The obliquus capitis inferior (OCI) muscles may be the most underappreciated of all the suboccipitals. Arising from the spinous process of C2 (axis) and inserting on the transverse process of C1 (atlas), their primary function is head-on-neck rotation. Notice in Image 1 how the hypercontracted right OCI causes reciprocal lengthening on the left. During intake exams, habitual stomach sleepers often recount waking one morning unable to turn the head left without triggering upper neck and head pain. Many of these stomach-sleeping headaches are rooted in neurovascular tension or compression from mechanical strain. In this article, I’ll present cervicogenic headache research, propose biomechanical explanations, and demonstrate Myoskeletal Alignment Techniques (MAT) for treating stomach-sleepers’ headaches.
One of the first to focus on cervicogenic head pain was famed spine researcher Nikolai Bogduk, MD, PhD. In his 1995 paper “Anatomy and Physiology of Headache,” Bogduk writes: “All headaches have common anatomy and physiology. All headaches are mediated by the trigeminocervical nucleus and are initiated by noxious stimulation of the endings of the nerves that synapse on this nucleus.”1 Bogduk explains that head pain arises from overstretched and compressed upper cervical spine dura and nerve roots (Image 2).
In a 2011 study published in the journal Spine, Frank Scali and colleagues state that optimal suboccipital balance prevents abnormal dural tension during atlas-axis rotation and occipitoatlantal flexion and extension.2 Interestingly, in 86 percent of the study’s dissected cadavers, OCI fibers penetrated the C1–2 interspace and attached to the dural membrane.  
Lacking are studies investigating the relationship between prolonged stomach sleeping and dural damage, but it seems plausible that altered cervical mechanics could prohibit the suboccipitals from safeguarding the dura from motion-related stress, tension, and inflammation. The following case study details how neck and head pain may arise in stomach-sleeping clients and offers suggestions for addressing this condition.

Biomechanical Explanations   
In this scenario, the stomach-sleeping client rises from bed and attempts to left rotate his head back to neutral. Optimally, the atlas vertebra rotates with the head, but with a neurologically shortened right OCI, the atlas drags the axis with it. Left untreated, an “atlas wedge” causes chronic OCI spasm that fixates C1 on C2 (Image 3). If the head is forced to left rotate, the joint jamming moves down the chain to C2–3. With the dura firmly attached to only three spinal segments (foramen magnum, C2–3, and sacrum), the brain abhors bony disturbances at this key neurological center. Mechanoreceptive and nociceptive bombardment from overstretched spinal ligaments, joint capsules, and suboccipital muscles may wreak enough havoc to convince the brain to protectively guard or elicit pain. Images 4, 5, and 6 demonstrate an effective MAT routine for releasing hypercontracted right-side OCI muscles, a gentle atlas-axis alignment technique, and a graded exposure stretch to relieve sympathetic guarding.  
Since the nervous system directs all bodily functions, it behooves today’s therapist to acquire skills for treating mechano-sensitivity in neural structures. Some therapists engage the nervous system via gentle skin manipulation, some through fascial stretch, and others, such as myself, include mobilizations for bones attaching to the dura mater.
Clients must understand that the brain is their best friend, and pain is there to protect their body from further perceived insult. It’s tempting but counterproductive to tell clients their pain results from muscle spasm, trigger points, or bones out of place. As discussed in my San Diego Pain Summit column (“Changing the Brain’s Mind About Pain,” Massage & Bodywork, July/August 2015, page 101), clients simply need to be reassured they are in a safe place, and that everything is all right, right now.   

Notes
1. N. Bogduk, “Anatomy and Physiology of Headache,” Biomedicine & Pharmacotherapy 49, no. 10 (1995): 435–45.
2. F. Scali, E. S. Marsili, and M. E. Pontell, “Anatomical Connection Between the Rectus Capitis Posterior Major and the Dura Mater,” Spine 36, no. 25 (December 2011): E1612–4.

Erik Dalton is the executive director of the Freedom from Pain Institute. Educated in massage, osteopathy, and Rolfing, Dalton has maintained a practice in Oklahoma City, Oklahoma, for more than three decades. For more information, visit www.erikdalton.com.