Research Review By Dr. Michael Haneline©


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Date Posted:

December 2022

Study Title:

Effectiveness of manual therapy in the treatment of cervicogenic headache: A systematic review


Núñez-Cabaleiro P & Leirós-Rodríguez R

Author's Affiliations:

Faculty of Physical Therapy, University of Vigo, Pontevedra, Spain

Publication Information:

Headache 2022 Mar; 62(3): 271-283. doi: 10.1111/head.14278.

Background Information:

Cervicogenic headache (CGH) is a secondary headache which emanates from bone, disc, and/or soft tissue(s) in the cervical spine. The pain follows a topographic course, typically extending from the cervical region to the oculo-fronto-temporal area and it is generally worsened by sustained neck positions and/or pressure over the occipital area. From 2.2% to 4.1% of the general population suffer from CGH and the condition affects women 4 times more than men (1).

Established diagnostic criteria for CGH are:
  1. clinical and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck which have been shown to cause headache; and
  2. evidence of causation demonstrated by at least 2 of the following:
    1. onset of headache in temporal relation to the development of a cervical disorder/lesion,
    2. headache significantly improved along with improvement or resolution of the cervical disorder/lesion,
    3. reduced cervical range of motion and headache is significantly worsened by provocative maneuvers, and/or
    4. headache is eliminated following diagnostic blockade of a cervical structure or its nerve supply (2).
Headaches in CGH patients often follow the cervical and trigeminal dermatomes, which led to the hypothesis that irritation in the convergence in the trigeminal-cervical caudalis nucleus of the afferent branches of the trigeminal and superior cervical spinal nerves may cause CGH (3).

Standard medical management often begins with medications, which do not address the source of the problem and may lead to overuse (1). Invasive procedures (ex. anesthetic and corticosteroid blocks, and pulsed radiofrequency) are used less frequently, although they typically only reduce pain temporarily.

Conservative interventions, like manual therapy (MT) techniques and exercise, have become preferred treatments and have been shown to provide long-term relief of CGH symptomatology (4). Nevertheless, there are a variety of MT techniques (including spinal manipulation and mobilization) but no consensus as to which are the most effective (5). The aim of this study was to investigate the MT methods and techniques that have been evaluated for the treatment of CGH and their effectiveness.

Pertinent Results:

Literature Search & Included Studies:
The literature search returned 365 non-duplicate studies. After screening titles and abstracts, 351 were excluded. The full text of the remaining 14 papers were read and assessed for eligibility with all of them being included in the final synthesis. The interventions used in these studies were as follows:
  • spinal manipulative therapy (SMT) in 3 studies;
  • Mulligan’s Sustained Natural Apophyseal Glides (SNAGs), 4 studies;
  • muscle techniques, including ischemic compression of trigger points, stretching, suboccipital muscle relaxation, and Jones strain/counterstrain technique, 4 studies;
  • translatory vertebral mobilization, 1 study;
  • a self-acupressure pillow in combination with MT techniques, 1 study; and
  • personalized versus non-personalized treatment with MT, 1 study.
11 of the studies were randomized controlled trials and 3 were quasi-experimental studies.

The methodological quality of the studies ranged from 1 to 5 (average 2.4) on the Jadad scale, which spans from 0 to 5. Lack of information about withdrawals and absence of blinding were the most common methodological shortcomings.

Studies that investigated the effect of SMT on CGH showed significant improvements in headache frequency after up to 18 sessions of manual manipulation of the cervical and upper thoracic regions at the sites of joint dysfunction (joint restriction or pain). Subjects in a placebo SMT group in one of the studies showed improvement in frequency after 12 sessions, although there were no improvements in the intensity or duration of CGH in that group. Improvements in the frequency and intensity of CGH that were reported by Haas et al. (6) remained for up to 1 year following treatment.

SMT was found to be significantly superior to massage, Maitland mobilization therapy and craniocervical flexion (CCF) exercises for relieving pain intensity and perceived disability. No adverse effects (AEs) were reported in one of the SMT studies, while mild and transient AEs were reported in another SMT study (AEs were also found in the placebo group).

Studies evaluating Mulligan’s SNAGs reported significant improvements in pain intensity and perceived disability which were statistically superior with the addition of suboccipital Muscle Energy Technique. Cervical ROM was shown to improve more with Mulligan’s SNAGs than with the Maitland’s anterior-posterior glides applied at C2. However, when compared with dry needling of the suboccipital, paraspinal, and trapezius muscles, Mulligan’s SNAGs did not result in improvement of pain pressure thresholds, although improvements were significantly greater when the interventions were combined.

Muscle MT techniques (Jones technique on the trapezius and neural mobilization therapy of the occipital nerve) showed significant improvements in CGH pain intensity and frequency, perceived disability, and cervical ROM. Ischemic compression of myofascial trigger points in the sternocleidomastoid muscles also significantly reduced the intensity, frequency, and duration of patients’ CGH. Trapezius muscle stretching and craniocervical flexion exercises showed improvements with active intervention in pain intensity and trapezius muscle fatigue.

Translatory vertebral mobilization (straight-line forces delivered in a parallel or perpendicular direction to a vertebral motion segment) applied at C1 resulted in immediate significant improvements in pain intensity, cervical ROM, and trapezius pain pressure threshold.

In the final included study, a self-acupressure pillow was not as effective as MT techniques at reducing frequency, pain intensity or perceived disability of CGH.

Clinical Application & Conclusions:

All the manual therapy (MT) techniques that were evaluated in this study were shown to improve CGH symptoms and, therefore, could be effective in the treatment of patients with this condition. Nevertheless, the self-acupressure pillow with a combination of MT techniques failed to reduce the intensity of headaches.

Upper cervical SMT was the most effective MT technique and can be used to maintain results long-term. The combination of different techniques, such as muscle energy techniques, SMT, and Mulligan’s SNAGs, as well as strengthening of the deep neck flexors, were also shown to be beneficial for the treatment of CGH.

SMT reduced CGH intensity to less than 2 out of 10 points, although when coupled with specific exercise, did not lead to additional improvements. The greatest reduction in pain intensity was achieved in studies that used between 6 and 8 sessions of SMT.

Study Methods:

This was a systematic review that followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines and the recommendations from the Cochrane Collaboration.

The criteria for study inclusion were as follows:
  • patients with CGH;
  • MT intervention;
  • involved a control group or comparison with other MT techniques;
  • outcomes that included characteristics of CGH, such as intensity, frequency, and duration, and cervical ROM;
  • published within the last 5 years; and
  • employed an experimental design.
Six databases were searched using various combinations of the following terms: secondary headache disorders, physical therapy modalities, musculoskeletal manipulations, cervicogenic headache, manual therapy, and physical therapy. Any duplicate publications were removed and then 2 reviewers independently screened articles for eligibility. Any disagreements were resolved by discussion between the reviewers until agreement was reached. The 2 reviewers also independently extracted data from the included studies for analysis. The quality of the included studies was assessed using the Oxford 2011 Levels of Evidence and the Jadad scale.

Pre-and post-test comparisons of each intervention group in the studies were analyzed; however, meta-analyses were not possible due to variability in the assessment methods that were used.

Study Strengths / Weaknesses

This systematic review was well done, considering that not many high-quality studies have been conducted on this topic and few of the studies analyzed long-term results. Also, the fact that there are so many types of MT techniques made it difficult to make useful comparisons.

The authors listed several study limitations, as follows:
  • only studies published in the last 5 years were included,
  • quasi-experimental studies were included, and
  • studies with small sample sizes were included.
The authors suggested that future research is needed that include studies of adequate methodological quality, studies that compare more MT techniques and in different combinations of techniques, including patients with acute and chronic diagnoses and populations of different age ranges, and to compare the effect of MT techniques between both sexes.

Additional References:

  1. Knackstedt H, Bansevicius D, Aasseth K, et al. Cervicogenic headache in the general population: the Akershus study of chronic headache. Cephalalgia 2010; 30: 1468-1476.
  2. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia 2018; 38(1): 1-211.
  3. Sedighi A, Ansari N, Naghdi S. Comparison of acute effects of superficial and deep dry needling into trigger points of suboccipital and upper trapezius muscles in patients with cervicogenic headache. J Bodyw Mov Ther 2017; 21(4): 810-14.
  4. Bogduk N, Govind J. Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. Lancet Neurol 2009; 8(10): 959-68.
  5. Fernandez M, Moore C, Tan J, et al. Spinal manipulation for the management of cervicogenic headache: a systematic review and meta-analysis. Eur J Pain 2020; 24(9): 1687-1702.
  6. Haas M, Bronfort G, Evans R, et al. Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial. Spine J 2018; 18(10): 1741-54.

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