Effectiveness of Manual Therapy in the Treatment of Cervicogenic Headache

A Systematic Review

Patricia Núñez-Cabaleiro PT; Raquel Leirós-Rodríguez PhD

Headache. 2022;62(3):351-359.

Abstract and Introduction

Abstract

Objective: The aim of this study was to identify the manual therapy (MT) methods and techniques that have been evaluated for the treatment of cervicogenic headache (CH) and their effectiveness.

Background: MT seems to be one of the options with the greatest potential for the treatment of CH, but the techniques to be applied are varied and there is no consensus on which are the most indicated.

Methods: A systematic search in Scopus, Medline, PubMed, Cinahl, PEDro, and Web of Science with the terms: secondary headache disorders, physical therapy modalities, musculoskeletal manipulations, cervicogenic headache, manual therapy, and physical therapy. We included articles published from 2015 to the present that studied interventions with MT techniques in patients with CH. Two reviewers independently screened 365 articles for demographic information, characteristics of study design, study-specific intervention, and results. The Oxford 2011 Levels of Evidence and the Jadad scale were used.

Results: Of a total of 14 articles selected, 11 were randomized control trials and three were quasi-experimental studies. The techniques studied were: spinal manipulative therapy, Mulligan's Sustained Natural Apophyseal Glides, muscle techniques, and translatory vertebral mobilization. In the short-term, the Jones technique on the trapezius and ischemic compression on the sternocleidomastoid achieved immediate improvements, whereas adding spinal manipulative therapy to the treatment can maintain long-term results.

Conclusions: The manual therapy techniques could be effective in the treatment of patients with CH. The combined use of MT techniques improved the results compared with using them separately. This review has methodological limitations, such as the inclusion of quasi-experimental studies and studies with small sample sizes that reduced the generalizability of the results obtained.

Introduction

Cervicogenic headache (CH) is a secondary headache caused by a disorder of the cervical spine and its disc or bony and/or periarticular components and is often accompanied by neck pain.^[1] The diagnostic criteria for CH are: (1) clinical and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck, which is known to cause headache; and (2) evidence of causation demonstrated by at least two of the following: headache has developed in temporal relation to the onset of the cervical disorder or appearance of the lesion, headache has significantly improved or resolved in parallel with improvement in or resolution of the cervical disorder or lesion, cervical range of motion (ROM) is reduced and headache is made significantly worse by provocative maneuvers, and/or headache is abolished following diagnostic blockade of a cervical structure or its nerve supply.^[2,3] Such pain shows a marked topographic course, usually starting in the cervical area, extending to the oculo-fronto-temporal area, and accentuated by sustained neck positions or pressure over the occipital area.^[4]

The prevalence of CH in the general population has been reported to be 2.2%–4.1% and appears to predominate in women four times more than in men.^[4,5] The cause of this headache may lie in the convergence in the trigeminal-cervical caudalis nucleus of the afferent branches of the trigeminal and superior cervical spinal nerves.^[6] This convergence could explain why patients with CH often present with headaches corresponding to the cervical and trigeminal dermatomes. Hence, sustaining a concussion or whiplash injury with neck pain and limitation of movement can lead to the development of CH.^[7]

This complex etiology means that CH benefits from multidisciplinary treatment.^[8] The medical approach usually begins with the administration of drugs, but they do not resolve the source of the problem and can lead to overuse.^[9] Invasive procedures, such as anesthetic and corticosteroid blocks^[10] of the occipital or cervical nerves,^[11] pulsed radiofrequency,^[10] and cryoanalgesia,^[9] have been suggested to reduce pain transiently. There is now a preference for more conservative interventions, such as those of physiotherapy, which have a greater capacity to resolve the symptomatology in the long term.^[8] Noninvasive treatment techniques consist mainly of electrotherapy, manual therapy (MT), and exercise prescription. MT seems to be one of the options with the greatest potential for the treatment of CH, but the techniques to be applied are varied and there is no consensus on which are the most indicated.^[4,12,13]

Therefore, the aim of this study was to identify the MT methods and techniques that have been evaluated for the treatment of CH and their effectiveness. It is hypothesized that MT, which includes a set of passive treatment techniques, is useful for the treatment of patients with CH and that the continuation of the patient on an active exercise program can prevent the recurrence of the presenting symptoms.

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Abstract and Introduction
Methods
Results
Discussion
Conclusions
References

Table 1. Search strategy according to the focused question (PICOS)
Database	Search equation
PubMed	"Headache Disorders, Secondary" [Mesh] AND "Physical Therapy Modalities" [Mesh]
	"Headache Disorders, Secondary" [Mesh] AND "Musculoskeletal Manipulations" [Mesh]
	"Physical Therapy Modalities" [Mesh] AND "cervicogenic headache"
	"Cervicogenic headache" AND "Manual Therapy"
	"Cervicogenic headache" AND "Physical Therapy"
Medline	(MH "Headache Disorders, Secondary") AND (MH "Physical Therapy Modalities")
	(MH "Headache Disorders, Secondary") AND (MH "Musculoskeletal Manipulations")
	(MH "Physical Therapy Modalities") AND "cervicogenic headache"
	"Cervicogenic Headache" AND "Manual Therapy"
	"Cervicogenic headache" AND "Physical Therapy"
CINAHL	"Headache Disorders, Secondary" AND "Physical Therapy Modalities"
	"Headache Disorders, Secondary" AND "Musculoskeletal Manipulations"
	"Physical Therapy Modalities" AND "cervicogenic headache"
	(MH "Manual Therapy") AND "cervicogenic headache"
	(MH "Physical Therapy") AND "cervicogenic headache"
Web of Science	TOPIC: ("Headache Disorders, Secondary") AND TOPIC: ("Physical Therapy Modalities")
	TEMA: ("Headache Disorders, Secondary") AND TOPIC: ("Musculoskeletal Manipulations")
	TOPIC: ("Cervicogenic Headache") AND TOPIC: ("Physical Therapy Modalities")
	TOPIC: ("Cervicogenic Headache") AND TOPIC: ("Manual Therapy")
	TOPIC: ("Cervicogenic Headache") AND TOPIC: ("Physical Therapy")
Scopus	TITLE-ABS-KEY ("Headache Disorders, Secondary") AND TITLE-ABS-KEY ("Physical Therapy Modalities")
	TITLE-ABS-KEY ("Headache Disorders, Secondary") AND TITLE-ABS-KEY ("Musculoskeletal Manipulations")
	TITLE-ABS-KEY ("Physical Therapy Modalities") AND TITLE-ABS-KEY ("cervicogenic headache")
	TITLE-ABS-KEY ("Manual Therapy") AND TITLE-ABS-KEY ("cervicogenic headache")
	TITLE-ABS-KEY ("physical therapy") AND TITLE-ABS-KEY ("cervicogenic headache")
PEDro	"Headache Disorders, Secondary" AND "Physical Therapy Modalities"
	"Headache Disorders, Secondary" AND "Musculoskeletal Manipulations"
	"Physical Therapy Modalities" AND "cervicogenic headache"
	"Physical Therapy" AND "cervicogenic headache"
	"Cervicogenic Headache" AND "Manual Therapy"

Abbreviations: MeSH, Medical Subject Headings; PICOS, population, intervention, comparison, outcome, and study design.

Table 2. Methodological characteristics of the studies analyzed
Authors	Design	Sample size (women), N	Inclusion criteria	Exclusion criteria	Jadad scale				LE
Authors	Design	Sample size (women), N	Inclusion criteria	Exclusion criteria	RD^a	BD^b	WD^c	FS	LE
Chaibi et al. (2017)¹⁷	RCT	12 (8)	Age between 18 and 70 years. Diagnosis of CH with at least 3 main CHISG criteria	Presence of contraindications for the application of spinal manipulative techniques, pregnancy, depression, and/or radiculopathy. History of treatment with spinal manipulative techniques in the previous month	2	2	1	5	I
Christian et al. (2017)²⁰	RCT	23 (11)	Age between 25 and 35 years. Diagnosis of CH according to International Headache Society criteria. Positive Flexion-Rotation test results. Reduced cervical range of motion	Presence of dizziness and/or symptoms of visual disturbances, primary headaches, congenital disturbances, inflammatory and/or infectious disturbances in the cervical spine, vertebra-basilar insufficiency, and/or cervical hypermobility. Consumption of steroids and/or analgesics	1	0	1	2	I
Dunning et al. (2016)¹⁸	MRCT	110 (74)	Age between 18 and 65 years. Diagnosis of CH according to Cervicogenic Headache International Study Group criteria. At least seminal frequency of CH for at least 3 months. Minimum pain intensity of 2 points on the Numerical Rating Scale. Score of at least 10 points on the Neck Disability Index	Presence of primary headaches, bilateral headaches, and/or neurological signs. Diagnosis of cervical spinal stenosis. History of whiplash in the previous 6 weeks, cranio-cervical surgery, and/or physiotherapy treatment in the previous 3 months	2	1	1	4	II
Fereira and Satralkar (2017)²⁶	RCT	30 (not described)	Age between 20 and 65 years. Diagnosis of CH. Presence of myofascial trigger points in upper trapezius. Occipital nerve neurodynamic test with positive findings. Positive Flexion-Rotation Test results (reduction of more than 30°). Drug use	Diagnosis of disc pathology, rheumatoid arthritis, ankylosing spondylitis, and/or primary muscle diseases. Presence of primary headaches, migraine and/or tension-type headaches, and/or infectious conditions causing headache. History of tumor and/or cervical surgery	1	0	0	1	I
Haas et al. (2018)¹⁶	RCT	256 (182)	Age older than 18 years. Diagnosis of CH according to diagnostic criteria of the International Headache Society. Minimum average pain intensity of 3 points on the Visual Analog Scale. Presence of restricted cervical movement	Presence of contraindications for the application of spinal manipulative techniques and/or pregnancy. History of treatment with physiotherapy in the previous 3 months or with drugs in the previous month, brain or spine surgery, cancer, spinal pathology, inflammatory arthropathy, anticoagulant conditions, autoimmune disorders, and/or neurodegenerative diseases	1	0	1	2	I
Jafari et al. (2017)²³	RCT	19 (not described)	Diagnosis of CH according to the International Headache Society. Presence of myofascial trigger points in sternocleidomastoid	Presence of other types of headaches, more than 1 active myofascial trigger point in the sternocleidomastoid, rheumatic diseases, phasic, and/or psychiatric limitations. History of treatment with physiotherapy during the previous year and/or neck or shoulder surgery	1	1	0	2	I
Malo-Urriés et al. (2017)²⁷	RCT	82 (62)	Age older than 18 years. Diagnosis of CH according to the CHISG	History of treatment of CH during the previous month. Presence of neurological signs and/or contraindications for manual therapy	2	0	1	3	I
Mohamed et al. (2019)²¹	ENCS	48 (20)	Presence of headaches for at least 3 months, unilateral neck pain and stiffness, limited range of motion of more than 10 degrees in the Flexion-Rotation Test, and dizziness caused by headaches and/or cervical extension	Presence of primary headaches, congenital spinal conditions, herniated discs, and/or fractures; contraindications for mobilization techniques; vertebra-basilar insufficiency; and/or vestibular dysfunction	1	0	0	1	II
Park et al. (2017)²⁴	RCT	30 (9)	Diagnosis of CH according to International Headache Society criteria. Presence of CH for a minimum of 4 months and a maximum of 2 years	Not described	1	0	0	1	I
Patra et al. (2018)²²	ENCS	114 (77)	Age between 20 and 50 years. Diagnosis of CH according to the main International Headache Society criteria	History of surgery and/or cervical trauma, vertebral neoplasm. Presence of congenital spinal deformity, cervical radiculopathy, dizziness, vertebra-basilar insufficiency, bone infection, fracture. Consumption of anti-inflammatory or muscle relaxants	1	0	1	2	II
Svedmark et al. (2016)²⁹	RCT	120 (120)	Presence of cervico-brachial pain for at least 6 weeks. Neck Disability Index score between 10 and 68. Impairment of work productivity owing to pain	History of trauma, cancer, surgery, and/or spinal fracture. Diagnosis of cervical radiculopathy, vestibular dysfunction, type I diabetes, rheumatic disease, anxiety, depression. Presence of concurrent low back pain, temporomandibular disorders, severely restricted range of motion and/or cervical flexion, catastrophic thoughts, low expectations for physical therapy treatment	2	0	1	3	I
Veena et al. (2018)¹⁸	RCT	30 (24)	Diagnosis of CH	Not described	2	0	1	3	I
Vernon et al. (2015)²⁸	RCT	34 (32)	Diagnosis of CH according to the International Headache Society. Presence of suboccipital tenderness and cervical dysfunction. Frequency of headaches of at least 6 times a month (and at least once a week)	Diagnosis of primary headache. Presence of contraindications to manual therapy	2	0	1	3	I
Yang and Da (2017)²⁵	RCT	30 (23)	Diagnosis of CH according to CHISG	Not described	1	0	0	1	I

Abbreviations: BD, blinding; CH, cervicogenic headache; CHISG, Cervicogenic Headache International Study Group; ENCS, experimental noncontrolled study; FS, final score; LE, level of evidence; MRCT, multicenter randomized clinical trial; RCT, randomized controlled trial; RD, randomization; WD, withdrawals.
^aOne point if randomization is mentioned; 2 points if the method of randomization is appropriate.
^bOne point if blinding is mentioned; 2 points if the method of blinding is appropriate.
^cOne point if the number and reasons in each group are stated.

Table 3. Characteristics of the interventions of the studies analyzed
Authors	Intervention		Time of intervention (no. of sessions)	Follow-up	Within group improvements statistically identified with manual therapy interventions
Authors	Experimental group	Control group	Time of intervention (no. of sessions)	Follow-up
Chaibi et al. (2017)¹⁷	Group 1: SMT	Without intervention	13 weeks (12)	12 months	Reduction of Headache Index and headache frequency
Chaibi et al. (2017)¹⁷	Group 2: Placebo SMT	Without intervention	13 weeks (12)	12 months	Reduction of Headache Index and headache frequency
Christian et al. (2017)²⁰	Group 1: Active exercise and Mulligan's SNAGs	Active exercises	1 week (6)	None	In the 2 groups: Increased range of motion. Reduction of Neck Disability Index and of the headaches' frequency and intensity
Christian et al. (2017)²⁰	Group 2: Active exercise and MMT	Active exercises	1 week (6)	None
Dunning et al. (2016)¹⁸	Group 1: SMT	–	4 weeks (6–8)	3 months	In the 2 groups: Reduction in headache intensity, frequency, duration, Neck Disability Index, and medication intake. Increased self-perceived improvement
Dunning et al. (2016)¹⁸	Group 2: Cranio-cervical flexion exercises and MMT	–	4 weeks (6–8)	3 months
Fereira and Satralkar (2017)²⁶	Group 1: Active exercises and SMT	–	2 weeks (4–10)	None	In the 2 groups: Increased cervical range of motion. Reduction of Neck Disability Index and pain intensity
Fereira and Satralkar (2017)²⁶	Group 2: Active exercises and Jones technique	–	2 weeks (4–10)	None
Haas et al. (2018)¹⁶	Group 1: 6 sessions of SMT	–	6 weeks (6–18)	12 months	In the 4 groups: Reduced frequency, intensity of headaches and Neck Disability Index. In the 12- and 18-sessions groups: Increased self-perceived improvement.
	Group 2: 12 sessions of SMT
	Group 3: 18 sessions of SMT
	Group 4: Massage
Jafari et al. (2017)²³	Ischemic compression	Without intervention	1 week (4)	2 weeks	Increased pain threshold to pressure. Reduced intensity, frequency, duration of headaches, and myofascial trigger point area
Malo-Urriés et al. (2017)²⁷	Vertebral translatory mobilization	Without intervention	1 day (1)	None	Increased range of motion in extension, rotations, lateral tilt, and total cervical range of motion. Reduction of headache intensity
Mohamed et al. (2019)²¹	Group 1: C2 Mulligan's SNAGs	–	4 weeks (12)	None	In the 3 groups: Increased quality of life and cervical range of motion. Reduction of Neck Disability Index
	Group 2: C1-C2 rotation Mulligan's SNAGs
	Group 3: C2 and C1-C2 rotation Mulligan's SNAGs
Park et al. (2017)²⁴	Group 1: Stretching and cranio-cervical flexion exercises	Without intervention	3 weeks (not described)	None	In the 2 groups: Reduced tone and stiffness of the suboccipital and upper trapezius muscles
Park et al. (2017)²⁴	Group 2: Stretching	Without intervention	3 weeks (not described)	None
Patra et al. (2018)²²	Group 1: Dry needling	–	6 weeks (not described)	None	Groups 1 and 3: Increased pain threshold to pressure. In the 3 groups: Reduction of Neck Disability Index
	Group 2: Mulligan's SNAGs
	Group 3: Dry needling and Mulligan's SNAGs
Svedmark et al. (2016)²⁹	Group 1: Personalized manual therapy	–	11 weeks (22–33)	15 months	In the 3 groups: Increase in self-perceived improvement and pressure pain threshold. Reduction of Neck Disability Index, cervical and headache pain intensity, headache frequency, and pain impact on work
	Group 2: Non-personalized manual therapy
	Group 3: Free manual therapy treatment
Veena et al. (2018)¹⁸	Group 1: Active exercises and Mulligan's SNAGs	–	4 weeks (20)	None	In the 2 groups: Increased cervical extension. Reduction of Neck Disability Index and pain intensity
Veena et al. (2018)¹⁸	Group 2: Active exercises and muscle energy techniques	–	4 weeks (20)	None
Vernon et al. (2015)²⁸	SMT, mobilizations, trigger point compression, massage, and self-acupressure pillow	SMT, mobilizations, trigger point compression, and massage	4–5 weeks (6)	None	In the intervention group: Reduction of headache frequency
Yang and Da (2017)²⁵	Group 1: Exercises of cranio-cervical flexion		4 weeks (20)	1 month	In the 2 groups: Reduction of pain intensity and muscle fatigue
Yang and Da (2017)²⁵	Group 2: Relaxation of the suboccipital musculature		4 weeks (20)	1 month

Note: Dashes indicate not applicable.
Abbreviations: MMT, Maitland mobilization therapy; SMT, spinal manipulative therapy; SNAGs, Mulligan's sustained natural apophyseal glides.