Monthly Archives: November 2014

I haven’t got time for a headache!

I seem to be seeing my fair share of patients presenting with headaches at the moment – this last week roughly half of my clinic time has spent working with patients presenting with a headache on its own, or in combination with other musculoskeletal complaints. There are a couple of things that I feel are important for breaking a headache cycle –
• The person needs to acknowledge a connection between their emotions/stress levels/current situation and how that is contributing to their headache
• They need to have some level of “body awareness” – to be able to tune into where they are holding tension in their body (jaw, shoulders, upper neck etc) and be therefore able to consciously relax that area.

Creating awareness around these areas can be a difficult task – some people walk in the door and are already on board with the ideas, telling you that things have worsened since circumstances have changed such as increased work hours or a stressful situation has reared its head. For other people, I sometimes feel like I am bashing my own head against the wall trying to get these concepts across – particularly for those who have some strongly entrenched ideas around the neck being the cause of their headache. These patients are often stuck in passive mode, believing that it is the practitioners’ job to take the headache away for them. They tend to have a cause and effect understanding about their headache which usually goes along the lines of “my neck is out/tight/sore and therefore I have a headache”. But the reality is, as discussed last time, a true cervicogenic headache is actually not that common. We will often be seeing patients with a tension type headache, who are also experiencing concurrent upper cervical pain, due to the way that the information from the head and neck are processed in the brain, particularly at the trigeminocervical nucleus.

One patient summed up the attitude that I felt I had been dealing with all week – “I haven’t got time for a headache”. A busy, self employed designer, working to some pretty tight deadlines, doing 15 hour days at the computer, sleeping in the spare room so as not to wake her partner when the insomnia was bad…………. You know the story! It took three weeks of both her GP and I saying the same things before if finally sunk in and she made some changes – we need to address the mechanical factors (time and posture at the desk), the stress levels (do your daily mindfulness exercises, make that appointment with the psychologist you have been saying you will do, schedule some down time into the diary) and for goodness sake, get some exercise! The absurdity of that statement and ironic laughs that followed probably helped to put it all into perspective for her.

So what does the literature tell us about treatment of headaches, particularly the persistent ones?
As discussed previously, a true cervicogenic headache will tend to respond fairly well to manual therapy and manipulation approaches as well as exercise approaches. A study done by Jull in 2002 (1) demonstrated that in a group of 200 subjects with a diagnosed cervicogenic headache (change in cervical range of motion, reduced control of craniocervical flexion muscles and pain on palpation of C0-C4) significant reductions in headache frequency and intensity were see in in both musculoskeletal therapy groups and specific muscle exercise therapy groups when compared to the control group. Furthermore, combining both exercise and manual therapy gave good relief to 10% more people than in the single intervention groups. Similarly a study by Haas in 2010 (2) demonstrated good reduction in cervicogenic headaches with weekly cervical manipulation, however doubling the number of treatments to two per week gave no further significant improvements.

In treating migraine headaches there is limited high quality data available regarding manual therapy interventions. Some lower quality studies demonstrated that manipulation was as effective as Amytriptyline (an older style antidepressant, often used in low doses for chronic conditions like migraine) in preventing onset of migraine. Another showed that mobilisation of the neck would have an effect on reducing migraines, but manipulation was no more effective than the mobilisation (3).

Several review articles (4,5) tell us that manual therapy is not effective for treating tension type headaches, however both reviews acknowledge that the studies included were of poor quality and therefore drawing solid conclusions about this is not possible. The tricky bit probably lies in the difficulty in accurately diagnosing a headache, given that frequently there are overlapping features of several types of headaches. See here for a reminder on the clinical features of the different types of common headaches. The answer to whether manual therapy is always the way forward is therefore going to be along the lines of how we answer this question for most chronic conditions – probably not on its own, but in conjunction with other approaches there is certainly a strong justification for its use. Manual therapists are going to be well placed to put together a management program that can combine these approaches and manage their implementation.

Mindfulness exercises, psychological approaches and exercises approaches are fairly well represented in the literature and show some really promising results in the treatment of a variety of different types of headaches, including migraines. Next time we will look at what these approaches are and how you can start using some of them in your private practice.

1. Jull, G., Trott, P., Potter, H., Zito, G., Niere, K., Shirley, D., Emberson, J., Marschner, I., & Richardson, C. (2002). A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine, 1:27(17), 1835-43.

2. Haas, M., Spegman, A., Peterson, D., Aickin, M & Vavrek, N. (2010). Dose-Response and Efficacy of Spinal Manipulation for Chronic Cervicogenic Headache: A Pilot Randomized controlled Trial. Spine, 10(2), 117.

3. Posadzki, P., & Ernst, E. (2011). Spinal Manipulation: an update of a systematic review of systematic reviews. New Zealand Medical Journal 12:124(1340), 55-71.

4. Bronfort,G., Haas, M., Evans, R., Leininger, B., & Triano, J. (2010). Effectiveness of manual therapies: The UK evidence report. Journal of Chiropractic and Osteopathy. 25, 18.

5. Fernandez-de-Las-Pena, C., Alonso-Blanco, C., Cuadrado, M., Miangolarra, J., Barriga, F & Pareja, J. (2006). Are manual therapies effective in reducing pain from tension-type headache?:a systematic review. Clinical Journal of Pain, 22(3), 278-85.

Do we have a role in managing chronic headaches?

Headaches are frequent causes for presentations at most manual therapy clinics.  Headaches can be debilitating, annoying and all encompassing, be they migraine, tension type headaches, cervicogenic  or the less common autonomic cephalgias such as cluster headaches (sometimes called suicide headaches). People will frequently seek out manual therapy because when their head hurts, they also will tend to have neck pain.  Studies tell us that 64-70% of people with headache and migraine will also have neck pain 1.

Is the neck the cause of the headache?

In some cases, yes.  In reality though, cervicogenic headaches actually make up a fairly small proportion (18%) of the headache sufferer population 2.  To be classified as a cervicogenic headache (and be therefore most likely to respond to manual therapy) the headache must be precipitated by neck movements or postures and/or pressure over the upper cervical/ occipital regions, have restriction in neck ROM and have weakness in the deep cervical flexors.  Cervicogenic headaches are also typically side dominant and don’t throb3.

Typically, manual therapists tend to place a lot of emphasis for diagnosis of a cervicogenic headache on the ability to reproduce the headache with palpation of the upper cervical region.  However this is a bit of an erroneous test because we know that almost 100% of patients with either a tension type headache or a migraine will also get reproduction of their headache with palpation of the upper cervicals4.   This is most likely due to the phenomenon of convergence at the Trigeminocervical nucleus(TCN) , where information from both the upper three cervical vertebra and the trigeminal nerve feed into the same region in the brain.  Like other types of convergence or referred pain, the brain can’t figure out where the pain is coming from and so both can tend to be painful.  In the chronic headache sufferer, the TCN undergoes central sensitisation processes, making it more likely to interpret and pass on information of a painful nature.

The literature tells us that physical treatment for headaches tends to only give sustained benefit to those people who genuinely fall into the cervicogenic headache category 5 .  However, as practitioners we have all seen instances when some level of relief from manual therapy has been achieved for a headache that falls outside of these categories, including for those suffering from tension type headaches.  In these instances, we are probably having a modulatory effect on the TCN.

As an occasional tension headache sufferer, I would argue that any benefit that can be achieved from manual therapy for a non cervicogenic headache  is  fantastic and is worth pursuing – with the caveat that both the practitioner and patient understand the context of use – to provide temporary relief as part of a bigger picture of treatment.  We should not be suggesting that we can comprehensively treat all types of headaches using manual therapy alone.  As in all chronic conditions, passive approaches such as this are not the answer.

The literature is very good at telling us what doesn’t work for a particular condition, and headaches are no different in this instance.  In the next blog post we will look at some of the approaches that are known to have an effect on headache frequency, intensity and medication use.  Surely all this research has to be good for something!


  1. Blau, J., MacGregor, E. (1994). Headache and the neck.  Headache, 35(2), 104-106.
  2. Nilsson, N. (1995). The prevalence of cervicogenic headache in a random population sample of 20-59 year olds. Spine, 1:20 (17) 1884-1888.
  3. Hall, T., Briffa, K., & Hoppa, D. (2008). Clinical evaluation of cervicogenic headache: A clinical perspective. The Journal of Manual and Manipulative Therapy, 16(2) 73-80.
  4. Watson, D., & Drummond, D. (2012). Headache pain referral during examination of the neck in migraine and tension-type headache. Headache, 52(8), 1226-35
  5. Bronfort,G., Haas, M., Evans, R., Leininger, B., & Triano, J. (2010). Effectiveness of manual therapies: The UK evidence report. Journal of Chiropractic and Osteopathy. 25, 18.