Welcome to Headache @ Chiro.Org   This section contains
a vast collection of articles detailing how chiropractic can help.


Headache and Chiropractic

This section was compiled by Frank M. Painter, D.C.
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If there are terms in these articles you don't understand, you can get a definition from the Merriam Webster Medical Dictionary. If you want information about a specific disease, you can access the Merck Manual. You can also search Pub Med for more abstracts on this, or any other health topic.

Jump to: Reference Materials Headache Articles Cervicogenic Headache

Chronic Tension Migraine Headache Other Management

Patient Satisfaction Cost-Effectiveness Safety of Chiropractic

Exercise + Chiropractic Chiropractic Rehab Integrated Care

Pediatric Section Veterans Care Disc Herniation

Chronic Neck Pain Low Back Pain Whiplash Section

Conditions That Respond Alternative Medicine Approaches to Disease


Headache Reference Materials

Headache Guidelines
A Chiro.Org article collection

Review this JMPT article titled: “Evidence-Based Guidelines for the Chiropractic Treatment of Adults With Headache” and another guideline from the Guidelines Development Committee titled: “Clinical Practice Guideline for the Management of Headache Disorders in Adults”

Chiropractors Are the Spinal Health Care Experts
A Chiro.Org article collection

Enjoy these learned articles about chiropractors as first-contact Spinal Health Care Experts.

Headaches in Children
A Chiro.Org article collection

This collection from our Pediatrics section focuses on headaches in children.

Neck and Back Pain in Children
A Chiro.Org article collection

This collection from our Pediatrics section specifically focuses on neck and spinal pain in children.

The Forward Head Posture Page
A Chiro.Org article collection

Persistent forward head posture (a.k.a “hyperkyphotic posture”) forces the suboccipital muscles to remain in constant contraction as they elevate the chin, and this puts pressure on the 3 suboccipital nerves. This nerve compression may cause headaches at the base of the skull, and can also mimic sinus (frontal) headaches.

Headache Classification System
A Chiro.Org collection

This page differentiates between “primary” and “secondary” headaches, and then describes these primary headache types:   Cervicogenic,   Tension-type,   Migraine,   and Cluster headaches.

Evidence-Based Guidelines for the Chiropractic Treatment of Adults With Headache
J Manipulative Physiol Ther. 2011 (Jun);   34 (5):   274–289 ~ FULL TEXT
Evidence suggests that chiropractic care, including spinal manipulation, improves migraine and cervicogenic headaches. The type, frequency, dosage, and duration of treatment(s) should be based on guideline recommendations, clinical experience, and findings. Evidence for the use of spinal manipulation as an isolated intervention for patients with tension-type headache remains equivocal.
You may also want to review the Headache Guidelines

Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache
Duke University Evidence-based Practice Center ~ 2001
In 1996, the Agency for Health Care Policy and Research (AHCPR) was scheduled to produce a set of clinical practice guidelines on available treatment alternatives for headache. This headache project was based on the systematic evaluation of the literature by a multidisciplinary panel of experts. Due to largely political circumstances, however, their efforts never came to fruition. The work was never released as guidelines, but was instead transformed with modifications and budget cuts into a set of evidence reports on only migraine headache. Thanks to FCER funding, the evidence reports have now been updated on both cervicogenic and tension-type headaches.
You might also enjoy Dr. Anthony Rosner's discussion
You may download the full 10-page Adobe Acrobat (PDF) version.
You will also enjoy FCER's announcement on the initial publication of the Duke Report


Headache Information Articles

Effectiveness of Chiropractic Manipulation Versus Sham Manipulation for
Recurrent Headaches in Children Aged 7-14 Years - A Randomised Clinical Trial

Chiropractic & Manual Therapies 2021 (Jan 7);   29:   1~ FULL TEXT

Chiropractic spinal manipulation resulted in fewer headaches and higher global perceived effect, with only minor side effects. It did not lower the intensity of the headaches. Since the treatment is easily applicable, of low cost and minor side effects, chiropractic spinal manipulation might be considered as a valuable treatment option for children with recurrent headaches.

Development and Validation of a Model Predicting Post-Traumatic Headache
Six Months After a Motor Vehicle Collision in Adults

Accident Analysis and Prevention 2020 (May 20);   142:   105580 ~ FULL TEXT

Post-traumatic headache is common and often persists beyond the acute period. Our model is useful in helping clinicians predict PTH six months after a traffic collision in primary care populations. The main priority for future research is to assess candidate interventions for people that are at high risk of PTH at six months. This work also suggests the potential usefulness of a prognostic approach to classifying PTH beyond the ICHD-3 Headache Classification Committee of the International Headache Society, 2013.

Chiropractic Treatment of Older Adults with Neck Pain with or without Headache
or Dizziness: Analysis of 288 Australian Chiropractors' Self-reported Views

Chiropractic & Manual Therapies 2019 (Dec 18);   27:   65 ~ FULL TEXT

This is the first known study to investigate chiropractic care of older adults living with neck pain. The findings suggest that chiropractors use well-established manual and physical therapy techniques to manage neck pain in older adults. The favourable outcomes reported by participants highlight a potential role for using non-pharmacological multimodal therapeutic approaches for the management of neck pain in older adults. The findings also indicate that this target group of patients may frequently integrate chiropractic care with other health services in order to manage their neck pain. Understanding the patient’s motivation for using multiple services may shed light on the health care needs of this population. Further research should also explore how chiropractic treatment of neck pain in older adults impacts patient experience, and other patient-reported outcomes. Given the high prevalence of neck pain in older people, the evidence for the effectiveness of manual and physical treatments for neck pain, the reported demand for chiropractic care in this population, the barriers to pain relief, and concerns among older adults regarding polypharmacy, further studies are needed to provide a more solid evidence-base upon which clinical guidelines for chiropractic management and/or co-management of this condition can be developed. Until then, we recommend that the current clinical guidelines be followed.

The Management of Common Recurrent Headaches by Chiropractors:
A Descriptive Analysis of a Nationally Representative Survey

BMC Neurology 2018 (Oct 17);   18 (1):   171 ~ FULL TEXT

Our national-based sample suggests headache is a substantial proportion of chiropractic caseload. While some aspects of chiropractic headache management, including the acceptance and use of headache diagnostic criteria, appears to be consistent with good clinical practice, other aspects of chiropractic headache management raise questions worthy of further research enquiry. Critically, there is a need for more detailed information on the proportion of headache types and level of headache chronicity and disability found within chiropractic headache patient populations. This information will help practitioners, researchers and policy-makers to better understand the healthcare needs associated with headache patients who seek help from this common provider of headache management.

Complementary and Integrative Medicine in the Management of Headache
British Medical Journal 2017 (May 16);   357:   j1805 ~ FULL TEXT

Headaches, including primary headaches such as migraine and tension-type headache, are a common clinical problem. Complementary and integrative medicine (CIM), formerly known as complementary and alternative medicine (CAM), uses evidence informed modalities to assist in the health and healing of patients. CIM commonly includes the use of nutrition, movement practices, manual therapy, traditional Chinese medicine, and mind-body strategies. This review summarizes the literature on the use of CIM for primary headache and is based on five meta-analyses, seven systematic reviews, and 34 randomized controlled trials (RCTs).

Variations in Patterns of Utilization and Charges for the Care of Headache
in North Carolina, 2000-2009: A Statewide Claims' Data Analysis

J Manipulative Physiol Ther. 2016 (May);   39 (4):   229–239 ~ FULL TEXT

Overall utilization and average charges for the treatment of headache increased considerably from 2000 to 2005 and then decreased in each subsequent year. Policy changes that took place between 2005 and 2007 may have affected utilization rates of certain providers and their associated charges. MD care accounted for the majority of total allowed charges throughout the decade. In general, patterns of care involving multiple providers and referral care incurred the largest charges, whereas patterns of care involving single or nonreferral providers incurred the least charges. MD-only, DC-only, and MD-DC care were the least expensive patterns of headache care; however, risk-adjusted charges (available 2006-2009) were significantly lower for DC-only care compared with MD-only care.
This is one of 3 of the Cost-Effectiveness Triumvirate articles.

Manual Therapies for Primary Chronic Headaches:
A Systematic Review of Randomized Controlled Trials

J Headache Pain. 2014 (Oct 2);   15:   67 ~ FULL TEXT

This is to our knowledge the first systematic review regarding the efficacy of manual therapy randomized clinical trials (RCT) for primary chronic headaches. A comprehensive English literature search on CINHAL, Cochrane, Medline, Ovid and PubMed identified 6 RCTs all investigating chronic tension-type headache (CTTH). One study applied massage therapy and five studies applied physiotherapy. Four studies were considered to be of good methodological quality by the PEDro scale. All studies were pragmatic or used no treatment as a control group, and only two studies avoided co-intervention, which may lead to possible bias and makes interpretation of the results more difficult.

An International Survey of Pain in Adolescents
BMC Public Health. 2014 (May 13);   14 (1):   447 ~ FULL TEXT

Adolescence marks the transition from childhood to adult life. Pain during adolescence is an important predictor of future pain. [1–3] A Danish twins study [4] found adolescents with persistent low back pain were 3.5 times more likely to have low back pain in adulthood. Co-occurrence of low back pain and headache in adolescence further increases the risk of developing future pain which draws attention to the significance of multiple pains. [4]

Is There a Difference in Head Posture and Cervical Spine Movement
in Children With and Without Pediatric Headache?

European Journal of Pediatrics 2013 (Oct);   172 (10):   1349–1356 ~ FULL TEXT

Cervical range of motion (ROM) in each cardinal plane was significantly less in the children with purported cervicogenic headache (CGH) compared to those without headache (Table 1). ROM values recorded in the asymptomatic group are comparable with a previous report for children. [3] While no previous studies have reported ROM values for children with CGH, these results are consistent with reports in adult populations. [23, 51, 52] Interestingly, ROM does not appear to be restricted in all directions in adults with headache [23, 51, 52], but the explanation for this is not clear. This study finding of reduced ROM in children with purported CGH supports the current criteria for CGH diagnosis. [20, 44]

Combination of Acupuncture and Spinal Manipulative Therapy: Management of a
32-year-old Patient With Chronic Tension-type Headache and Migraine

Journal of Chiropractic Medicine 2012 (Sep);   11 (3):   192–201

A 32-year-old woman presented with chronic, daily headaches of 5 months' duration. After 5 treatments over a 2-week period (the first using acupuncture only, the next 3 using acupuncture and chiropractic spinal manipulative therapy), her headaches resolved. The patient had no recurrences of headaches in her 1-year follow-up.

Chiropractic Management of Post-concussion Headache and Neck Pain
In a Young Athlete and Implications For Return-To-Play

Topics in Integrative Health Care 2011 (Oct 7);   2 (3) ~ FULL TEXT

Each year there are an estimated 1.6 to 3.8 million sports-related brain injuries; 136,000 of which occur in young athletes in the course of high school sports. The purpose of this article is to discuss the management and outcome of a post-concussive headache and neck pain in a young athlete and implications for return to play.

Symptomatic Reactions, Clinical Outcomes and Patient Satisfaction Associated with
Upper Cervical Chiropractic Care: A Prospective, Multicenter, Cohort Study

BMC Musculoskelet Disord. 2011 (Oct 5);   12:   219 ~ FULL TEXT

A total of 1,090 patients completed the study having 4,920 (4.5 per patient) office visits requiring 2,653 (2.4 per patient) upper cervical adjustments over 17 days. Three hundred thirty- eight (31.0%) patients had symptomatic reactions (SRs) meeting the accepted definition. Intense SR (NRS ≥8) occurred in 56 patients (5.1%). Outcome assessments were significantly improved for neck pain and disability, headache, mid-back pain, as well as lower back pain and disability (p <0.001) following care with a high level (mean = 9.1/10) of patient satisfaction. The 83 chiropractors administered >5 million career upper cervical adjustments without a reported incidence of serious adverse event.

Referred Pain from Myofascial Trigger Points in Head and Neck-shoulder
Muscles Reproduces Head Pain Features in Children With
Chronic Tension type Headache

J Headache Pain. 2011 (Feb);   12 (1):   35–43 ~ FULL TEXT

The current controlled and blinded study showed the existence of multiple active TrPs in head, neck and shoulder musculature in children with chronic tension type headache (CTTH). Both local and referred pain characteristics elicited by palpation of active muscle TrPs reproduced the head pain patterns in children with CTTH. Referred pain areas elicited by active TrPs were larger in children with CTTH as compared to healthy children. The size of referred pain areas of some muscles was positively related to some headache clinical parameters. Our results support a role of active TrP in children with CTTH.

Cervicogenic Headache Revisited
The Chiropractic Report 2010: Vol. 24 No. 5

“In my experience, cervical migraine is the type of headache most frequently seen in general practice and also the type most frequently misinterpreted. It is usually erroneously diagnosed as classical migraine, tension headache, vascular headache. Such patients have usually received an inadequate treatment and have often become neurotic and drug-dependent”. ~ Frykholm, neurosurgeon, Sweden (1972) [1]

Physical Examination and Self-Reported Pain Outcomes From
a Randomized Trial on Chronic Cervicogenic Headache

J Manipulative Physiol Ther. 2010 (Jun);   33 (5):   338–348 ~ FULL TEXT

We have noted that, at baseline, the study participants' subjective headache experience was most associated with PE measures of inclinometric cervical active ROM and elicited pain. However, this pattern shifted at week 12, 4 weeks after the final treatment. At week 12, the measure most associated with study participants' CGH subjective outcomes was the final examination pain pressure threshold (algometric pain thresholds).
You will also enjoy this   PowerPoint Presentation by the authors.

Illustrating Risk Difference and Number Needed to Treat from a Randomized
Controlled Trial of Spinal Manipulation for Cervicogenic Headache

Chiropractic & Osteopathy 2010 (May 24);   19 (9) ~ FULL TEXT

Spinal manipulation demonstrated a benefit in terms of a clinically important improvement of cervicogenic headache pain. The use of adjusted NNT is recommended; however, adjusted RD may be easier to interpret than NNT. The study demonstrated how results may depend on the threshold for dichotomizing variables into binary outcomes.

Intractable Migraine Headaches During Pregnancy Under Chiropractic Care
Complementary Therapies in Clinical Practice 2009 (Nov);   15 (4):   192–197

The absence of hormone fluctuations and/or the analgesic effects of increased beta-endorphins are thought to confer improvements in headache symptoms during pregnancy. However, for a number of pregnant patients, they continue to suffer or have worsening headache symptoms. The use of pharmacotherapy for palliative care is a concern for both the mother and the developing fetus and alternative/complementary care options are sought. We present a 24-year-old gravid female with chronic migraine headaches since age 12years. Previous unsuccessful care included osteopathy, physical therapy, massage and medication. Non-steroidal anti-inflammatory medication with codeine provided minor and temporary relief. Chiropractic care involving spinal manipulative therapy (SMT) and adjunctive therapies resulted in symptom improvement and independence from medication. This document provides supporting evidence on the safety and possible effectiveness of chiropractic care for patients with headaches during pregnancy.

Diagnosis and Chiropractic Treatment of Infant Headache Based on Behavioral Presentation
and Physical Findings: A Retrospective Series of 13 Cases

J Manipulative Physiol Ther. 2009 (Oct);   32 (8):   682–686 ~ FULL TEXT

This case series offers information about potential signs of benign infant headache. The patients in this study responded favorably to chiropractic management.

Recurrent Neck Pain and Headaches in Preadolescents Associated with
Mechanical Dysfunction of the Cervical Spine: A Cross-Sectional
Observational Study With 131 Students

J Manipulative Physiol Ther 2009 (Oct);   32 (8):   625–634 ~ FULL TEXT

Forty percent of the children (n = 52) reported neck pain and/or recurrent headache. Neck pain and/or headache were not associated with forward head posture, impaired functioning in cervical paraspinal muscles, and joint dysfunction in the upper and middle cervical Spine in these subjects. However, joint dysfunction in the lower cervical Spine was significantly associated with neck pain and/or headache in these preadolescents. Most of the students had nonsymptomatic biomechanical dysfunction of the upper cervical Spine. There was a wide variation between parental report and the child's self-report of trauma history and neck pain and/or headache prevalence.

Headache in a National Sample of American Children: Prevalence and Comorbidity
J Child Neurol 2009 (May);   24 (5):   536–543 ~ FULL TEXT

The purpose of this study was to determine the prevalence, sociodemographic correlates, and comorbidity of recurrent headache in children in the United States. Participants were individuals aged 4 to 18 years (n = 10,198) who participated in the National Health and Nutrition Examination Surveys. Data on recurrent and other health conditions were analyzed. Frequent or severe headaches including migraine in the past 12 months were reported in 17.1% of children. Asthma, hay fever, and frequent ear infections were more common in children with headache, with at least 1 of these occurring in 41.6% of children with headache versus 25.0% of children free of headache. Other medical problems associated with childhood headaches include anemia, overweight, abdominal illnesses, and early menarche. Recurrent headache in childhood is common and has significant medical comorbidity. Further research is needed to understand biologic mechanisms and identify more homogeneous subgroups in clinical and genetic studies.

Chronic Daily Headache in Adolescents: Prevalence, Impact, and Medication Overuse
Neurology 2006 (Jan 24);   66 (2):   193–197

Chronic daily headache (CDH) was common in a large nonreferred adolescent sample. Based on the International Classification of Headache Disorders, 2nd edition, criteria, chronic tension-type headache was the most common subtype; Although this article does not discuss care options for chronic tension-type headache, conservative chiropractic care is the natural choice.

Headaches - Tension, Migraine and Cluster
American Chiropractic Association

A report released in 2001 by researchers at the Duke University Evidence-Based Practice Center in Durham, NC, found that spinal manipulation resulted in almost immediate improvement for those headaches that originate in the neck, and had significantly fewer side effects and longer-lasting relief of tension-type headache than a commonly prescribed medication.

Musculoskeletal Abnormalities in Chronic Headache:
A Controlled Comparison of Headache Diagnostic Groups

Headache. 1999 (Jan);   39 (1):   21–27

There was a significant difference in the presence of postural abnormalities between the controls and the patients, with posture abnormalities more likely to be present in those with headache. The patients were also significantly more likely to have active trigger points and trigger points in the neck than were the control subjects. There were no significant group differences identified in the mechanical measures, nor were there any significant differences among the three headache categories.

Four Articles Which Describe the Relationship Between the
Upper Cervical Spine and Headaches and Chronic Head Pain

  1. Atrophy of Suboccipital Muscles in Chronic Pain Patients
    We have observed previously unreported muscle atrophy in the rectus capitis posterior minor (RCPMI) muscles of a group of chronic pain patients. We hypothesize that chronic pain, in this select group of patients, is a consequence of tramua that occurs to the C1 dorsal ramus during whiplash.

  2. Magnetic Resonance Imaging of the Upper Cervical Spine
    We are currently using MRI to investigate the functional integrity of the upper cervical Spine. We started out looking for hypertonic muscles in a population of patients who were suffering from chronic head and neck pain. My first task was to collect MRI data and to identify suboccipital muscles within the MR images. So I brought together a physician and an anatomy professor to see if they could help me out. Their comments were classic. The anatomy professor said, "The reason you can't find those muscles is because they are not there." The physician immediately responded by saying, "No wonder these patients don't get any better." I had been using images that were collected from a chronic pain patient, and it was apparent that the rectus capitis posterior minor muscles were missing. When we looked at images from a control subject it was very easy to locate these muscles. At that point, the focus of our research switched from looking for hypertonic muscles to comparing muscle density between the control group and the chronic pain group.

  3. Anatomic Relation Between the Rectus Capitis Posterior Minor Muscle
    and the Spinal Dura Mater

    We observed that the PAO membrane was securely fixed to the surface of the dural tube by multitudinous fine connective tissue fibers. There was no real interlaminar space between these two structures and they appeared to function as a single entity. The influence of the RCPMI muscle on the dura mater was artificially produced in the hemisected specimen. Artificially functioning the muscle produced obvious movement of the spinal dura between the occiput and the atlas, and resultant fluid movement was observed to the level of the pons and cerebellum.

  4. Visualization of the Muscle-Dural Bridge in the Visible Human Female Data Set
    Spine Journal 1995;   20 (23):   2484–2486

    It has been speculated that the function of the muscle dural bridge may be to prevent folding of the dura mater during hyperextension of the neck. Also, clinical evidence suggests that the muscle dural bridge may play an important role the pathogenesis of the cervicogenic headaches.

Upper Cervical Spine Information
This remarkable website, designed by a former Microsoft employee, clearly defines many aspects of the Upper Cervical Subluxation, and it's impact on health.




   SKULL BASE [Craniocervical] ANATOMY

The Headache Diagnosis and Management Series for the Chiropractor
by Darryl Curl, DDS, DC

Part I Part II Part III
Part IV Part V Part VI

A Holistic Approach to Severe Headache Symptoms in a Patient
Unresponsive to Regional Manual Therapy

J Manipulative Physiol Ther 1996 (Mar);   19 (3):   202–207

This patient seemed to respond favorably to conservative care that included regions of Spine not traditionally associated with headache pain. This suggests that some individuals may require a more comprehensive evaluation if regional care fails to promote a positive response within a few weeks. Controlled, randomized trials will assist in comparing effectiveness of various treatment interventions.

An Open Study Comparing Manual Therapy With the Use of Cold Packs
in the Treatment of Post-traumatic Headache

Cephalalgia 1990 Oct;   10(5):   241–250

It is concluded that the type of manual therapy used in this study seems to have a specific effect in reducing post-traumatic headache. The result supports the hypothesis of a cervical mechanism causing post-traumatic headache and suggests that post-traumatic dizziness, visual disturbances and ear symptoms could be part of a cervical syndrome.

The Accuracy of Manual Diagnosis for Cervical Zygapophysial Joint Pain Syndromes
Med J Aust. 1988 (Mar 7);   148 (5):   233–236

The manipulative therapist identified correctly all 15 patients with proven symptomatic zygapophysial joints, and specified correctly the segmental level of the symptomatic joint. None of the five patients with asymptomatic joints was misdiagnosed as having symptomatic zygapophysial joints. Thus, manual diagnosis by a trained manipulative therapist can be as accurate as can radiologically-controlled diagnostic blocks in the diagnosis of cervical zygapophysial syndromes.

Subluxation and Neurology Articles
There are many other articles that explain the relationship between headaches and spinal subluxations o0n this page.


Cervicogenic Headache

Cervicogenic headache originates from disorders of the neck and is recognized as a referred pain in the head. Primary sensory afferents from the cervical nerve roots C1–C3 converge with afferents from the occiput and trigeminal afferents on the same second order neuron in the upper cervical Spine. Consequently, the anatomical structures innervated by the cervical roots C1–C3 are potential sources of cervicogenic headache.

Cervical headache is often precipitated by neck movement and/or sustained awkward head positioning (such as painting the ceiling, or washing the floor) and can reproduced with pressure over the upper cervical or occipital region on the symptomatic side. It is often accompained by restricted cervical range of motion, ipsilateral neck, shoulder, or arm pain of a rather vague non-radicular nature or, occasionally, arm pain of a radicular nature.


Dose-Response and Efficacy of Spinal Manipulation for Care of
Cervicogenic Headache: A Dual-Center Randomized Controlled Trial
Spine J. 2018 (Oct);   18 (10):   1741–1754 ~ FULL TEXT

A linear dose-response was observed for all follow-ups, a reduction of approximately 1 CGH day/4 weeks per additional 6 SMT visits (p<.05); a maximal effective dose could not be determined. CGH days/4 weeks were reduced from about 16 to 8 for the highest and most effective dose of 18 SMT visits. Mean differences in CGH days/4 weeks between 18 SMT visits and control were -3.3 (p=.004) and -2.9 (p=.017) at the primary endpoints, and similar in magnitude at the remaining endpoints (p<.05). Differences between other SMT doses and control were smaller in magnitude (p > .05). CGH intensity showed no important improvement nor differed by dose. Other secondary outcomes were generally supportive of the primary.

Chiropractic Spinal Manipulative Therapy for Cervicogenic Headache:
A Single-blinded, Placebo, Randomized Controlled Trial
BMC Res Notes. 2017 (Jul 24);   10 (1):   310 ~ FULL TEXT

Nineteen participants were equally randomized into the three groups, and 12 participants completed the randomized controlled trial. Headache frequency improved at all time points in the chiropractic spinal manipulative therapy and the placebo group. Headache index improved in the chiropractic spinal manipulative therapy group at all time points, while it improved at 6 and 12 months' follow-up in the placebo group. The control group remained unchanged during the whole study period. Adverse events were few, mild and transient. Blinding was concealed throughout the RCT. Thus, our results suggest that manual-therapy might be a safe treatment option for participants with cervicogenic headache, but data need to be confirmed in a randomized controlled trial with sufficient sample size and statistical power.

Dose-response of Spinal Manipulation for Cervicogenic Headache:
Study Protocol for a Randomized Controlled Trial
Chiropractic & Manual Therapies 2016 (Jun 8);   24:   23 ~ FULL TEXT

With growing concerns regarding the costs and side effects of commonly used conventional treatments, greater numbers of headache sufferers are seeking other approaches to care. This is the first full-scale randomized controlled trial assessing the dose-response of spinal manipulation therapy on outcomes for cervicogenic headache. The results of this study will provide important evidence for the management of cervicogenic headache in adults.

Diagnostic Testing Considerations in Pediatric Cervicogenic Headache
ACA News ~ May 23, 2016 ~ FULL TEXT

Cervicogenic headache is common in pediatric patients and is defined by the International Headache Society as a condition caused by cervical Spine dysfunction that is usually accompanied by neck pain. We chose this type of headache because it is commonly seen in chiropractic offices. With these thoughts in mind, we performed a search for office-based tests to help substantiate a diagnosis of cervicogenic headache diagnosis in a pediatric patient.

Mobilization and Manipulation of the Cervical Spine in Patients
with Cervicogenic Headache: Any Scientific Evidence?

Front Neurol. 2016 (Mar 21);   7:   40 ~ FULL TEXT

Seven of the 10 studies had statistically significant findings that subjects who received mobilization or manipulation interventions experienced improved outcomes or reported fewer symptoms than control subjects. These results suggest that mobilization or manipulation of the cervical Spine may be beneficial for individuals who suffer from cervicogenic headache (CEH), although heterogeneity of the studies makes it difficult to generalize the findings.

Upper Cervical and Upper Thoracic Manipulation Versus Mobilization
and Exercise in Patients with Cervicogenic Headache:   A Multi-center
Randomized Clinical Trial

BMC Musculoskelet Disord. 2016 (Feb 6);   17 (1):   64 ~ FULL TEXT

The 2X4 ANOVA demonstrated that individuals with cervicogenic headache (CH) who received both cervical and thoracic manipulation experienced significantly greater reductions in headache intensity (p < 0.001) and disability (p < 0.001) than those who received mobilization and exercise at a 3-month follow-up.

Chiropractic Spinal Manipulative Therapy for Cervicogenic Headache:
A Study Protocol of a Single-blinded Placebo-controlled Randomized Clinical Trial
Springerplus. 2015 (Dec 16);   4:   779 ~ FULL TEXT

Cervicogenic headache (CEH) is a secondary headache which affects 1.0–4.6 % of the population. Although the costs are unknown, the health consequences are substantial for the individual; especially considering that they often suffers chronicity. Pharmacological management has no or only minor effect on CEH. Thus, we aim to assess the efficacy of chiropractic spinal manipulative therapy (CSMT) for CEH in a single-blinded placebo-controlled randomized clinical trial (RCT).

Manual Treatment For Cervicogenic Headache And Active Trigger Point In The
Sternocleidomastoid Muscle: A Pilot Randomized Clinical Trial

J Manipulative Physiol Ther. 2013 (Sep);   36 (7):   403–411 ~ FULL TEXT

The purpose of this preliminary study was to determine feasibility of a clinical trial to measure the effects of manual therapy on sternocleidomastoid active trigger points (TrPs) in patients with cervicogenic headache (CeH).

Manual Therapies for Cervicogenic Headache: A Systematic Review
J Headache Pain. 2012 (Jul);   13 (5):   351–359 ~ FULL TEXT

Current RCTs suggest that physiotherapy and SMT might be an effective treatment in the management of cervicogenic headache (CEH). However, the RCTs mostly included participant with infrequent CEH. Future challenges regarding CEH are substantial both from a diagnostic and management point of view.

Cervicogenic Headache in the General Population:
The Akershus Study of Chronic Headache

Cephalalgia. 2010 (Dec);   30 (12):   1468–1476

The questionnaire response rate was 71% and the participation rate of the interview was 74%. The prevalence of CEH was 0.17% in the general population, with a female preponderance. Fifty per cent had co-occurrence of medication overuse and 42% had co-occurrence of migraine.   The pericranial muscle tenderness score was significantly higher on the pain than non-pain side (p < .005). The cervical range of motion was significantly reduced compared to healthy controls (p < .005). The mean duration of cervicogenic headache (CEH) was eight years.

A Preliminary Path Analysis of Expectancy and Patient-Provider
Encounter in an Open-Label Randomized Controlled Trial of Spinal
Manipulation for Cervicogenic Headache

J Manipulative Physiol Ther 2010 (Jan);   33 (1):   5–13 ~ FULL TEXT

Clearly, blinding is often not possible in efficacy and relative efficacy studies seeking to evaluate the independent effects of a single component of care (such as SMT). It is therefore important to control the effects of the patient-provider interaction on study outcomes to help optimize study internal validity. It appears that equipoise by the same providers across intervention types can be accomplished. It also appears that it is possible to reduce the confounding effect of the PPE to a relatively small proportion of the treatment effect found for the interventions under study. A challenging methodological issue that remains is determining to what extent equipoise in the PPE across treatment arms can serve as a surrogate for double blinding in randomized controlled trials.

Cervicogenic Headache: An Assessment of the Evidence on
Clinical Diagnosis, Invasive Tests, and Treatment

Lancet Neurol. 2009 (Oct);   8 (10):   959–968 ~ FULL TEXT

Cervicogenic headache is characterised by pain referred to the head from the cervical Spine. Although the International Headache Society recognises this type of headache as a distinct disorder, some clinicians remain sceptical. Laboratory and clinical studies have shown that pain from upper cervical joints and muscles can be referred to the head. Clinical diagnostic criteria have not proved valid, but a cervical source of pain can be established by use of fluoroscopically guided, controlled, diagnostic nerve blocks. In this Review, we outline the basic science and clinical evidence for cervicogenic headache and indicate how opposing approaches to its definition and diagnosis affect the evidence for its clinical management. We provide recommendations that enable a pragmatic approach to the diagnosis and management of probable cervicogenic headache, as well as a rigorous approach to the diagnosis and management of definite cervical headache.

Dose Response and Efficacy of Spinal Manipulation for Chronic Cervicogenic Headache:
A Pilot Randomized Controlled Trial

The Spine Journal 2010 (Feb):   10 (2):   117–128 ~ FULL TEXT

Eighty patients with chronic cervicogenic headache (CGH) were randomized to receive either 8 or 16 treatment sessions with either chiropractic care (Spinal Manipulation or SMT) or a minimal light massage (LM) as the control group. Both SMT groups improved much more than the control groups, with greater improvements in the group that received more care.
You may also enjoy this PowerPoint Presentation by the authors of this study.

Intertester Reliability and Diagnostic Validity of the Cervical Flexion-Rotation Test
J Manipulative Physiol Ther 2008 (May);   31 (4):   293–300 ~ FULL TEXT

Cervicogenic headache (CeH) has been classified by the International Headache Society (IHS) [1] and is said to account for 15% to 20% of all chronic and recurrent headaches. [2] Individuals report reduced quality of life [3] and experience considerable restriction of daily function and emotional distress. [4] There is encouraging evidence that CeH can be successfully managed by physical treatment. [5, 6]

Clinical Test of Musculoskeletal Dysfunction in the Diagnosis of Cervicogenic Headache
Manual Therapy 2006 (May);   11 (2):   91–166

The results indicated that when compared to the migraine with aura and control groups who scored similarly in the tests, the cervicogenic headache group had less range of cervical flexion/extension (P=0.048) and significantly higher incidences of painful upper cervical joint dysfunction assessed by manual examination (all P<0.05) and muscle tightness (P<0.05). Sternocleidomastoid normalized EMG values were higher in the latter three stages of the cranio-cervical flexion test although they failed to reach significance. There were no between group differences for other measures. A discriminant analysis revealed that manual examination could discriminate the cervicogenic headache group from the other subjects (migraine with aura and control subjects combined) with an 80% sensitivity.

Spinal Manipulative Therapy in the Management of Cervicogenic Headache
Headache. 2005 (Oct);   45 (9):   1260–1263

Patients suffering from cervicogenic headache (CeH) are commonly treated with spinal manipulative therapy. We have analyzed the quality and the outcomes of published, randomized, controlled trials assessing the effectiveness of spinal manipulation in CeH. Among 121 relevant articles, only two met all the inclusion criteria. Methodological quality scores were 8/10 and 7/10 points. Only one of the trials made use of a headache diary. Both the trials reported positive (+) results on headache intensity, headache duration, and medication intake, so that spinal manipulative therapy obtained strong evidence of effectiveness (level 1) with regard to these outcomes.

Cervicogenic Head and Neck Pain in the ENT Clinic
HNO 2005 (Sep);   53 (9):   804–809

It is discussed controversially whether cervicogenic pain in the head and/or neck is a pathogenic entity. The good results obtained with manual therapy in patients with head and neck pain contradict the refusal of the majority of the neurologists to accept the diagnosis "cervicogenic headache." Complaints about headache are frequently encountered in the general ENT clinic. The versatile picture of the cervicogenic headache is caused by the complex neural connections in the region of the upper cervical Spine. The differential diagnosis of the cervicogenic headache is described.

Non-invasive Physical Treatments for Chronic/Recurrent Headache
Cochrane Database Syst Review 2004;   (3):   CD001878

For the prophylactic treatment of migraine headache, there is evidence that spinal manipulation may be an effective treatment option with a short-term effect similar to that of a commonly used, effective drug (amitriptyline). For the prophylactic treatment of chronic tension-type headache, amitriptyline is more effective than spinal manipulation during treatment. However, spinal manipulation is superior in the short term after cessation of both treatments. For the prophylactic treatment of cervicogenic headache, there is evidence that both neck exercise (low-intensity endurance training) and spinal manipulation are effective in the short and long term when compared to no treatment. There is also evidence that spinal manipulation is effective in the short term when compared to massage or placebo spinal manipulation, and weaker evidence when compared to spinal mobilization.

Dose Response for Chiropractic Care of Chronic Cervicogenic
Headache and Associated Neck Pain: A Randomized Pilot Study

J Manipulative Physiol Ther 2004 (Nov);   27 (9):   547–553 ~ FULL TEXT

Patients were randomly allocated to 1, 3, or 4 visits per week for 3 weeks. All patients received high-velocity low-amplitude spinal manipulation. Doctor of Chiropractics could apply up to 2 physical modalities at each visit from among heat and soft tissue therapy. They could also recommend modification of daily activities and rehabilitative exercises. A large clinical trial on the relationship between pain relief and the number of chiropractic treatments is feasible. Findings give preliminary support for the benefit of larger doses, 9 to 12 treatments, of chiropractic care for the treatment of cervicogenic headache.

Upper Crossed Syndrome and Its Relationship to Cervicogenic Headache
J Manipulative Physiol Ther 2004 (Jul);   27 (6):   414–420 ~ FULL TEXT

The principles of upper crossed syndrome and the use of exercise, chiropractic care, and myofascial release in the treatment of cervicogenic headache are discussed. A review of the literature indicates that analyzing muscle imbalance as well as vertebral subluxation may increase the effectiveness of chiropractic treatment for cervicogenic headache.
There are more articles on this topic at our Rehabilitation Diplomate Information Page

Cervicogenic Headache: The True Pain in the Neck
Foundation for Chiropractic Education and Research ~ 2004

For decades, Doctors of Chiropractic have successfully treated headaches. Success was so quick and profound in some instances that chiropractors theorized that some headaches are caused by dysfunction in the neck and cervical Spine. This theory was largely over-looked by the scientific community as they knew of no biological or physiological link. But the chiropractors were right! In 1995, a team of researchers at the University of Maryland in Baltimore were intricately dissecting cadavers and discovered the biological link–a connective tissue bridge from a muscle in the head to the membrane covering the brain and the spinal cord (the dura mater). [1]

A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache
Spine (Phila Pa 1976) 2002 (Sep 1);   27 (17):   1835–1843

Manipulative therapy and exercise can reduce the symptoms of cervicogenic headache, and the effects are maintained.

Chiropractic Spinal Manipulation for Cervicogenic Headache in an 8-Year-Old
J Neuromusculoskeletal System 2002 (Fall); 10 (3): 98–103

A case of cervicogenic headache (CEH) in an 8-year-old boy that improved after chiropractic spinal manipulation is reported. A significant decrease in headache frequency as reported by the patient and parent was seen after the first treatment. After four treatments the headache frequency decreased to approximately one per month. The patient was followed for 2 months after termination of care and reported headache frequency of approximately two per month. There is evidence that spinal manipulation is effective in the treatment of CEH in adults.

Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache
Duke University Evidence-based Practice Center ~ 2001

In 1996, the Agency for Health Care Policy and Research (AHCPR) was scheduled to produce a set of clinical practice guidelines on available treatment alternatives for headache. This headache project was based on the systematic evaluation of the literature by a multidisciplinary panel of experts. Due to largely political circumstances, however, their efforts never came to fruition. The work was never released as guidelines, but was instead transformed with modifications and budget cuts into a set of evidence reports on only migraine headache. Thanks to FCER funding, the evidence reports have now been updated on both cervicogenic and tension-type headaches.
You might also enjoy Dr. Anthony Rosner's discussion
You may download the full 10-page Adobe Acrobat (PDF) version.
You will also enjoy FCER's announcement on the initial publication of the Duke Report

Cervicogenic Headache: Diagnostic Evaluation and Treatment Strategies
Curr Pain Headache Rep 2001 (Aug);   5 (4):   361–368

The clinical presentation of cervicogenic headache suggests that there is an activation of the trigeminovascular neuroinflammatory cascade, which is thought to be one of the important pathophysiologic mechanisms of migraine. Another convergence of sensorimotor fibers has been described involving intercommunication between the spinal accessory nerve (CN XI), the upper cervical nerve roots, and ultimately the descending tract of the trigeminal nerve. This neural network may be the basis for the well- recognized patterns of referred pain from the trapezius and sternocleidomastoid muscles to the face and head.

Cervicogenic Headache: Anatomic Basis and Pathophysiologic Mechanisms
Curr Pain Headache Rep 2001 (Aug);   5 (4):   382–386

Cervicogenic headache is pain perceived in the head but referred from a primary source in the cervical Spine. The physiologic basis for this pain is convergence between trigeminal afferents and afferents from the upper three cervical spinal nerves.

Cervicogenic Headache: Manual and Manipulative Therapies
Curr Pain Headache Rep 2001 (Aug);   5 (4):   369–375

This article reviews current literature on the role of manual medicine in the diagnosis and treatment of cervicogenic headache. Manual diagnostic procedures and treatment procedures are described for the cervical Spine. Emphasis is placed on accurate diagnosis using a biomechanical model and precise localization of forces.

Clinical Study on Manipulative Treatment of Derangement of the Atlantoaxial Joint
J Tradit Chin Med 1999 (Dec);   19 (4):   273–278

The clinical diagnosis of derangement consists of: dizziness, headache, prominence and tenderness on one side of the affected vertebra, deviation of the dens for 1 mm–4 mm on the open-mouth X-ray film, abnormal movement of the atlantoaxial joint on head-rotated open-mouth X-ray film. An accurate and delicate adjustment is the most effective treatment.

A Proposed Etiology of Cervicogenic Headache: The Neurophysiologic Basis
and Anatomic Relationship Between the Dura Mater and the Rectus Posterior
Capitis Minor Muscle

J Manipulative Physiol Ther 1999 (Oct);   22 (8):   534–539 ~ FULL TEXT

A sizable body of clinical studies note the effect of manipulation on headache. These results support its effectiveness. The dura-mascular, dura-ligamentous connections in the upper cervical Spine and occipital areas may provide anatomic and physiologic answers to the cause of the cervicogenic headache.

Systematic Review of Randomized Clinical Trials of Complementary/
Alternative Therapies in the Treatment of Tension-type and
Cervicogenic Headache

Complementary Therapies in Medicine 1999 (Sep);   7 (3):   142–155

Twenty-four RCTs were identified in the categories of acupuncture, spinal manipulation, electrotherapy, physiotherapy, homeopathy and other therapies. Headache categories included tension-type (under various names pre-1988), cervicogenic and post-traumatic. Quality scores for the RCT reports ranged from approximately 30 to 80 on a 100 point scale.

Further Clinical Clarification of the Muscle Dysfunction in Cervical Headache
Cephalalgia 1999 (Apr);   19 (3):   179–185

From the perspective of physical characterization of cervical headache, it appears that response from passive stretch of muscle may not be a strong criterion for cervical headache but deep neck flexor performance may have potential to identify musculoskeletal involvement in headache. The finding may also provide positive directions for conservative treatment of cervical headache.

The Effect of Spinal Manipulation in the Treatment of Cervicogenic Headache
J Manipulative Physiol Ther 1997 (Jun);   20 (5):   326–330

The use of analgesics decreased by 36% in the manipulation group, but was unchanged in the soft-tissue group. The number of headache hours per day decreased by 69% in the manipulation group, compared with 37% in the soft-tissue group. Finally, headache intensity per episode decreased by 36% in the manipulation group, compared with 17% in the soft-tissue group.
You might also enjoy this sidebar article Chiropractic Effective for Cervicogenic Headache.

Headache in Cervical Syndrome
Ther Umsch 1997 (Feb);   54 (2):   94–97

Headache is a common symptom in patients suffering from cervical Spine disorders. The percentage of headaches in association with degenerative changes of the cervical Spine ranges from 13 to 79% and that in association with indirect trauma of the cervical Spine from 48 to 82%. Based on neuroanatomical and neurophysiological studies, the relationship of the upper cervical Spine and the trigeminal nuclei has been demonstrated and serves as an explanation for perceived head pain in cervical Spine disorders. As a source of pain, tension in the suboccipital muscles, irritation of the third occipital nerve, and degenerative changes of the C2/C3 joints have been discussed. Bogduk, in his studies, asserts a direct causative role of mechanical derangement of the cervical Spine in the pathogenesis of cervicogenic headaches.

Manipulation and Mobilization of the Cervical Spine. A Systematic Review of the Literature
Spine (Phila Pa 1976) 1996 (Aug 1);   21 (15):   1746–1760

The combination of three of the randomized controlled trials comparing spinal manipulation with other therapies for patients with subacute or chronic neck pain showed an improvement on a 100-mm visual analogue scale of pain at 3 weeks of 12.6 mm (93% confidence interval, –0.15, 25.5) for manipulation compared with muscle relaxants or usual medical care. The highest quality randomized controlled trial demonstrated that spinal manipulation provided short-term relief for patients with tension-type headache. The complication rate for cervical Spine manipulation is estimated to be between 5 and 10 per 10 million manipulations.

A Randomized Controlled Trial of the Effect of Spinal Manipulation
in the Treatment of Cervicogenic Headache

J Manipulative Physiol Ther. 1995 (Sep);   18 (7):   435–440

Thirty-nine subjects suffering from frequent headaches who fulfilled the IHS criteria for cervicogenic headache received high-velocity, low-amplitude cervical manipulation twice/wk for 3 wk. The other half received low-level laser in the upper cervical region and deep friction massage (including trigger points) in the lower cervical/upper thoracic region, also twice/wk for 3 wk. Despite a significant reduction in the manipulation group on all three outcome measures, differences between the two treatment groups failed to reach statistical significance.
Editor's Comment: This study suffered from the affliction I refer to as The Problem with Placebos/Shams.   Although there may not have been any pre-1995 literature in English regarding low-level laser or deep friction massage as palliative treatments, this study certainly demonstrates that both groups actually improved.   However, there was no significant difference between both groups because BOTH groups received (some form of) active treatment.

The Prevalence of Cervicogenic Headache in a Random Population Sample of 20-59 Year Olds
Spine (Phila Pa 1976) 1995 (Sep 1);   20 (17):   1884–1888

A short questionnaire on headaches was mailed to 826 randomly selected residents of a midsized Danish town. A group of 57 individuals in the age range 20-59 years who reported having headache episodes on 5 or more days in the previous month were identified. Forty-five of the 57 were eventually interviewed and examined with respect to the IHS criteria for cervicogenic headache (the radiological criteria were omitted on ethical grounds). Of the 45 persons examined, eight fulfilled the diagnostic criteria for cervicogenic headache, equivalent to a prevalence in the headache group of 17.8%

The Effect of Manipulation (Toggle Recoil Technique) for Headaches
With Upper Cervical Joint Dysfunction: A Pilot Study

J Manipulative Physiol Ther 1994 (Jul);   17 (6):   369–375

Since the results of this pilot study were not adequately controlled they cannot be seen as proof supporting the clinical efficacy of manipulation for chronic headaches. However, as a group for duration, severity and frequency all measures were significant. These findings would suggest that further study of upper cervical manipulation for the treatment of chronic headaches with upper cervical joint dysfunction in a randomized, controlled clinical trial is needed.

Cervical Headache: An Investigation of Natural Head Posture
and Upper Cervical Flexor Muscle Performance

Cephalalgia 1993 (Aug);   13 (4):   272–284

In this study, 60 female subjects, aged between 25 and 40 years, were divided into two equal groups on the basis of absence or presence of headache. A passive accessory intervertebral mobility (PAIVM) examination was performed to confirm an upper cervical articular cause of the subjects' headache and a questionnaire was used to establish a profile of the headache population. Measurements of cranio-cervical posture and isometric strength and endurance of the upper cervical flexor muscles were compared between the two groups of subjects. The headache group was found to be significantly different from the non-headache group in respect to forward head posture (FHP) (t = -5.98, p < 0.00005), less isometric strength (t = 3.43, p < 0.001) and less endurance (t = 8.71, p < 0.0005) of the upper cervical flexors.

Cervicogenic Dysfunction in Muscle Contraction Headache and Migraine: A Descriptive Study
J Manipulative Physiol Ther 1992 (Sep);   15 (7):   418–429

A case of cervicogenic headache (CEH) in an 8-year-old boy that improved after chiropractic spinal manipulation is reported. Both muscle contraction/tension-type headache (MCH) and common migraine without aura (CM) subjects demonstrate high occurrences of: a) occipital and neck pain during headaches; b) tender points in the upper cervical region; c) greatly reduced or absent cervical curve; and d) X-ray evidence of joint dysfunction in the upper and lower cervical Spine. These findings support the premise that the neck plays an important, but largely ignored role in the manifestation of adult benign headaches. A case-control study should be conducted to confirm the greater prevalence of cervicogenic dysfunction in headache as compared to nonheadache subjects.

Spinal Manipulation and Headaches of Cervical Origin
J Manipulative Physiol Ther 1989 (Dec);   12 (6):   455–468

This article reviews the published clinical studies of manipulation in the treatment of tension and migraine headaches. The topic of cervical headaches in general is reviewed and the current model of cervicogenic headache is critiqued. A representative case history is used to illustrate the thesis that the current model of cervicogenic headache may be too restrictive. The role of spinal manipulation as a trial of therapy in individual patients is also discussed. a retrospective diagnosis of cervical headache can often be confirmed by a successful outcome.


Migraine Headache

Migraine headaches are less common than tension–type headaches. Nevertheless, migraines afflict 25 to 30 million people in the United States. As many as 6% of all men, and up to 18% of all women experience a migraine headache at some time.

Among the most distinguishing features is the potential disability accompanying the headache pain of a migraine: migraines may last 4–72 hours, are typically unilateral (60% of reported cases), throbbing, of moderate to severe intensity, and are aggravated by routine physical activity.

Nausea, with or without vomiting, and/or sensitivity to light and sound often accompany migraines. An “aura” may occur before head pain begins – involving a disturbance in vision, and/or an experience of brightly colored or blinking lights in a pattern that moves across the field of vision. About one in five migraine sufferers experiences an aura.


Outcome Measures for Assessing the Effectiveness of Non-pharmacological Interventions<
in Frequent Episodic or Chronic Migraine: A Delphi Study

BMJ Open. 2020 (Feb 12);   10 (2):   e029855 ~ FULL TEXT

The aim of this Delphi survey was to establish an international consensus on the most useful outcome measures for research on the effectiveness of non-pharmacological interventions for migraine. Results suggest the use of the Migraine Disability Assessment (MIDAS), Headache Impact Test (HIT-6) and headache frequency as primary outcome measures. Patient experts suggested the inclusion of a measure of quality of life and evaluation of associated symptoms and fear of attacks.

The Integrative Migraine Pain Alleviation Through Chiropractic Therapy (IMPACT) Trial:
Study Rationale, Design and Intervention Validation

Contemp Clin Trials Commun 2020 (Jan 22);   17:   100531 ~ FULL TEXT

This pilot study represents a novel contribution to the field because prior studies among individuals with migraine have only focused on spinal manipulation and have not evaluated chiropractic care as an integrative approach to migraine treatment [5]. In addition, as part of this pilot study, we developed and report here a chiropractic care protocol for individuals with migraine that was validated by a team of senior chiropractors using the Delphi method. As a next step in a large trial, we will evaluate the fidelity of protocol delivery. Finally, we used the PRECIS-2 framework to articulate the rationale for choosing key study design elements, which includes both pragmatic and explanatory features. This analysis could assist others in the design of other complex, multimodal and non-pharmacological interventions for the treatment of other neuromusculoskeletal pain-related conditions.

The Impact of Spinal Manipulation on Migraine Pain and Disability:
A Systematic Review and Meta-Analysis

Headache. 2019 (Apr);   59 (4):   532–542 ~ FULL TEXT

Spinal manipulation may be an effective therapeutic technique to reduce migraine days and pain/intensity. However, given the limitations to studies included in this meta-analysis, we consider these results to be preliminary. Methodologically rigorous, large-scale RCTs are warranted to better inform the evidence base for spinal manipulation as a treatment for migraine.

Integrating Chiropractic Care Into the Treatment of Migraine Headaches
in a Tertiary Care Hospital: A Case Series

Glob Adv Health Med. 2019 (Mar 28);   8:   2164956119835778 ~ FULL TEXT

This case series illustrates an integrated model of care for migraine that combines standard neurological care with chiropractic treatment. For each patient, we describe the rationale for referral, diagnosis by both the neurologist and chiropractor, the coordinated care plan, communication between the neurologist and chiropractor based on direct face-to-face "hallway" interaction, medical notes, team meetings, and clinical outcomes. Findings are evaluated within the broader context of the multicause nature of migraine and the impact of integrative chiropractic. Suggestions for future areas of research evaluating integrative approaches are discussed.

Chiropractic Spinal Manipulative Therapy For Migraine: A Three-Armed,
Single-Blinded, Placebo, Randomized Controlled Trial

Eur J Neurol. 2017 (Jan);   24 (1):   143–153 ~ FULL TEXT

The blinding was strongly sustained throughout the RCT, adverse events (AEs) were few and mild, and the effect in the chiropractic spinal manipulative therapy (CSMT) and placebo group was probably a placebo response. Because some migraineurs do not tolerate medication because of AEs or co-morbid disorders, CSMT might be considered in situations where other therapeutic options are ineffective or poorly tolerated.

Chiropractic Spinal Manipulative Therapy for Migraine: A Study Protocol
of a Single-blinded Placebo-controlled Randomised Clinical Trial

BMJ Open. 2015 (Nov 19);   5 (11):   e008095 ~ FULL TEXT

Migraine affects 15% of the population, and has substantial health and socioeconomic costs. Pharmacological management is first-line treatment. However, acute and/or prophylactic medicine might not be tolerated due to side effects or contraindications. Thus, we aim to assess the efficacy of chiropractic spinal manipulative therapy (CSMT) for migraineurs in a single-blinded placebo-controlled randomised clinical trial (RCT).

Manual Therapies for Migraine: A Systematic Review
The Journal of Headache and Pain 2011 (Apr);   12 (2):   127–133 ~ FULL TEXT

Migraine occurs in about 15% of the general population. Migraine is usually managed by medication, but some patients do not tolerate migraine medication due to side effects or prefer to avoid medication for other reasons. Non-pharmacological management is an alternative treatment option. We systematically reviewed randomized clinical trials (RCTs) on manual therapies for migraine. The RCTs suggest that massage therapy, physiotherapy, relaxation and chiropractic spinal manipulative therapy might be equally effective as propranolol and topiramate in the prophylactic management of migraine. However, the evaluated RCTs had many methodological shortcomings.

A Case of Chronic Migraine Remission After Chiropractic Care
J Chiropractic Medicine 2008 (Jun);   7 (2):   66–70 ~ FULL TEXT

The average frequency of migraine episodes before treatment was 1 to 2 per week, including nausea, vomiting, photophobia, and phonophobia; and the average duration of each episode was 1 to 3 days. The patient was treated with CSMT. She reported all episodes being eliminated after CSMT. The patient was certain there had been no other lifestyle changes that could have contributed to her improvement. She also noted that the use of her medication was reduced by 100%. A 7-year follow-up revealed that the person had still not had a single migraine episode in this period.

Analgesic Use: A Predictor of Chronic Pain and Medication Overuse Headache
Neurology 2003 (Jul 22);   61 (2):   160–164 ~ FULL TEXT

Overuse of analgesics strongly predicts chronic pain and chronic pain associated with analgesic overuse 11 years later, especially among those with chronic migraine.

A Randomized Controlled Trial of Chiropractic Spinal Manipulative Therapy for Migraine
J Manipulative Physiol Ther 2000 (Feb);   23 (2):   91–95 ~ FULL TEXT

The results of this study support previous results showing that some people report significant improvement in migraines after chiropractic SMT. A high percentage (>80%) of participants reported stress as a major factor for their migraines. It appears probable that chiropractic care has an effect on the physical conditions related to stress and that in these people the effects of the migraine are reduced.

Chiropractic Management of Migraine Without Aura: A Case Study
Australasia Chiropractic and Osteopathic Journal 1999 (Nov):   8 (3):   85–90 ~ FULL TEXT

It now appears clear that chiropractic care may be used to assist patients with migraine. Research is currently being undertaken to investigate the potential mechanisms of chiropractic in the treatment of migraine. This research should also assess what (if any) prognostic signs can be identified to assist practitioners making a more informed decision on the treatment of choice for migraine.

A Twelve Month Clinical Trial of Chiropractic Spinal Manipulative Therapy for Migraine
Australasia Chiropractic and Osteopathic Journal 1999 (Jul):   8 (2):   61–65 ~ FULL TEXT

32 participants showed statistically significant (p < 0.05) improvement in migraine frequency, VAS, disability, and medication use, when compared to initial baseline levels. A further assessment of outcomes after a six month follow up (based on 24 participants), continued to show statistically significant improvement in migraine frequency (p < 0.005), VAS (p < 0.01), disability (p < 0.05), and medication use (p < 0.01), when compared to initial baseline levels.

The Efficacy of Spinal Manipulation, Amitriptyline and the Combination
of Both Therapies for the Prophylaxis of Migraine Headache

J Manipulative Physiol Ther 1998 (Oct);   21 (8):   511–519

There was no advantage to combining amitriptyline and spinal manipulation for the treatment of migraine headache. Spinal manipulation seemed to be as effective as a well-established and efficacious treatment (amitriptyline), and on the basis of a benign side effects profile, it should be considered a treatment option for patients with frequent migraine headaches.


Chronic Tension-type Headache

Tension type headaches are the most common, affecting upwards of 75% of all headache sufferers. As many as 90% of adults experience tension–type headache.

Tension–type headaches usually involve a steady ache, rather than a throbbing one, are described as a feeling of pressure or tightening, may last minutes to days, affect both sides of the head, and and do not worsen with routine physical activity. It may also be accompanied by photophobia or phonophobia (hypersensitivity to light and noise, respectively.). Nausea is usually absent. Some people get tension–type (and migraine) headaches in response to stressful events. Tension–type headaches may also be chronic, occurring frequently or daily. Psychologic factors have been overemphasized as causes of headaches.


Long-term Relief from Tension-type Headache and Najor Depression
Following Chiropractic Treatment

J Family Med Prim Care 2018 (May);   7 (3):   629–631~ FULL TEXT

We report the case of a 44-year-old school teacher who experienced long-term relief from tension-type headache (TTH) and major depression following chiropractic treatment. It is well recognized that psychiatric comorbidity and suicide risk are commonly found in patients with painful physical symptoms such as chronic headache, backache, or joint pain. Recent studies indicated that autonomic dysfunction plays a role in the pathogenesis of TTHs and depressive disorders. The autonomic nervous system is mainly controlled by reflex centers located in the spinal cord, brain stem, and hypothalamus. This report highlights the rewarding outcomes from spinal adjustment in certain neuropsychiatric disorders. Long-term results of chiropractic adjustment in this particular case were very favorable. Further studies with larger groups are warranted to better clarify the role of chiropractic.

Do Manual Therapy Techniques Have a Positive Effect on Quality of Life in People
with Tension-type Headache? A Randomized Controlled Trial

Eur J Phys Rehabil Med. 2016 (Aug);   52 (4):   447–456 ~ FULL TEXT

Controversy exists regarding the effectiveness of manual therapy for the relief of tension-type headache (TTH). However most studies have addressed the impact of therapy on the frequency and intensity of pain.   No studies have evaluated the potentially significant effect on the patient's quality of life.   Post treatment and at the one month follow-up, the combined treatment group (suboccipital inhibitory pressure and suboccipital spinal manipulation) showed improved vitality and the two treatment groups that involved manipulation showed improved mental health.

Prevalence of Neck Pain in Migraine and Tension-type Headache: A Population Study
Cephalalgia 2015 (Mar);   35 (3):   211–219 ~ FULL TEXT

In conclusion, we demonstrated that neck pain is highly prevalent in the general population and is more prevalent in individuals with migraine and tension-type headache (TTH). Prevalence of neck pain was highest in coexistent headache and pure TTH followed by migraine. Finally, we showed that myofascial pericranial tenderness is significantly increased in individuals with neck pain compared to individuals without neck pain, indicating a possible shared pathophysiological mechanism with primary headache.

Effect of Manual Therapy Techniques on Headache Disability in Patients
With Tension-type Headache. Randomized Controlled Trial

European J Physical and Rehab Med 2014 (Dec);   50 (6):   641–647

Patients were randomly divided into four treatment groups: 1) suboccipital soft tissue inhibition; 2) occiput-atlas-axis manipulation; 3) combined treatment of both techniques; 4) control. Four sessions were applied over 4 weeks and disability was assessed before and after treatment using the Headache Disability Inventory (HDI).   Headache frequency was significantly reduced with the manipulative and combined treatment (P<0.05), and the severity and functional subscale of the HDI changed in all three treatment groups (P<0.05). Manipulation treatment also reduced the score on the emotional subscale of the HDI (P<0.05). The combined intervention showed a greater effect at reducing the overall HDI score compared to the group that received suboccipital soft tissue inhibition and to the control group (both P<0.05). In addition, photophobia, phonophobia and pericranial tenderness only improved in the group receiving combined therapy (P<0.05).

Efficacy of Manual and Manipulative Therapy in the Perception of Pain and
Cervical Motion in Patients with Tension-type Headache:
A Randomized, Controlled Clinical Trial

Journal of Chiropractic Medicine 2014 (Mar);   13 (1):   4–13 ~ FULL TEXT

Both treatments (group 1 received manual therapy treatment, group 2 received manipulative treatment, and group 3 received a combination of both treatments), administered both separately and combined together, showed efficacy for patients with tension-type headache with regard to pain perception. As for cervical ranges of motion, treatments produced greater effect when separately administered.

Referred Pain from Myofascial Trigger Points in Head and Neck-shoulder
Muscles Reproduces Head Pain Features in Children With
Chronic Tension type Headache

J Headache Pain. 2011 (Feb);   12 (1):   35–43 ~ FULL TEXT

The current controlled and blinded study showed the existence of multiple active TrPs in head, neck and shoulder musculature in children with chronic tension type headache (CTTH). Both local and referred pain characteristics elicited by palpation of active muscle TrPs reproduced the head pain patterns in children with CTTH. Referred pain areas elicited by active TrPs were larger in children with CTTH as compared to healthy children. The size of referred pain areas of some muscles was positively related to some headache clinical parameters. Our results support a role of active TrP in children with CTTH.

Effectiveness of Manual Therapy for Chronic Tension-type Headache:
A Pragmatic, Randomised, Clinical Trial

Cephalalgia. 2011 (Jan);   31 (2):   133–143 ~ FULL TEXT

After 8 weeks (n = 80) and 26 weeks (n = 75), a significantly larger reduction of headache frequency was found for the manual therapy (MT) group (mean difference at 8 weeks, -6.4 days; 95% CI -8.3 to -4.5; effect size, 1.6). Disability and cervical function showed significant differences in favour of the MT group at 8 weeks but were not significantly different at 26 weeks.   Manual therapy is more effective than usual GP care in the short- and longer term in reducing symptoms of chronic tension-type headache (CTTH).

Short-Term Effects of Manual Therapy on Heart Rate Variability,
Mood State, and Pressure Pain Sensitivity in Patients With
Chronic Tension-Type Headache: A Pilot Study

J Manipulative Physiol Ther. 2009 (Sep);   32 (7):   527–535 ~ FULL TEXT

The application of a single session of manual therapy program produces an immediate increase of index heart rate variability (HRV) and a decrease in tension, anger status, and perceived pain in patients with chronic tension-type headache (CTTH).

A Randomized, Placebo-Controlled Clinical Trial of Chiropractic and Medical
Prophylactic Treatment of Adults With Tension-Type Headache:
Results From a Stopped Trial

J Manipulative Physiol Ther 2009 (Jun);   32 (5):   344–351 ~ FULL TEXT

Although the sample size was smaller than initially required, a statistically significant and clinically important effect was obtained for the combined treatment group. There are considerable difficulties with recruitment of subjects in such a trial. This trial should be replicated with a larger sample.

Myofascial Trigger Points, Neck Mobility, and Forward Head Posture
in Episodic Tension-Type Headache

Headache 2007 (May);   47 (5):   662–672

Active TrPs in the upper trapezius, sternocleidomastoid, and temporalis muscles were more common in ETTH (Episodic Tension-Type Headache) subjects than in healthy controls, although TrP activity was not related to any clinical variable concerning the intensity and the temporal profile of headache. ETTH patients showed greater FHP and lesser neck mobility than healthy controls, although both disorders were not correlated with headache parameters.

Trigger Points in the Suboccipital Muscles and Forward Head Posture
in Tension-Type Headache

Headache: The Journal of Head and Face Pain 2006 (Mar);   46 (3):   454–460

Twenty chronic tension-type headache (CTTH) subjects and 20 matched controls without headache participated. Trigger points (TrPs) were identified by eliciting referred pain with palpation, and increased referred pain with muscle contraction. Side-view pictures of each subject were taken in sitting and standing positions, in order to assess forward head posture (FHP) by measuring the craniovertebral angle. Suboccipital active TrPs and FHP were associated with CTTH. CCTH subjects with active TrPs reported a greater headache intensity and frequency than those with latent TrPs. The degree of FHP correlated positively with headache duration, headache frequency, and the presence of suboccipital active TrPs.

Non-invasive Physical Treatments for Chronic/Recurrent Headache
Cochrane Database Syst Review 2004;   (3):   CD001878

For the prophylactic treatment of migraine headache, there is evidence that spinal manipulation may be an effective treatment option with a short-term effect similar to that of a commonly used, effective drug (amitriptyline). For the prophylactic treatment of chronic tension-type headache, amitriptyline is more effective than spinal manipulation during treatment. However, spinal manipulation is superior in the short term after cessation of both treatments. For the prophylactic treatment of cervicogenic headache, there is evidence that both neck exercise (low-intensity endurance training) and spinal manipulation are effective in the short and long term when compared to no treatment. There is also evidence that spinal manipulation is effective in the short term when compared to massage or placebo spinal manipulation, and weaker evidence when compared to spinal mobilization.

Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache
Duke University Evidence-based Practice Center ~ 2001

In 1996, the Agency for Health Care Policy and Research (AHCPR) was scheduled to produce a set of clinical practice guidelines on available treatment alternatives for headache. This headache project was based on the systematic evaluation of the literature by a multidisciplinary panel of experts. Due to largely political circumstances, however, their efforts never came to fruition. The work was never released as guidelines, but was instead transformed with modifications and budget cuts into a set of evidence reports on only migraine headache. Thanks to FCER funding, the evidence reports have now been updated on both cervicogenic and tension-type headaches.
You might also enjoy Dr. Anthony Rosner's discussion
You may download the full 10-page Adobe Acrobat (PDF) version.
You will also enjoy FCER's announcement on the initial publication of the Duke Report

Efficacy of Spinal Manipulation for Chronic Headache: A Systematic Review
J Manipulative Physiol Ther 2001 (Sep);   24 (7):   457–466 ~ FULL TEXT

SMT appears to have a better effect than massage for cervicogenic headache. It also appears that SMT has an effect comparable to commonly used first-line prophylactic prescription medications for tension-type headache and migraine headache.

Spinal Manipulation in the Treatment of Episodic Tension-Type Headache:
A Randomized Controlled Trial
JAMA 1998 (Nov 11);   280 (18):   1576-1579

Manipulation and Tension Headaches in the AMA Journal
Review Bove's 1998 JAMA article (see it, immediately above) on tension headaches and chiropractic, and correspondence with the author. Responses from the academic and research community are also included.

Spinal Manipulation vs. Amytriptyline for the Treatment of
Chronic Tension-type Headaches:   A Randomized Clinical Trial

J Manipulative Physiol Ther 1995 (Mar);   18 (3):   148–154

The results of this study show that spinal manipulative therapy is an effective treatment for tension headaches. Amitriptyline was slightly more effective in reducing pain by the end of the treatment period, but was associated with more side effects. Four weeks after cessation of treatment however, patients who received spinal manipulation experienced a sustained therapeutic benefit in all major outcomes in contrast to the amitriptyline group, who reverted to baseline values.

Impact of Migraine and Tension-type Headache on Life-style, Consulting Behaviour,
and Medication Use: A Canadian Population Survey

Can J Neurol Sci 1993 (May);   20 (2):   131–137

A large sample of Canadian adults was surveyed by telephone to determine the prevalence and characterization of headache, and the effects of headache on life-style, consulting behaviours and medication use. We reported prevalence and characterization in a previous issue; here, we detail the effects of headaches on sufferers. Sixteen and one-half percent of adult Canadians experience migraine and 29% tension-type headaches. In over 70% of headache sufferers interpersonal relationships are impaired. Regular activities are limited in 78% of migraine attacks and 38% of tension-type headaches. Despite this, only 64% of migraine and 43% of tension-type headache sufferers had ever sought medical attention, and of these only 32% returned for ongoing care. Fourteen percent of migraine and 8% of tension-type headache sufferers had used emergency departments. Most headache sufferers take medication, primarily over-the-counter varieties. Measures to reach the headache population are needed, as are safe effective treatment options that will encourage them to participate in their medical care.


Other Management Approaches for Headache

The Role of Nutrients in the Pathogenesis and Treatment of Migraine Headaches: Review
Biomed Pharmacother. 2018 (Jun);   102:   317–325 ~ FULL TEXT

Migraine as a disabling neurovascular disease affects 6% of men and 18% of women worldwide. The deficiency of many nutrients including magnesium, niacin, riboflavin, cobalamin, coenzymes Q10, carnitine, α-lipoic acid and vitamin D is associated with migraine. Some researchers postulate that mitochondrial dysfunction and impaired antioxidant status can cause migraine. Also increase in homocysteine level can lead to migraine attacks; therefore, some Nutraceuticals play a vital role in migraine prevention. Thus, the aim of the current study was to review randomized controlled trials (RCT) assessing the effect of nutritional supplements on migraine patients.

Cannabis for Pain and Headaches: Primer
Curr Pain Headache Rep. 2017 (Apr);   21 (4):   19 ~ FULL TEXT

Synthetic cannabinoids are being developed and synthesized from the marijuana plant such as dronabinol and nabilone. The US Food and Drug Administration approved the use of dronabinol and nabilone for chemotherapy-associated nausea and vomiting and HIV (Human Immunodeficiency Virus) wasting. Nabiximols is a cannabis extract that is approved for the treatment of spasticity and intractable pain in Canada and the UK. Further clinical trials are studying the effect of marijuana extracts for seizure disorders. Phytocannabinoids have been identified as key compounds involved in analgesia and anti-inflammatory effects. Other compounds found in cannabis such as flavonoids and terpenes are also being investigated as to their individual or synergistic effects. This article will review relevant literature regarding medical use of marijuana and cannabinoid pharmaceuticals with an emphasis on pain and headaches.

Nutritional and Botanical Interventions to Assist with the Adaptation to Stress
Alternative Medicine Review 1999 (Aug);   4 (4):   249–265 ~ FULL TEXT

Prolonged stress, whether a result of mental/emotional upset or due to physical factors such as malnutrition, surgery, chemical exposure, excessive exercise, sleep deprivation, or a host of other environmental causes, results in predictable systemic effects. The systemic effects of stress include increased levels of stress hormones such as cortisol, a decline in certain aspects of immune system function such as natural killer cell cytotoxicity or secretory-IgA levels, and a disruption of gastrointestinal microflora balance. These systemic changes might be a substantial contributor to many of the stress-associated declines in health.

Neurolysis of the Greater Occipital Nerve in Cervicogenic Headache: A Follow up Study
Headache 1992;   32 (4) Apr:   175–179

Entrapment of the greater occipital nerve (GON) in its peripheral course has been thought to be of possible pathogenic significance in cervicogenic headache. We have performed a "liberation" operation ("neurolysis") of the nerve in the nuchal musculature, with special attention to the trapezius insertion, and the follow-up results in 50 patients are presented. The immediate effect of the operation was quite good, but the pain gradually recurred in the majority (46/50) of the patients. The present study shows that other therapeutic approaches should be searched for in cervicogenic headache.

Can Magnesium Cure Migraines?
Magnesium's role in the origins of migraine headaches has been demonstrated in a number of studies. It seems magnesium concentration affects serotonin receptors, nitric oxide synthesis and release, as well as other migraine-related receptors and neurotransmitters. In fact, evidence suggests some 50 percent of patients have low levels of ionized magnesium (IMg++) during an acute migraine attack. [1]

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