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 Table of Contents  
Year : 2017  |  Volume : 11  |  Issue : 1  |  Page : 8-11

An evaluative commentary on physical therapy intervention in headache

Department of Neurophysiotherapy, KLEU Institute of Physiotherapy, Belgaum, Karnataka, India

Date of Web Publication18-Aug-2017

Correspondence Address:
Jorida Fernandes
KLEU Institute of Physiotherapy, JNMC Campus, Nehru Nagar, Belgaum - 590 010, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/PJIAP.PJIAP_1_17

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How to cite this article:
Kumar S, Fernandes J. An evaluative commentary on physical therapy intervention in headache. Physiother - J Indian Assoc Physiother 2017;11:8-11

How to cite this URL:
Kumar S, Fernandes J. An evaluative commentary on physical therapy intervention in headache. Physiother - J Indian Assoc Physiother [serial online] 2017 [cited 2021 Apr 15];11:8-11. Available from: https://www.pjiap.org/text.asp?2017/11/1/8/213274

This paper evaluates the usefulness of various physical therapy interventions used to treat a headache. According to the World Health Organization's ranking of causes of disability, headache disorders are listed among the ten most disabling conditions for both males and females. It is among the five most disabling disorder among women.[1] Headache is a major debilitating condition faced by most people of all age's worldwide. Pain can range from mild to very severe in intensity causing personal and societal burdens related to disability, quality of life, and financial liability. Making the correct diagnosis of headaches is very important for various reasons. A few headaches may have serious underlying pathologies, and early diagnosis is paramount to prevent severe complications. On the other hand, some headaches respond only to a specific drug. Therefore, a correct diagnosis is essential for good treatment. However, choosing which treatment is best effective for headaches is very demanding, and confusion is frequently encountered in clinical practice as to whether to treat pain with medications or physical therapy or a combination of both may help the patient.

  Definition Top

Headache is defined as pain in the head with the pain being above the eyes or the ears, occipital area, or in the back of the upper neck.[2] Recurrent headache is the most common disorder of the central nervous system. There are primary headache disorders, namely migraine, tension-type headache (TTH), and cluster headache and secondary headache disorders caused by a long list of other conditions, the most common of which is medication-overuse headache.[1] Commonly treated headaches by physiotherapist include migraine, TTH and cervicogenic headache (CGH).

  Epidemiology Top

According to the United Nations, 350 million patients were identified with migraine, 624 million with TTH, and 112 million with CGH in the Asia-Pacific which equaled to the estimated population of 3.85 billion in 2010.[3] According to a study conducted in India (Bengaluru), 1 year prevalence of headache was found to be 63.9% and 1-day prevalence was 5.9%. The prevalence was higher in the age groups of 18–5 years and among females. The prevalence was higher in rural 71.2% than in urban areas 57.3%. About 1.1% proportion of days were lost to headache from paid work, while overall productivity loss from both paid and household work was 2.8%.[4]

  Barriers to Effective Physiotherapy Treatment Top

Lack of awareness among health-care professionals regarding the means of treatment using physiotherapy is a major barrier. Patients want quicker relief with medications, though unaware with its other effects.

  Testing Top

According to a consensus statement, 11 physical examination tests were considered clinically useful. These include manual joint palpation, cervical flexion-rotation test, active range of cervical movement, the craniocervical flexion test, head forward position, muscle testing of strength of the shoulder girdle, trigger point (TrP) palpation, passive physiological intervertebral movements, reproduction and resolution of headache symptoms, combined movement tests, and screening of the thoracic spine. These 11 tests were suggested as a minimum standard for the physical examination of musculoskeletal dysfunctions in patients with a headache.[5],[6]

  Physiotherapy Treatment Top

An exhaustive literature search about physiotherapy intervention on headache [Table 1] revealed that there was statistically significant reduction in the intensity, frequency and duration of migraine, TTH and CGH.[7] Positive beneficial effects were also recorded in geriatric population receiving physiotherapy. Subjects reported significant reductions in headache frequency immediately after treatment.[8]
Table 1: Summary of studies quoted in the article

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The effectiveness of soft tissue techniques and neural mobilization techniques in the management of patients with frequent episodic TTH and chronic TTH (CTTH) was studied. Three groups received physiotherapy intervention such as soft tissue techniques, neural mobilization, and the combination of both. While one group received placebo superficial massage. Except the placebo group, remaining three groups noticed a significant change in pain pressure threshold of supraorbital region and temporal muscles and also frequency and intensity. Group which received a combination of soft tissue techniques and neural mobilization has shown significant improvement in frequency, intensity with positive impact of activities of daily living.[9]

Episodic TTHs should be managed with low load endurance craniocervical and cervicoscapular exercises. Patients with CTTHs also benefit with similar exercises. Other noninvasive and nonpharmacological treatment that helps in the management of headache include relaxation training with stress coping therapy; or multimodal care that includes spinal mobilization, craniocervical exercises, and postural correction. Manual therapy like manipulation with or without mobilization to the cervical and thoracic spine may also be helpful along with craniocervical and cervicoscapular exercises for CGH.[10]

Dry needling (DN) which is a new technique has a positive effect on headache. The rationale for applying DN in headaches relates to the etiologic role of TrPs in these pain conditions. The application of TrP-DN on individuals with headaches may reduce both peripheral and central sensitization. This is achieved by eliminating a long cause of peripheral nociceptive inputs. Other mechanism postulated for reducing headache in DN are by modulating spinal efficacy in the dorsal horn and by activating central inhibitory pain pathways. All these effects are apparently initiated when active TrPs receive the needling intervention.[11]

A meta-analysis was conducted using MEDLINE, PubMed, AMED, EMBASE, EBSCO, CINAHL, SCOPUS, Cochrane Collaboration Trials Register, PEDro, Cochrane Database of Systematic Reviews, and were searched to compare the efficacy of multimodal manual therapy versus pharmacological care for controlling TTH pain. It included all randomized controlled trials comparing any manual therapy versus medication for treating TTH in adults. The main outcome was headache intensity, frequency, and duration. It was found that manual therapies were more effective than pharmacological care in reducing intensity, frequency and duration of the headache instantly after treatment.[12]

Another study suggested that myofascial release for 3 min, 5 times a week for 6 weeks with conventional therapy is more effective than conventional therapy alone in the management of CGH. Conventional therapy included-moist pack for 10 min, followed by stretching of the cervical muscles, and strengthening of deep cervical flexors and postural correction [Table 1].[13]

Limited literature is available on the effectiveness of mulligans mobilization in headache. C1-C2 self-sustained natural apophyseal glides (SNAG) helps in reducing CGH symptoms sustained over a 1 year period. One possible mechanism by which the C1-C2 self-SNAG reduces headache symptoms is by the neuromodulator effect of joint mobilization. It works on the theory proposed by Melzac and Walls - the gate control theory. Stimulation of mechanoreceptors due to mobilization within the joint capsule and adjacent tissues causes an inhibition of pain at the spinal cord. Moreover, the end range positioning in rotation with the C1-C2 self-SNAG may involve these inhibitory systems and decrease the pain. The potential importance of this technique is that the a patient can implement this exercise self-sufficiently at home, without constant supervision.[14],[15]

Current evidence has shown that the efficiency of these interventions is based on correct clinical reasoning as not all interventions are equally effective for all headache pain conditions. For instance, evidence of physiotherapy in migraine is more debatable than in TTH, as migraine pathogenesis involves activation of subcortical structures and the trigeminovascular system, whereas pathogenesis of the latter is more related with musculoskeletal conditions, for example, muscle pain. It seems that multimodal approaches including different interventions are more effective for patients with TTH, migraine, and CGH.[16]

In our clinical practice and regular interaction with patients, we could find a considerable reduction in symptoms and frequency of headache with exercise therapy and transcutaneous electrical nerve stimulation (TENS). It was found that progressive muscular relaxation and TENS had similar effects on intensity of pain.[17] After the extensive literature search and clinical practice we infer that TTH and CGH headache can be effectively treated with physiotherapy intervention or physiotherapy can be used as an adjunct therapy with other methods of treatment.

The commentary is intended to give information about the scope of physiotherapy intervention in treating TTH and CGH by physiotherapist in tandom with other healthcare professionals.

  References Top

WHO. Headache Disorders; 2016. Available from: http://www.who.int/mediacentre/factsheets/fs277/en/. [Last updated on 2016 Apr; Last cited on 2016 Nov 08].  Back to cited text no. 1
Medicine Net. Definition of Headache; 2016. Available from: http://www.medicinenet.com/script/main/art.asp?articlekey=11396. [Last updated on 2016 May; Last cited on 2016 Nov 08].  Back to cited text no. 2
Peng KP, Wang SJ. Epidemiology of headache disorders in the Asia-Pacific region. Headache 2014;54:610-8.  Back to cited text no. 3
Gururaj G, Kulkarni GB, Rao GN, Subbakrishna DK, Stovner LJ, Steiner TJ. Prevalence and sociodemographic correlates of primary headache disorders: Results of a population-based survey from Bangalore, India. Indian J Public Health 2014;58:241-8.  Back to cited text no. 4
[PUBMED]  [Full text]  
Luedtke K, Boissonnault W, Caspersen N, Castien R, Chaibi A, Falla D, et al. International consensus on the most useful physical examination tests used by physiotherapists for patients with headache: A Delphi study. Man Ther 2016;23:17-24.  Back to cited text no. 5
Kumar D. Manual of Mulligan Concept: Revised Edition. New Delhi: Capri Institute of Manual Therapy; 2015.  Back to cited text no. 6
Luedtke K, Allers A, Schulte LH, May A. Efficacy of interventions used by physiotherapists for patients with headache and migraine-systematic review and meta-analysis. Cephalalgia 2016;36:474-92.  Back to cited text no. 7
Uthaikhup S, Assapun J, Watcharasaksilp K, Jull G. Effectiveness of physiotherapy for seniors with recurrent headaches associated with neck pain and dysfunction: A randomized controlled trial. Spine J 2017;17:46-55.  Back to cited text no. 8
Ferragut-Garcías A, Plaza-Manzano G, Rodríguez-Blanco C, Velasco-Roldán O, Pecos-Martín D, Oliva-Pascual-Vaca J, et al. Effectiveness of a treatment involving soft tissue techniques and/or neural mobilization techniques in the management of tension-type headache: A randomized controlled trial. Arch Phys Med Rehabil 2017;98:211-9.e2.  Back to cited text no. 9
Varatharajan S, Ferguson B, Chrobak K, Shergill Y, Cote P, Wong JJ, et al. 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. Eur Spine J 2016;25:1971-99.  Back to cited text no. 10
Fernández-De-Las-Peñas C, Cuadrado ML. Dry needling for headaches presenting active trigger points. Expert Rev Neurother 2016;16:365-6.  Back to cited text no. 11
Mesa-Jiménez JA, Lozano-López C, Angulo-Díaz-Parreño S, Rodríguez-Fernández ÁL, De-la-Hoz-Aizpurua JL, Fernández-de-Las-Peñas C. Multimodal manual therapy vs. pharmacological care for management of tension type headache: A meta-analysis of randomized trials. Cephalalgia 2015;35:1323-32.  Back to cited text no. 12
Shrivastava S, Srivastava N, Joshi S. A study to compare the efficacy of MFR along with conventional therapy vs. conventional therapy alone in the management of cervicogenic headache. Indian J Physiother Occup 2015;9:44-50.  Back to cited text no. 13
Fernández-de-las-Peñas C, Cuadrado ML. Physical therapy for headaches. Cephalgia 2015; pii: 0333102415596445.  Back to cited text no. 14
Shin EJ, Lee BH. The effect of sustained natural apophyseal glides on headache, duration and cervical function in women with cervicogenic headache. J Exerc Rehabil 2014;10:131-5.  Back to cited text no. 15
Hall T, Chan HT, Christensen L, Odenthal B, Wells C, Robinson K. Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache. J Orthop Sports Phys Ther 2007;37:100-7.  Back to cited text no. 16
Kumar S, Raje A. Effect of progressive muscular relaxation exercises versus transcutaneous electrical nerve stimulation on tension headache: A comparative study. Hong Kong Physiother J 2014;32:86-91.  Back to cited text no. 17


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