An In-Depth Review of the Efficacy of Manual Therapy for Neck Pain and Headaches

Introduction:

Neck pain and headaches can be incredibly debilitating, with many sufferers seeking all manner of interventions to alleviate pain and discomfort. As remedial massage therapists and myotherapists, headaches are among some of the most common complaints our patients present with, in clinic. We know firsthand how patients can benefit from tailored manual therapy protocols for cervicogenic pain.

So does the current scientific research support the empirical evidence among practitioners?

It turns out there’s plenty of data showing that various manual therapy interventions can drastically reduce neck pain, headaches and cervical dysfunction among patients. In this article, we will look in-depth at the efficacy of spinal manipulative therapies, trigger point therapy, stretching and vertebral mobilisation techniques for relieving neck pain and headaches. The bottom line is that manual therapy, in many forms, is a great solution for headache patients that provides targeted benefits with demonstrable efficacy.

The Burden of Cervicogenic Neck Pain and Headaches:

As defined in the International Classification of Headache Disorders by Olsen (2018)1, a cervicogenic headache is a ‘secondary headache arising from a disorder in the cervical spine and its periarticular components, often accompanied by neck pain. The majority of cervicogenic pain is due to dysfunction or sensitisation in the upper neck and spinal segments of C1, C2 and C3’.

Recent reports suggest that headaches affect 2.2%-4.1% of the general population, with a higher occurrence in women than in men by a factor of four2. There can be a range of reasons why people sustain cervicogenic headaches, from direct trauma and injuries such as whiplash, chronic poor posture, cervical musculature weakness and other neurological conditions.

These headaches are commonly caused by the convergence of sensory branches from the trigeminal and superior cervical spinal nerves in the trigeminalcervical caudalis nucleus3. This may explain why both cervical and trigeminal regions (head, neck and jaw) are a classic presentation that many patients present with. In most cases, imaging or clinical examination must be performed to confirm a lesion or disorder in the neck or local soft tissues known to cause headaches.

To determine a cause-and-effect relationship, practitioners also need to see at least two of the following: the headache began around the same time as the cervical disorder or lesion appeared, the headache improved as the cervical disorder or lesion improved, moving the neck worsens the headache and reduces the range of neck movement, or the headache goes away after blocking a nerve or structure in the neck4.

Because cervicogenic headaches and related neck dysfunction have complex causes, multidisciplinary interventions are typically the most beneficial.

Which Manual Therapies Are The Most Helpful?

Historically, the standard medical approach typically involves medication as a first-line therapy. However, this may not address the root cause of the issue and could result in dependency and other metabolic disturbances. Treatments such as anaesthetic and corticosteroid blocks of the occipital or cervical nerves, pulsed radiofrequency, and cold therapy are also commonly proposed methods to temporarily alleviate pain from an allopathic standpoint.

Currently, healthcare professionals opt for more conservative interventions, such as manual therapy that can effectively resolve symptoms in the long run. Non-invasive techniques like dry needling, stretching, mobilisations and exercise prescription are the primary components of such treatments. There is great potential for some manual therapies to resolve cervicogenic headaches, but the types that are the most indicated will vary for each patient.

A systematic review published by Borrella-Andrés et al. (2021)5 investigated the effectiveness of manual therapy techniques on cervical radiculopathy. This review, consisting of 17 studies, found that manual therapy protocols had a positive impact on pain indices and cervical disability outcomes, irrespective of the therapy applied. While there was no statistically significant difference between each intervention, the most effective results were due to cervical mobilisations which encouraged intervertebral foramen opening. This technique increased the intervertebral space using transverse mobilisations on the spinal segments of the neck.

A 2022 systematic review published in the journal Headache (2022)6 included 14 clinical trials that evaluated the efficacy of spinal manipulative therapy, Mulligan’s Sustained Natural Apophyseal Glides (SNAGs), muscle energy techniques (METs), trigger point therapy, suboccipital muscle relaxation, positional release techniques and translatory vertebral mobilisation techniques. Every intervention listed had success in reducing headache intensity across all the studies evaluated.

While all the interventions managed to reduce the intensity of headaches, the quality of improvements found in this comprehensive review is as follows:

• The best short-term improvements were the positional release and ischaemic pressure (trigger point) techniques.

• The best longer-term improvements were seen in translatory vertebral mobilisation, spinal manipulative therapy and SNAGs in combination with massage techniques as above.

• The most beneficial pattern of treatment involved one to two sessions per week for six weeks.

What Makes Them So Effective?

The reduction in headaches and neck pain brought about by these interventions is due to some potent physiological events. The initial improvements are likely due to the mechanical activation of the nociceptive inhibitory systems, which confer instant ‘hypoalgesic effects’. Specifically, soft tissue techniques and spinal mobilisation techniques both act by modulating local blood flow, improving hypoxic tissue states and increasing endorphins and endogenous opioids. Finally, manual techniques that involve pressure changes enable the fascia and any focal adhesions to reorganise, facilitating a healthy homeostatic balance in the tissue.

Is There a Gold Standard Therapy for Neck Pain and Headaches?

As most of us know, an ideal approach is to treat the patient, not the condition. With this in mind, establishing a treatment plan that takes into account the complexities of each patient is paramount. Aside from this, the clinical features of cervicogenic headaches are readily identifiable among manual therapists and as discussed, we have a wealth of non-invasive, highly effective treatment options at our fingertips.

So is there anything we can add to deliver a ‘gold standard’ approach to cervicogenic headaches and neck pain?

The missing piece, according to the research, is rehabilitation and strengthening. An article from The International Journal of Sports Physical Therapy (2011)7 says that most patients with cervicogenic headaches have weak deep neck flexors, compared to patients with other headache types. Together with manual therapies, correcting postural imbalances, and strengthening cervical spine musculature can serve as a more well-rounded approach to cervicogenic headaches.

By building better neuromuscular control from targeted training, patients experience a higher reduction in pain frequency and intensity across all demographics. This approach should help guarantee long-term, sustained recovery for patients with this cervicogenic pain, headaches and related conditions 8 .

Shaun Brewster ANTA National President BHSc (Musculoskeletal Therapy) Graduate Diploma (Exercise Science)