Research Review By Dr. Brynne Stainsby©


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Date Posted:

January 2018

Study Title:

Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration


Varatharajan S, Ferguson B, Chrobak K, Shergill Y et al.

Author's Affiliations:

UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology and Canadian Memorial Chiropractic College, Oshawa, ON, Canada; Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada; University of Ottawa Centre for Interdisciplinary Pain Research, Ottawa Hospital Research Institute, The Ottawa Hospital General Campus, Ottawa, Canada; Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology, Oshawa, ON, Canada; Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON, Canada; Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, Joseph and Wolf Lebovic Health Complex, Toronto, ON, Canada; Clinical Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada; D'anatomie Universite du Quebec a Trois-Rivieres, Trois-Rivieres, PQ, Canada; Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto, ON, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; Institute for Work and Health, Toronto, ON, Canada; Injury Prevention Centre and School of Public Health, University of Alberta, Edmonton, AB, Canada; Orthopedic Surgery and Environmental Medicine, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, USA; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Certification Program in Insurance Medicine and Medico-legal Expertise, Faculty of Medicine, University of Montreal, QC, Canada.

Publication Information:

European Spine Journal 2016; 25(7): 1971-99. doi: 10.1007/s00586-016-4376-9.

Background Information:

Headaches (HA) originating from the neck are one of the most common associated symptoms of neck pain (1-4). For example, those with neck pain (NP) are 2-10 times more likely to suffer from HA (compared to those without NP) (5) and most patients with whiplash-associated disorders report HA (some reports indicate more than 80% [6])!.

The International Classification of Headache Disorders (ICHD-2) suggests the following three types of HA are associated with NP: cervicogenic HA (CHA), whiplash-related HA (WRHA) and tension-type HA (TTHA) (7). Tension-type HA are the most common and it is estimated that up to 38% of adults suffer TTHA annually, with a lifetime prevalence up to 86% (8-11). The point prevalence of CHA in the general population is 2.5% and up to 17.8% in those who suffer from five or more headache days each month (12).

Given the prevalence of HA in patients with NP, it is important to understand the evidence-based management of these conditions. The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (NPTF) identified a lack of high quality evidence for treating these patients (13), and the purpose of this OPTIMa systematic review was to update the findings of the NPTF and examine the effectiveness of interventions for the management of HA in patients with NP.

Pertinent Results:

  • A total of 17 236 titles and abstracts were screened for eligibility, and 15 were eligible for critical appraisal.
  • Ten studies (all RCTs) were deemed to be of high quality and included in the synthesis (14, 15-25).
  • These studies addressed: episodic TTHA (15), chronic TTHA (16, 20, 23, 24), both episodic and chronic TTHA (17, 21, 22, 25) and chronic CHA (14, 18, 19).
For episodic TTHA, evidence from one RCT suggests that cervical manipulation does not provide benefit (15).

For chronic TTHA, evidence from one RCT suggests that multimodal care including cervical and thoracic mobilization, craniocervical exercise and postural correction is more effective than usual GP care (16). Evidence from another RCT suggested that a brief stress-management program does not benefit these patients compared to tricyclic antidepressants (20). Finally, evidence suggests that combined relaxation training and stress coping therapy may be more effective than general exercise and needle acupuncture in terms of HA-free days, though no differences were found in HA intensity or quality of life (23, 24).

For episodic and chronic TTHA, evidence from one RCT suggests that low-load endurance exercises in addition to physiotherapy is superior to physiotherapy alone for improving HA frequency (25). Conflicting evidence was found regarding the effectiveness of acupuncture: two studies found needle acupuncture was associated with greater reduction in HA frequency (17, 21), however another found that sham and needle acupuncture led to similar outcomes, though both demonstrated clinical improvements compared to waitlist (22).

For chronic CHA, the addition of manipulation to light massage and heat resulted in improvements in pain, disability and HA frequency (18, 19). A second RCT demonstrated that both manipulation/mobilization and exercise were more effective than no intervention, but equally effective when compared to each other with respect to improving HA frequency and intensity and pain associated with neck movements and joint tenderness (14).

Adverse Events:
Seven of the studies measured major adverse events and none were reported (14, 16, 20-22, 25). Five reported minor (mild to moderate and transient) adverse events (14, 17, 20-22).

Clinical Application & Conclusions:

This OPTIMa systematic review expanded on the findings of the NPTF regarding the effectiveness of interventions for HA associated with NP. It clearly demonstrates the role of exercise for all types of HA associated with NP. Further, the literature demonstrates that manual therapy is likely to improve outcomes for patients with CHA and chronic TTHA, though has not been found to be effective for those with episodic TTHA. Further, for patients with chronic TTHA, multimodal care is an important consideration and may include relaxation training, stress coping therapy, manual therapy, exercise and postural correction. The effectiveness of needle acupuncture in the management of patients with TTHA has not yet been determined in the literature.

Importantly, given the heterogeneity of the studies, little information could be determined regarding the optimal frequency and duration of interventions, or the specifics of the treatments themselves. This review highlights the need for high quality research regarding the effectiveness of interventions for HA associated with NP, particularly WRHA.

Study Methods:

  • This review summarised the findings of six systematic review protocols, each examining a different intervention: 1) exercise; 2) manual therapy; 3) acupuncture; 4) multimodal care; 5) structured patient education and self-management, passive physical modalities and soft tissue therapy; and 6) work disability prevention.
  • The authors included studies of adults and/or children diagnosed with TTHA, CHA or WRHA, however studies of those with migraines, traumatic brain injuries and underlying pathologies were excluded. Studies comparing non-invasive and non-pharmacological interventions to other interventions, placebo/sham or no interventions were included in the review. Studies had to include patient-centred outcomes in order to be included.
  • A systematic search strategy was developed in consultation with a health sciences librarian and reviewed by a second librarian.
  • Eight distinct databases were searched in 2013 and updated in 2015, covering the time period from January 1st, 1990 to March 2nd, 2015 using appropriate search terms for each database.
  • Two authors independently screened titles and abstracts for inclusion.
  • Random pairs of independent reviewers assessed the risk of bias (internal validity) using the Scottish Intercollegiate Guidelines Network (SIGN) Criteria (26).
  • The lead author extracted data from studies with a low risk of bias and built evidence tables. A second reviewer confirmed the data.
  • When available, minimal clinically important difference (MCID) thresholds were used to assess differences between groups.

Study Strengths / Weaknesses:

  • The OPTIMa group, as always, utilized a clearly defined research question investigated via a thorough and systematic search.
  • The authors provided a clear definition of each type of HA associated with NP.
  • Independent screening of titles and abstracts, and full texts.
  • Only those trials assessed as being of high quality were included.
  • Assessment of risk of bias was performed with a validated set of criteria.
  • Two authors independently extracted the data from the included articles.
  • Only those studies assessed as high quality trials were included.
  • The primary limitation of this study relates more to the quality of the body of evidence than the methodology of the review itself. Despite screening 17 236 titles and abstracts, only 10 studies were admissible for synthesis.
  • The authors used the SIGN criteria which requires the scientific judgment of each reviewer, however this limitation was mitigated by training reviewers and using standardized methods.

Additional References:

  1. Carroll LJ, Cassidy JD, Cote P. Frequency, timing, and course of depressive symptomatology after whiplash. Spine 2006; 31(16): E551-E556.
  2. Carroll LJ, Liu Y, Holm LW et al. Pain-related emotions in early stages of recovery in whiplash-associated disorders: their presence, intensity, and association with pain recovery. Psychosom Med 2011; 73(8): 708-715.
  3. Hincapie CA, Cassidy JD, Cote P et al. Whiplash injury is more than neck pain: a population-based study of pain localization after traffic injury. J Occup Environ Med 2010; 52(4): 434-440.
  4. Haldeman S, Carroll LJ, Cassidy JD. The empowerment of people with neck pain: Introduction: The bone and joint decade 2000-2010 task force on neck pain and its associated disorders. Spine 2008; 33(4 Suppl): S8-S13.
  5. Cote P, Cassidy JD, Carroll L. The factors associated with neck pain and its related disability in the Saskatchewan population. Spine 2000; 25(9): 1109-1117.
  6. Cassidy JD, Carroll LJ, Cote P et al. Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury. N Engl J Med 2000; 342(16): 1179-1186.
  7. The international classification of headache disorders, 2nd edition. Cephalalgia 2004; 24 (1):1-151.
  8. Posadzki P, Ernst E. Spinal manipulations for tension-type headaches: a systematic review of randomized controlled trials. Complement Ther Med 2012; 20(4): 232-239.
  9. Jensen R, Stovner LJ. Epidemiology and comorbidity of headache. Lancet Neurol 2008; 7(4): 354-361.
  10. Ertas M, Baykan B, Orhan EK et al. One-year prevalence and the impact of migraine and tension-type headache in Turkey: a nationwide home-based study in adults. J Headache Pain 2012; 13(2): 147-157.
  11. Andersen LL, Mortensen OS, Zebis MK et al. Effect of brief daily exercise on headache among adults - secondary analysis of a randomized controlled trial. Scand J Work Environ Health 2011; 37(6): 547-550.
  12. Nilsson N. The prevalence of cervicogenic headache in a random population sample of 20-59 year olds. Spine 1995; 20(17): 1884-1888.
  13. Carroll LJ, Hurwitz EL, Cote P et al. Research priorities and method- ological implications: the bone and joint decade 2000-2010 task force on neck pain and its associated disorders. J Manip Physiol Ther 2009; 32(2 Suppl): S244-S251.
  14. Jull G, Trott P, Potter H et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002; 27(17): 1835-1843.
  15. Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache: a randomized controlled trial. JAMA J Am Med Assoc 1998; 280(18): 1576-1579.
  16. Castien RF, van der Windt DA, Grooten A et al. Effectiveness of manual therapy for chronic tension-type head- ache: a pragmatic, randomised, clinical trial. Cephalalgia 2011; 31(2): 133-143.
  17. Endres HG, Bowing G, Diener HC et al. Acupuncture for tension-type headache: a multicentre, sham-controlled, patient-and observer-blinded, randomised trial. J Headache Pain 2007; 8(5):306-314.
  18. Haas M, Spegman A, Peterson D et al. Dose response and efficacy of spinal manipulation for chronic cervicogenic headache: a pilot randomized controlled trial. Spine J Off J N Am Spine Soc 2010; 10(2): 117-128.
  19. Haas M, Schneider M, Vavrek D. Illustrating risk difference and number needed to treat from a randomized controlled trial of spinal manipulation for cervicogenic headache. Chiropr Osteopat 2010; 18: 9.
  20. Holroyd KA, O'Donnell FJ, Stensland M et al. Management of chronic tension-type headache with tricyclic antidepressant medication, stress management therapy, and their combination: a randomized controlled trial. JAMA J Am Med Assoc 2001; 285(17): 2208-2215.
  21. Jena S, Witt CM, Brinkhaus B et al. Acupuncture in patients with headache. Cephalalgia 2008; 28(9): 969-979.
  22. Melchart D, Streng A, Hoppe A et al. Acupuncture in patients with tension-type headache: randomised controlled trial. BMJ 2005; 331(7513): 376-382.
  23. Soderberg E, Carlsson J, Stener-Victorin E. Chronic tension-type headache treated with acupuncture, physical training and relaxation training. Between-group differences. Cephalalgia 2006; 26(11): 1320-1329.
  24. Soderberg EI, Carlsson JY, Stener-Victorin E et al. (2011) Subjective well-being in patients with chronic tension-type headache: effect of acupuncture, physical training, and relaxation training. Clin J Pain 2011; 27(5): 448-456.
  25. van Ettekoven H, Lucas C. Efficacy of physiotherapy including a craniocervical training programme for tension-type headache; a randomized clinical trial. Cephalalgia 2006; 26(8): 983-991.
  26. Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines. BMJ 2001; 323(7308): 334-336.