Research Review By Dr. Ceara Higgins©


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Date Posted:

April 2019

Study Title:

Non-pharmacological Management of Persistent Headaches Associated with Neck Pain: A Clinical Practice Guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration


Côté P, Yu H, Shearer HM, et al.

Author's Affiliations:

University of Ontario Institute of Technology (UOIT), Ontario, Canada; Canadian Memorial Chiropractic College (CMCC), Ontario, Canada; University of Alberta, Edmonton, Alberta, Canada; NYU School of Medicine, New York University, USA; Mount Sinai Hospital, Toronto, Canada; Kingston General Hospital, Kingston, Canada; School of Medicine, Queen’s University, Kingston, Canada; University of Toronto, Canada; Institute for Work and Health, Toronto, Canada; University of Southern Denmark, Denmark; University of Ottawa, Ontario, Canada; Western University, London, Canada; Open Policy Ontario; Université de Montréal, Quebec, Canada.

Publication Information:

European Journal of Pain 2019; 23: 1051-1070. doi:10.1002/ejp.1374.

Background Information:

Canadians with disabling neck pain are ten times more likely to experience co-morbid headaches than individuals without neck pain (4); and, after a motor vehicle collision, more than 80% of individuals reporting headaches also report neck pain (3) – demonstrating how common it is for the two to occur together. The International Classification of Headache Disorders (ICHD-3) links both tension-type headaches (TTH) and cervicogenic headaches (CGH) to the cervical spine, with tension-type headaches defined as ‘typically bilateral, pressing or tightening in quality, and of mild to moderate intensity, lasting minutes to days or unremitting on average for at least three months’ (8). TTHs do not worsen with usual physical activity, may or may not be associated with nausea, photophobia or phonophobia, and may be coupled with pericranial tenderness with palpation of the muscles of the head and neck. Cervicogenic headaches are caused by disorders in the bones, discs, and/or soft tissues of the cervical spine, and are commonly accompanied by neck pain (8).

Previous evidence suggests that exercises for the cervical spine or manual therapy are effective for treatment of TTH or CGH. Reassurance, acupuncture, exercise, physical therapy (including massage, spinal manipulation, heat or cold, ultrasound, and electrical stimulation), and psychological interventions have been recommended for the treatment of tension-type headaches, while exercise, spinal manipulation and cervical mobilization have been recommended as treatment for cervicogenic headaches. However, these recommendations are from guidelines based on evidence from more than five years ago. Thus, the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration sought to develop up-to-date clinical guidelines for non-pharmacological management of persistent headaches associated with neck pain.

Pertinent Results:

In cases of headache, clinicians should perform a comprehensive clinical evaluation to rule out major structural (or other) pathologies or migraines, as well as identify any red flags from the history or examination which warrant further investigation and referral. Once major pathology has been ruled out, headaches should be classified as tension-type (TTH) or cervicogenic (CGH) to allow the patient to receive the appropriate evidence-based interventions.

It is important to try to understand the beliefs and expectations of your patients and use proper education and reassurance to address any misunderstandings or apprehension. Patients should be advised to stay active/exercise, be given information about pain mechanisms, be reassured with regard to the nature and course of their headaches, and be provided with effective interventions within a limited time frame. In patients who are found to have factors that may lead to a delayed recovery, a discussion of these factors and an appropriate adjustment to their plan of care is necessary.

Tension-Type Headaches – Evidence for Treatment:

In patients with episodic tension-type headaches, current evidence supports providing patients with information about the nature, management, and course of their headaches, as well as providing low load endurance craniocervical and cervicoscapular exercises. These should be provided through a combination of supervised and home-based sessions, with a maximum of 8 sessions over 6 weeks in a supervised clinical environment. Patients should be taught to perform slow and controlled craniocervical flexion against resistance to improve muscular control in the craniocervical and cervicoscapular regions. No manipulation of the cervical spine should be offered as there is currently no evidence of effectiveness, and there is evidence showing that cervical manipulation combined with massage is no more effective than inert LASER combined with massage, suggesting that cervical manipulation is ineffective for the treatment of episodic tension-type headaches.

Patients with chronic tension-type headaches should also receive information about the nature, management, and course of tension-type headaches. Clinicians can also consider the use of general exercises (warm-up, neck and shoulder stretching and strengthening, and aerobic exercise) provided through both clinic- and home-based programming, with clinic-based sessions limited to 25 sessions over 12 weeks. Low load endurance craniocervical and cervicoscapular exercises as described above may also be considered with a session maximum of 8 clinic-based sessions over 6 weeks. A maximum of 9 sessions of multimodal care offered over 8 weeks, and including spinal mobilization, craniocervical exercises, and postural correction can also be offered. Finally, 8 sessions of clinical massage may be offered at a length of 45-minutes per session at a frequency of 2 sessions per week for 4 weeks. As noted for episodic tension-type headaches, the current evidence does not support the use of cervical spinal manipulation for those with chronic TTH.

Cervicogenic Headaches – Evidence for Treatment:

As with tension-type headaches, patients with persistent cervicogenic headaches should receive information about the nature, management and course of their headaches. Low load craniocervical and cervicoscapular exercises with resistance, both supervised (up to 8 sessions over 6 weeks) and home-based, or manual therapy (manipulation with or without mobilization) of the cervical and thoracic spine to a maximum of 10 sessions over 6 weeks, should be considered. This should be an ‘either-or’ situation. Multimodal care cannot be recommended based on evidence showing that combining low-load endurance exercises with spinal manipulation and mobilization provides no additional benefits to providing either intervention alone, and that providing craniocervical flexion exercises and spinal mobilization is less effective than providing spinal manipulation alone.

Patients should be discharged as soon as they report significant recovery. It is recommended that clinicians utilize the following self-rated recovery question and answers. “How well do you feel you are recovering from your injuries?” (1, 6): 1) completely better, 2) much improved, 3) slightly improved, 4) no change, 5) slightly worse, 6) much worse, 7) worse than ever. Patients reporting themselves to be “completely better” or “much improved” should be considered recovered and discharged.

Some non-pharmacological treatments were not recommended due to a lack of evidence in high-quality studies, or inconclusive evidence of effectiveness. These include needle acupuncture, passive physical modalities, stand-alone structured patient education, and work disability prevention interventions.

These guidelines generally agree with previous guidelines with a few important differences. Previous guidelines recommended needle acupuncture where these guidelines did not. However, previous guidelines included studies with a high risk of bias and small sample sizes, which may account for the difference.

Clinical Application & Conclusions:

The OPTIMa recommendations regarding non-pharmacologic management of persistent headaches associated with neck pain are as follows:
  • Recommendation 1: Evaluation of Headaches Associated with Neck Pain – Clinicians should rule out major structural or other pathologies, or migraines as the cause of headaches. Clinicians should classify headaches as tension-type headache or cervicogenic headache.
  • Recommendation 2: Management of Persistent Headaches Associated with Neck Pain – Clinicians should provide care in partnership with the patient and involve the patient in care planning and decision-making.
  • Recommendation 3: Management of Episodic Tension-Type Headaches – Clinicians may consider low load endurance craniocervical and cervicoscapular exercises and structured patient education. As there is no evidence of effectiveness, manipulation of the cervical spine should not be offered.
  • Recommendation 4: Management of Chronic Tension-Type Headaches – Clinicians may consider general exercise, low load endurance craniocervical and cervicoscapular exercises, multimodal care (including spinal mobilization, craniocervical exercise, and postural correction), or clinical massage in addition to structured patient education. Manipulation of the cervical spine should not be offered as the sole form of treatment, as there is evidence that it is not effective.
  • Recommendation 5: Management of Persistent Cervicogenic Headaches – For patients with cervicogenic headaches > 3 months duration, clinicians may consider low load endurance craniocervical and cervicoscapular exercises or manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine, in addition to structured patient education. There is no additional benefit to combining spinal manipulation, spinal mobilization, and exercises.
  • Recommendation 6: Re-evaluation and Discharge – Patients should be reassessed at every visit to determine if the patient needs additional care, if their condition is worsening, or if the patient has recovered.
Implementation of these recommendations help to ensure patients receive uniform, high-quality care based on the best available evidence, helping to improve outcomes, minimize variation in care among locations and providers and improve the efficiency of our healthcare system.

Study Methods:

The OPTIMa Collaboration, a multidisciplinary team comprised of expert clinicians, academics, scientists, a patient liaison, a consumer advocate, a retired judge and automobile insurance industry experts, developed up to date clinical guidelines for a population of adults ( 18 years of age), with persistent headaches associated with neck pain (> 3 months duration), including tension-type (TTH) or cervicogenic headaches (CGH). For the purposes of this study, non-pharmacological interventions included acupuncture, exercise, manual therapy, multimodal care, passive physical modalities, soft tissue therapies, structured patient education, and work disability prevention interventions, excluding medications.

Clinical recommendations were developed based on the goals of:
  1. accelerating recovery;
  2. reducing the intensity of symptoms;
  3. promoting early restoration of function;
  4. preventing chronic pain and disability;
  5. improving health related quality of life;
  6. reducing recurrences; and
  7. promoting patients’ active participation in their care.
Systematic reviews from the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (9) were updated with: 1) six new systematic reviews (published between January 1990 and February 25th, 2017) on the effectiveness and safety of non-invasive, non-pharmacological interventions for the management of persistent headaches associated with neck pain; and 2) one systematic review conducted (but not yet published) by the collaboration on cost-effectiveness of non-invasive, non-pharmacological interventions. Randomized controlled trials (RCTs), cohort studies, and case-control studies comparing non-pharmacological interventions to other interventions, placebo/sham interventions, non-intervention effects associated with wait listing, or no intervention were included.

Clinical outcomes considered included self-rated recovery, functional recovery, disability, pain intensity, health-related quality of life, psychological outcomes, or adverse events. Only studies published in English were included. For the cost-effectiveness review, only full economic evaluations which jointly analysed costs and health outcomes were included. Studies of migraine (with or without aura), traumatic brain injuries, and underlying pathological processes were excluded.

Eligible studies were screened and appraised by random pairs of independent, trained reviewers, using the Scottish Intercollegiate Guidelines Network (SIGN) criteria (7). Only studies deemed to have a low risk of bias were included. The OPTIMa Collaboration developed the guidelines based on the principles of patient-centered care and the Ontario Health Technology Advisory Committee framework (10), which include evidence-based recommendations based on overall clinical benefits, value for money, and consistency with expected societal and ethical values. A technical team conducted the systematic reviews and the Guideline Expert Panel reviewed and approved all methodology, analysis, and interpretation of the systematic reviews, reviewed and modified draft recommendations, and approved the final recommendations. In cases where the research evidence was scant, evidence from three other headache guidelines was used to inform the recommendations (2, 5, 11). Interventions needed evidence of statistically significant and clinically important benefits, identified in at least one RCT with a low risk of bias, to be considered effective and recommended. In cases of inconclusive evidence of effectiveness, the intervention was not recommended.

Recommended duration of care for specific interventions was based on frequency and duration of care in the low risk of bias study when only one study was used, or on mean frequency and duration of an intervention across studies when more than one low risk of bias study was included.

Study Strengths / Weaknesses:

  • This study improves on previous clinical practice guidelines by only including studies with a low risk of bias and including information on optimal dosage of interventions (frequency and duration).
  • These guidelines are based on a comprehensive literature search and very solid overall methodology (as with all OPTIMa reviews!).
  • The recommendations were based on effectiveness, safety, cost-effectiveness, and consistency with societal and ethical values, as well as the lived experiences of patients, and considered effect sizes to determine the usefulness of an intervention.
  • No high-quality studies were found to evaluate some non-pharmacological interventions. This makes it possible that some effective interventions were discounted due to a lack of quality evidence at this time.
  • Little evidence was found on the cost-effectiveness of non-pharmacological interventions for headache associated with neck pain, or the effectiveness of recommended interventions when compared to sham treatments or placebo.
  • Only articles published in English were considered, making it possible that high-quality studies in other languages were missed.

Additional References:

  1. Carroll LJ, Lia A, Weiser S, et al. How well do you expect to recover, and what does recovery mean, anyway? Qualitative study of expectations after a musculoskeletal injury. Phys Ther 2016; 96(6): 797-807.
  2. Carville S, Padhi S, Reason T, et al. Diagnosis and management of headaches in young people and adults: summary of NICE guidance. BMJ 2012; 345: e5765.
  3. 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.
  4. 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.
  5. Duncan CW, Watson DP, Stein A. Diagnosis and management of headache in adults: summary of SIGN guidelines. BMJ 2008; 337: a2329.
  6. Fischer D, Stewart AL, Bloch DA, et al. Capturing the patient’s view of change as a clinical outcome measure. JAMA 1999; 282(12): 1157-1162.
  7. Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines. BMJ 2001; 323(7308): 334-336.
  8. Headache Classification Subcommittee of the International Headache Society. Headache Classification Committee of the International Headache Society (HIS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia 2018; 38(1): 1-211.
  9. Hurwitz EL, Carragee EJ, van der Velde G, et al. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008; 33(4 Suppl): S123-152.
  10. Johnson AP, Sikich NJ, Evans G, et al. Health technology assessment: a comprehensive framework for evidence-based recommendations in Ontario. Int J Technol Assess Health Care 2009; 25(2): 141-150.
  11. Perry JJ, Sivilotti ML, Sutherland J, et al. Validation of the Ottawa Subarachnoid Hemorrhage Rule in patients with acute headache. CMAJ 2017; 189(45): E1379-E85.