressing the anterior cerebrospinal space. Patient 2 was a 62-year-old female who sustained a whiplash injury; her cervical movements became restricted, which precipitated headaches. Magnetic resonance imaging revealed a paramedian disk hernia between the C4 and C5 vertebrae that intruded into the right ventral cerebrospinal space.
  
  
  RESULTS
  After 4 weeks of manipulative therapy for patient 1, both active and passive range of motion returned to normal, and the high tumor necrosis factor-alpha (TNF-alpha) level (63 pg/mL) was substantially reduced (28 pg/mL). Patient 2 was started on manipulative therapy twice a week for 4 weeks; after 2 months, the patient became symptom-free, and high TNF-alpha level (72 pg/mL) was reduced greatly (35 pg/mL).
  
  
  CONCLUSIONS
  Two patients with whiplash injury and disk herniation developed CHA associated with very high TNF-alpha levels. After manipulative therapy, these patients became symptom-free, and their TNF-alpha levels decreased substantially.
authors.affiliation: Department of Rehabilitation, Hungarian National Institute for Rheumatology and Physiotherapy (HNIRP), Budapest, Hungary. ormos-kovacs@t-online.hu
authors.forename: Gábor
authors.initials: G
authors.lastname: Ormos
authors.forename: J N
authors.initials: JN
authors.lastname: Mehrishi
authors.forename: Tibor
authors.initials: T
authors.lastname: Bakács
mesh_terms: D000328:Adult; D015415:Biomarkers / Q000097:blood; D002574:Cervical Vertebrae / Q000293:injuries / Q000473:pathology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015601:Injury Severity Score; D007405:Intervertebral Disc Displacement / Q000097:blood / Q000209:etiology / Q000534:rehabilitation*; D008279:Magnetic Resonance Imaging; D020393:Manipulation, Spinal / Q000379:methods*; D008875:Middle Aged; D010147:Pain Measurement; D051298:Post-Traumatic Headache / Q000097:blood* / Q000209:etiology / Q000534:rehabilitation*; D016059:Range of Motion, Articular / Q000502:physiology; D020127:Recovery of Function; D018570:Risk Assessment; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000097:blood*; D014911:Whiplash Injuries / Q000097:blood / Q000150:complications*
chemical_list: D015415:Biomarkers; D014409:Tumor Necrosis Factor-alpha