The effectiveness of manual and exercise therapy on headache intensity and frequency among patients with cervicogenic headache: a systematic review and meta-analysis

Pietro Bini; David Hohenschurz-Schmidt; Vincenzo Masullo; Diana Pitt; Jerry Draper-Rodi

doi:10.1186/s12998-022-00459-9

Table 1
For each study, the type of intervention and comparators, the number of participants for each group, all outcome measures analyzed, the duration and frequency of the intervention and the time-points for each follow-up measurement are reported
Authors Intervention (N) Intervention description Comparator (N) Primary outcome measures Secondary outcome measures Duration and frequency of intervention Measurement time points
Bodes-Pardo et al. [51] Trigger point therapy + stretching (10) Passive progressive manual pressure over trigger points (hyperirritable spot within a taut band of a skeletal muscle that elicits a referred pain upon examination) Sham trigger point therapy (10) HI (NPRS 0–10) Cervical ROM (degrees). Pressure pain sensitivity (analogical algometer). Deep cervical flexors motor performance (CCFT) 3 sessions over 1 week Baseline; 1 week

Chaibi et al. [52] Cervical manipulation (4) High-velocity, low-amplitude spinal manipulation Sham manual therapy (4); Control (4) HI (VAS 0–10), HF (days/month) HD (hours/day), Headache Index (HI × HF × HD) 12 sessions over 3 months Baseline; 3 months; 6 months; 12 months

Dunning et al. [53] Cervical and thoracic manipulation (58) High-velocity, low-amplitude spinal manipulation Cervical and thoracic mobilization and cranio-cervical flexion exercises (52) HI (NPRS 0–10), HF (days/week) HD (hours/week), Disability (NDI), Global Rating of Change Scale (GRCS), Medictions intake 6–8 sessions over 4 weeks Baseline; 1 week; 4 weeks; 3 months

Esin et al. [54] Kinesiotaping (34) Application of elastic tape over the vertical and horizontal portions of the trapezius muscle Sham taping (34); Education and autonomous rehabilitation instructions (33) HI (VAS 0–100), HF (days/month) Pressure pain threshold 20 applications over 4 weeks Baseline, 4 weeks, 8 weeks

Haas et al. [55] Cervical and thoracic manipulation—8 sessions (20); Cervical and thoracic manipulation—16 sessions (20) High-velocity, low-amplitude spinal manipulation Moist heat and light massage—8 sessions (20); Moist heat and light massage—16 sessions (20) HI (MVK 0–100), HF (days/4 weeks) Disability (MVK 0–10), Others headache frequency, Medications intake 8 or 16 sessions over 8 weeks. Groups undergoing 8 sessions also had 8 sessions of discussion and manual assessment Baseline, 4 weeks, 8 weeks, 12 weeks, 16 weeks, 20 weeks, 24 weeks

Haas et al. [56] Cervical and thoracic manipulation—6 sessions (65); Cervical and thoracic manipulation—12 sessions (64); Cervical and thoracic manipulation—18 sessions (63) High-velocity, low-amplitude spinal manipulation Sham massage (64) HI (VAS 0–10), HF (days/4 weeks) Disability (MVK), Drugs intake (N in the past 4 weeks), Other headache frequency (episodes in the past month) 6, 12 or 18 sessions over 6 weeks depending on group allocation. In the remaining visits, light massage was applied to experimental groups Baseline, 6 weeks, 12 weeks, 18 weeks, 24 weeks, 39 weeks, 42 weeks

Hall et al. [57] C1-2 SNAG (16) The self-directed use of a self-SNAG strap to emphasize C1-2 rotation through passive motion Sham SNAG (16) Headache index (HI × HF × HD) CROM (FRT), perceived benefit (VAS 0–10) Daily self-administration for 12 months Baseline, 4 weeks, 12 months

Jafari et al. [58] Trigger point therapy (9) Passive progressive manual pressure over trigger points No treatment control (10) HI (VAS 0–10), HF (days/2 weeks) Change in elastic modulus in trigger point area (Pa), Trigger point area (cm2), Pressure pain threshold (Algometer, VAS), CGH duration (hrs in the last 2 weeks) 4 sessions over 8 days Baseline, 3 weeks

Jull et al. [59] Spinal mobilization and manipulation (51); low load endurance exercises for cervico-scapular muscle (52); Comination of the above (49)
Spinal manipulation: High-velocity, low-amplitude spinal manipulation
Spinal mobilization: low-velocity spinal mobilization
Low-load endurance exercise: a program of low-load exercises to train muscle control of the cervico-scapular region
No treatment control (48) HI (VAS 0–10), HF (days/week) Cervical pressure pain threshold (VAS), Deep Cervical flexors performance (CCFT), Pain with neck movement (VAS 0–10), Neck pain index (Northwick Park), CGH duration (hrs in the past week), Medication intake 8 to 12 sessions over 6 weeks Baseline, 1 week, 3 months, 6 months, 12 months

Malo-Urriès et al. [60] Upper cervical mobilization (41) Low-velocity spinal mobilization Control (lay supine for 30') (41) HI (VAS 0–10) General cervical spine ROM (using CROM device), Upper cervical spine ROM (using CROM device during FRT), Cervical, suboccipital, trapezius pressure pain threshold (Algometer, Kg/cm2) Single intervention Baseline, immediately after treatment

Nilsson et al. [61] Cervical manipulation (28) High-velocity, low-amplitude spinal manipulation G2: Deep friction massage, trigger point therapy to upper back and neck, laser light therapy (26) HI (VAS 0–100) Medications intake 6 sessions over 3 weeks Baseline; 5 weeks

Sedighi et al. [62] Sub-occipital and trapezius dry needling (15) An invasive intervention where a solid filament needle is inserted into a trigger point Sham sub-occipital and trapezius dry needling (15) Headache index (HI × HF) Cervical spine ROM (4-points scale), Sub-occipital and trapezius pressure pain threshold (4-points scale, Function (FRI) Single intervention Baseline, post-intervention, 1 weeks

Sharma et al. [63] Multimodal therapy (9); G2: exercise therapy (low load and mobility exercise program for the cervical spine, postural correction intervention) (9) Multimodal therapy: spinal mobilization, low load and mobility exercise program for the cervical spine, postural correction intervention) Postural correction (9) HI (MVK 0–100), HF (days/week) Deep Cervical flexors performance (CCFT), Disability (NDI), CGH duration (hrs in the past week) 12 sessions over 4 weeks Baseline, 1 week, 2 weeks, 3 weeks, 4 weeks

von Piekartz et al. [64] Manual therapy + exercise (22) TMJ mobilization, trigger point therapy and stretching, TMJ coordination-ROM-home exercises Usual care (cranio-cervical manual and exercise therapy) (21) HI (CAS 0–10) Anamnestic questionnaire (AQ), Graded-chronic pain status (GCPS-NL, scale 1 to 4), Temporo-mandibular pressure pain threshold (Digital algometer, Kgf), Disability (NDI), TMJ noise (presence/absence of click, TMJ-related disability (GCPS), TMJ ROM (cm), Pain with TMJ opening, Mandibular deviation (presence/absence) 6 sessions over 3–6 weeks Baseline, 3 months, 6 months

Yang and Kang [65] Hot pack and low frequency therapy on trapezius + cranio cervical flexion exercises (10); Hot pack and low frequency therapy on trapezius + sub-occipital relaxation (10)
Cranio-cervical exercise: low-intensity exercise aimed at recruiting deep cervical spine flexors painlessly
Sub-occipital relaxation: light, prolonged manual pressure over the suboccipital muscles
Hot pack and low frequency therapy on trapezius (10) HI (VAS 0–100) Muscular fatigue (Hz), Muscle tone (N/m) 20 sessions over 4 weeks Baseline, 2 weeks, 4 weeks

Youssef and Shanb [66] Cervical mobilization and exercise (20) Low-velocity spinal mobilization Massage and exercise (18) HI (VAS 0–10), HF (days/4 weeks) Cervical spine ROM (cm), Disability (NDI), HD (hours/week) 12 sessions over 6 weeks Baseline, 7 weeks

Abdel et al. [67] Exercise Therapy (stretching, isometric contractions, postural correction) + Graston technique (30) Graston technique: an instrument-assisted soft tissue mobilization Exercise Therapy (stretching, isometric contractions, postural correction) (30) HI (VAS 0–100), HF (days/week) Disability (NDI), Cervical spine ROM (CROM device), HD (hours in the past week), Medication intake 12 sessions over 4 weeks Baseline, 2 weeks, 4 weeks

Dunning et al. [68] Spinal manipulation and electrical dry needling (74)
High-velocity, low-amplitude spinal manipulation
Electrical dry needling: application of needles over the cervical, occipital, temporal and oculo-frontal areas with low-frequency electrostimulation
Spinal mobilization and scapular and cranio-cervical exercise (68) HI (NPRS 0–10), HF (days/week) HD (hours in the past week), Disability (NDI), Global Rating of Change (GROC), Medication intake 4 to 8 sessions over 4 weeks Baseline, 1 week, 4 weeks, 3 months

Lerner-Lentz et al. [69] Spinal manipulation, cranio-cervical and scapular exercise (24) Spinal manipulation: High-velocity, low-amplitude spinal manipulation Spinal mobilization and scapular and cranio-cervical exercise (21) HI (NPRS 0–10) Disability (NDI, HIT-6), GRC, Patient Acceptable Symptoms Scale (PASS) Two sessions, uncertain timing Baseline, 2 days, 1 week, 1 month

Moustafa et al. [70] Myofascial release, spinal mobilization, cranio-cervical and scapular exercise, Dennerol cervical extension traction (30) Dennerol cervical traction: the use of an orthotic device in supine position creating cervical spine traction Myofascial release, spinal mobilization, cranio-cervical and scapular exercise (30) HF (days/2 weeks) Disability (HIT-6; HDI), Radiographic cervical alignment variables, Daily Defined Dose (DDD) 30 sessions over 10 weeks Baseline, 10 weeks, 1 year, 2 years

N number of participants, CCFT cranio-cervical flexion test, FRT flexion-rotation test, TMJ temporo-mandibular joint, HI headache intensity, HF headache frequency, ROM range of motion, HD headache duration, NDI Neck Disability Index

Authors	Intervention (N)	Intervention description	Comparator (N)	Primary outcome measures	Secondary outcome measures	Duration and frequency of intervention	Measurement time points
Bodes-Pardo et al. [51]	Trigger point therapy + stretching (10)	Passive progressive manual pressure over trigger points (hyperirritable spot within a taut band of a skeletal muscle that elicits a referred pain upon examination)	Sham trigger point therapy (10)	HI (NPRS 0–10)	Cervical ROM (degrees). Pressure pain sensitivity (analogical algometer). Deep cervical flexors motor performance (CCFT)	3 sessions over 1 week	Baseline; 1 week

Chaibi et al. [52]	Cervical manipulation (4)	High-velocity, low-amplitude spinal manipulation	Sham manual therapy (4); Control (4)	HI (VAS 0–10), HF (days/month)	HD (hours/day), Headache Index (HI × HF × HD)	12 sessions over 3 months	Baseline; 3 months; 6 months; 12 months

Dunning et al. [53]	Cervical and thoracic manipulation (58)	High-velocity, low-amplitude spinal manipulation	Cervical and thoracic mobilization and cranio-cervical flexion exercises (52)	HI (NPRS 0–10), HF (days/week)	HD (hours/week), Disability (NDI), Global Rating of Change Scale (GRCS), Medictions intake	6–8 sessions over 4 weeks	Baseline; 1 week; 4 weeks; 3 months

Esin et al. [54]	Kinesiotaping (34)	Application of elastic tape over the vertical and horizontal portions of the trapezius muscle	Sham taping (34); Education and autonomous rehabilitation instructions (33)	HI (VAS 0–100), HF (days/month)	Pressure pain threshold	20 applications over 4 weeks	Baseline, 4 weeks, 8 weeks

Haas et al. [55]	Cervical and thoracic manipulation—8 sessions (20); Cervical and thoracic manipulation—16 sessions (20)	High-velocity, low-amplitude spinal manipulation	Moist heat and light massage—8 sessions (20); Moist heat and light massage—16 sessions (20)	HI (MVK 0–100), HF (days/4 weeks)	Disability (MVK 0–10), Others headache frequency, Medications intake	8 or 16 sessions over 8 weeks. Groups undergoing 8 sessions also had 8 sessions of discussion and manual assessment	Baseline, 4 weeks, 8 weeks, 12 weeks, 16 weeks, 20 weeks, 24 weeks

Haas et al. [56]	Cervical and thoracic manipulation—6 sessions (65); Cervical and thoracic manipulation—12 sessions (64); Cervical and thoracic manipulation—18 sessions (63)	High-velocity, low-amplitude spinal manipulation	Sham massage (64)	HI (VAS 0–10), HF (days/4 weeks)	Disability (MVK), Drugs intake (N in the past 4 weeks), Other headache frequency (episodes in the past month)	6, 12 or 18 sessions over 6 weeks depending on group allocation. In the remaining visits, light massage was applied to experimental groups	Baseline, 6 weeks, 12 weeks, 18 weeks, 24 weeks, 39 weeks, 42 weeks

Hall et al. [57]	C1-2 SNAG (16)	The self-directed use of a self-SNAG strap to emphasize C1-2 rotation through passive motion	Sham SNAG (16)	Headache index (HI × HF × HD)	CROM (FRT), perceived benefit (VAS 0–10)	Daily self-administration for 12 months	Baseline, 4 weeks, 12 months

Jafari et al. [58]	Trigger point therapy (9)	Passive progressive manual pressure over trigger points	No treatment control (10)	HI (VAS 0–10), HF (days/2 weeks)	Change in elastic modulus in trigger point area (Pa), Trigger point area (cm2), Pressure pain threshold (Algometer, VAS), CGH duration (hrs in the last 2 weeks)	4 sessions over 8 days	Baseline, 3 weeks

Jull et al. [59]	Spinal mobilization and manipulation (51); low load endurance exercises for cervico-scapular muscle (52); Comination of the above (49)	Spinal manipulation: High-velocity, low-amplitude spinal manipulation Spinal mobilization: low-velocity spinal mobilization Low-load endurance exercise: a program of low-load exercises to train muscle control of the cervico-scapular region	No treatment control (48)	HI (VAS 0–10), HF (days/week)	Cervical pressure pain threshold (VAS), Deep Cervical flexors performance (CCFT), Pain with neck movement (VAS 0–10), Neck pain index (Northwick Park), CGH duration (hrs in the past week), Medication intake	8 to 12 sessions over 6 weeks	Baseline, 1 week, 3 months, 6 months, 12 months

Malo-Urriès et al. [60]	Upper cervical mobilization (41)	Low-velocity spinal mobilization	Control (lay supine for 30') (41)	HI (VAS 0–10)	General cervical spine ROM (using CROM device), Upper cervical spine ROM (using CROM device during FRT), Cervical, suboccipital, trapezius pressure pain threshold (Algometer, Kg/cm2)	Single intervention	Baseline, immediately after treatment

Nilsson et al. [61]	Cervical manipulation (28)	High-velocity, low-amplitude spinal manipulation	G2: Deep friction massage, trigger point therapy to upper back and neck, laser light therapy (26)	HI (VAS 0–100)	Medications intake	6 sessions over 3 weeks	Baseline; 5 weeks

Sedighi et al. [62]	Sub-occipital and trapezius dry needling (15)	An invasive intervention where a solid filament needle is inserted into a trigger point	Sham sub-occipital and trapezius dry needling (15)	Headache index (HI × HF)	Cervical spine ROM (4-points scale), Sub-occipital and trapezius pressure pain threshold (4-points scale, Function (FRI)	Single intervention	Baseline, post-intervention, 1 weeks

Sharma et al. [63]	Multimodal therapy (9); G2: exercise therapy (low load and mobility exercise program for the cervical spine, postural correction intervention) (9)	Multimodal therapy: spinal mobilization, low load and mobility exercise program for the cervical spine, postural correction intervention)	Postural correction (9)	HI (MVK 0–100), HF (days/week)	Deep Cervical flexors performance (CCFT), Disability (NDI), CGH duration (hrs in the past week)	12 sessions over 4 weeks	Baseline, 1 week, 2 weeks, 3 weeks, 4 weeks

von Piekartz et al. [64]	Manual therapy + exercise (22)	TMJ mobilization, trigger point therapy and stretching, TMJ coordination-ROM-home exercises	Usual care (cranio-cervical manual and exercise therapy) (21)	HI (CAS 0–10)	Anamnestic questionnaire (AQ), Graded-chronic pain status (GCPS-NL, scale 1 to 4), Temporo-mandibular pressure pain threshold (Digital algometer, Kgf), Disability (NDI), TMJ noise (presence/absence of click, TMJ-related disability (GCPS), TMJ ROM (cm), Pain with TMJ opening, Mandibular deviation (presence/absence)	6 sessions over 3–6 weeks	Baseline, 3 months, 6 months

Yang and Kang [65]	Hot pack and low frequency therapy on trapezius + cranio cervical flexion exercises (10); Hot pack and low frequency therapy on trapezius + sub-occipital relaxation (10)	Cranio-cervical exercise: low-intensity exercise aimed at recruiting deep cervical spine flexors painlessly Sub-occipital relaxation: light, prolonged manual pressure over the suboccipital muscles	Hot pack and low frequency therapy on trapezius (10)	HI (VAS 0–100)	Muscular fatigue (Hz), Muscle tone (N/m)	20 sessions over 4 weeks	Baseline, 2 weeks, 4 weeks

Youssef and Shanb [66]	Cervical mobilization and exercise (20)	Low-velocity spinal mobilization	Massage and exercise (18)	HI (VAS 0–10), HF (days/4 weeks)	Cervical spine ROM (cm), Disability (NDI), HD (hours/week)	12 sessions over 6 weeks	Baseline, 7 weeks

Abdel et al. [67]	Exercise Therapy (stretching, isometric contractions, postural correction) + Graston technique (30)	Graston technique: an instrument-assisted soft tissue mobilization	Exercise Therapy (stretching, isometric contractions, postural correction) (30)	HI (VAS 0–100), HF (days/week)	Disability (NDI), Cervical spine ROM (CROM device), HD (hours in the past week), Medication intake	12 sessions over 4 weeks	Baseline, 2 weeks, 4 weeks

Dunning et al. [68]	Spinal manipulation and electrical dry needling (74)	High-velocity, low-amplitude spinal manipulation Electrical dry needling: application of needles over the cervical, occipital, temporal and oculo-frontal areas with low-frequency electrostimulation	Spinal mobilization and scapular and cranio-cervical exercise (68)	HI (NPRS 0–10), HF (days/week)	HD (hours in the past week), Disability (NDI), Global Rating of Change (GROC), Medication intake	4 to 8 sessions over 4 weeks	Baseline, 1 week, 4 weeks, 3 months

Lerner-Lentz et al. [69]	Spinal manipulation, cranio-cervical and scapular exercise (24)	Spinal manipulation: High-velocity, low-amplitude spinal manipulation	Spinal mobilization and scapular and cranio-cervical exercise (21)	HI (NPRS 0–10)	Disability (NDI, HIT-6), GRC, Patient Acceptable Symptoms Scale (PASS)	Two sessions, uncertain timing	Baseline, 2 days, 1 week, 1 month

Moustafa et al. [70]	Myofascial release, spinal mobilization, cranio-cervical and scapular exercise, Dennerol cervical extension traction (30)	Dennerol cervical traction: the use of an orthotic device in supine position creating cervical spine traction	Myofascial release, spinal mobilization, cranio-cervical and scapular exercise (30)	HF (days/2 weeks)	Disability (HIT-6; HDI), Radiographic cervical alignment variables, Daily Defined Dose (DDD)	30 sessions over 10 weeks	Baseline, 10 weeks, 1 year, 2 years