Research Review By Dr. Jeff Muir©


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Date Posted:

December 2019

Study Title:

The association between headache and low back pain: a systematic review


Vivekanantham A, Edwin C, Pincus T, Matharu M, Parsons H, Underwood M

Author's Affiliations:

University of Warwick, Coventry, UK; University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK; Centre for Epidemiology Versus Arthritis, University of Manchester, UK; Royal Holloway University of London, UK; University College London (UCL) Queen Square Institute of Neurology, London, UK; Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.

Publication Information:

The Journal of Headache and Pain 2019; 20: 82.

Background Information:

Worldwide, headache and low back pain are among the leading causes of disability (1, 2). Migraine and tension-type headache each affect more than 10% of the world’s population (1), with chronic headache impacting 3-4% of adults worldwide (3). Low back pain is similarly prevalent and responsible for between 8-12 million general practitioner visits each year in the United Kingdom (4) and 90 million workdays lost. The numbers are equally impactful in other global regions!

Chronic headache and low back pain are traditionally treated separately and not often by experts in chronic pain management (5). This may be a less than ideal approach, especially for patients living with both conditions simultaneously, as previous work has identified a possible association between headache and low back pain (6). The purpose of this study was to systematically review the available observational evidence regarding the association between primary and chronic headaches and persistent low back pain.

Pertinent Results:

15 papers reporting on 14 studies were identified as eligible from the authors’ database searches. A total of 460,195 patients were enrolled in these studies, with an age range of 9.8-102 years.

Study Characteristics:
Heterogeneity among studies was present, but all noted an association between headache and low back pain. The odds ratios (OR) ranged from 1.55 [95% CI 1.13-2.11] to 8 [5.3-12.1] (this means essentially that those with headache are nearly 2-8 times more likely to also have low back pain). Studies included populations of children, adolescents and adults and were completed in several countries worldwide. Study size ranged from 88 (7) to 404,206 participants (8).

Methodological Quality Assessment:
The majority of studies, including 3 eligible cohort studies and 6 eligible cross-sectional studies were judged to be “good” with respect to study methodology.

Definitions of Headache and Low Back Pain (LBP):
Definitions of LBP varied across studies. In general, LBP was self-reported but varying pain scales and questionnaires were utilized. Persistency of low back pain was not routinely described. Studies enrolled patients with “chronic low back pain”, using varying definitions of chronic.

Headache definitions were similarly varied. Only 2 studies used the ICHD definitions. Others used validated questionnaires, interviews, surveys and self-reporting, while others provided no specific definition.

Relationship between specific headache types and persistent LBP:
One study (9) noted a positive correlation between the number of days with tension-type headache and number of days with low back pain (r = 0.25, p < 0.001, r = 0.16, p < 0.001, respectively). They also noted that low back pain frequency was higher in patients with primary migraine or tension-type headache than those without headache (87.2 vs. 77.7%, p = 0.001; OR 1.7, 95% confidence interval [1.2-2.5]).

Other studies noted an association between migraine and low back pain (OR 1.2 [0.7-2.1]) (9) and frequent LBP and episodic migraine (OR 4.6 [4.0-5.4]) (6). Episodic headache and LBP were also related (OR 1.7 [1.2-2.5]) (9), as were frequent LBP and episodic headache (OR 3.8 [3.4-4.2]) (6). Tension-type headache was associated with low back pain, with ORs varying from 1.9 [1.2-3.1] to 3.5 [3.0-4.1]).

Combined tension-type and migraine headache with LBP:
ORs of 2.4 [1.3-4.4] (9) and 4.8 [4.2-5.5] (6) were noted between combined definitions of headache and low back pain.

Chronic headache and LBP:
In a cohort of 40 patients experiencing chronic headache, the OR for LBP was 1.9 [0.8-4.5] (9). In another study, chronic LBP and chronic headache were associated, with ORs ranging from 4.4 [2.1-9.0] to 9.5 [4.9-18.4] (6).

Clinical Application & Conclusions:

These authors found that a positive association exists between primary headache and LBP, a finding that was consistent across studies of varying methodological design. While this finding was noted, they recommend that further studies be prospective and focus on chronic headache and persistent LBP. They also recommend that future studies investigate the mechanisms responsible for these observations.

EDITOR’S NOTE: These authors mentioned that patients with coexisting headache and LBP may be an underserved patient population from a pain management perspective. This may be true for clinics that focus solely on chronic pain, but I think many in practice see patients like this all the time and I also feel there is high value in a full-body treatment approach from a chiropractic perspective. At this time, there isn’t any research to directly support this notion, apart from the experience of many clinicians (including myself) in the field. Hopefully studies on this approach will eventually be published.

Study Methods:

One author searched the following databases: Medline, Embase, Applied Social Sciences Index and Abstracts (ASSIA), PsychINFO and Web of Knowledge.

The primary outcome was the association between chronic headache disorders and persistent low back pain. Secondary outcomes included the relationship between severity of headache and low back pain and the relationship between headache sub-groups and persistent low back pain. Cross-sectional, cohort and case-controlled studies published in English were included. There were no restrictions regarding the age of participants in the included studies.

Methodological quality was assessed using the Newcastle-Ottawa Quality Assessment Scale (10).

Data were extracted by 2 independent reviewers. Headache and low back pain definitions were extracted per individual author definitions. Data pooling was not possible due to study heterogeneity.

Study Strengths / Weaknesses:

  • Strong, comprehensive search criteria were utilized.
  • Relevant search criteria and by condition were used.
  • The authors comprehensively assessed methodological quality of the included papers.
  • Heterogeneity among studies limited the ability to pool data.
  • Potential publication bias may exist, as positive outcomes are more likely to be published than negative outcomes.
  • Non-English studies were not included and may have provided valuable data.

Additional References:

  1. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388: 1474–547X (Electronic).
  2. Hartvigsen J, Hancock MJ, Kongsted A et al. What low back pain is and why we need to pay attention. Lancet 2018; 391(10137): 2356–2367.
  3. Stovner LJ, Hagen K, Jensen R et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 2007; 27(3): 193–210.
  4. Dunn KM, Croft PR. Epidemiology and natural history of low back pain. Europa Medicophysica 2004; 40: 0014–2573.
  5. National Institute for Health and Care Excellence (NICE). Low back pain and sciatica in over 16s: assessment and management. United Kingdom National Institute for Clinical Excellence. 2016.
  6. Yoon MS, Manack A, Schramm S et al. Chronic migraine and chronic tension-type headache are associated with concomitant low back pain: results of the German headache consortium study. Pain 2013; 154: 484–492
  7. Sjolie AN. Psychosocial correlates of low-back pain in adolescents. Eur Spine J 2002; 11: 582–588.
  8. Swain MS, Henschke N, Kamper SJ et al. An international survey of pain in adolescents. BMC Public Health 2014; 14: 447.
  9. Ashina S, Lipton RB, Bendtsen L et al. Increased pain sensitivity in migraine and tension-type headache coexistent with low back pain: a cross-sectional population study. Eur J Pain 2018; 22(5): 904–914.
  10. Wells G, Shea B, O’Connell D, et al. Newcastle-Ottawa Quality Assessment Scale, Cohort Studies. 2014.