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. 

In This Article

Abstract and Introduction


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.


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.