Which Examination Tests Detect Differences in Cervical Musculoskeletal Impairments in People With Migraine? A Systematic Review and Meta-Analysis

The effectiveness of aerobic exercise and neck exercises in pediatric migraine treatment: a randomized controlled single-blind study

BACKGROUND

Migraine is a prevalent condition with debilitating effects. In the context of pediatric migraine, there exists a notable scarcity of data regarding the effectiveness of exercise interventions. Furthermore, despite the prevalent occurrence of neck pain in these patients, the role of cervical musculoskeletal disorders in the etiology continues to be a debated topic.

AIMS

This study is aimed at evaluating the effectiveness of aerobic and neck exercises for treatment of pediatric migraine.

METHODS

This randomized, controlled, single-blind trial included 51 pediatric migraine patients. Participants were divided into two groups: one performing aerobic exercise and the other performing neck exercises. Assessments included attack frequency, severity, duration, and neck pain for over 3 months.

RESULTS

Both exercise groups exhibited significant reductions in the attack frequency, severity, and duration. After 3 months, the aerobic exercise group showed a lower attack frequency than the neck exercise group. Subgroup analysis involving patients with neck pain showed similar neck pain reduction but favored the aerobic exercise group for attack frequency and severity.

CONCLUSIONS

Aerobic and neck exercises are effective in reducing the symptoms of pediatric migraine. Aerobic exercise may be particularly beneficial for reducing the attack frequency. These findings contribute to the limited data on exercise interventions for pediatric migraineurs and highlight the importance of tailored exercise programs for managing this condition. Future studies should consider more extensive exercise modalities and include diverse patient cohorts.

TRIAL REGISTRATION

Clinicaltrials.gov ID: NCT0606875.

Differences in physical examination findings between those who present with or without headache soon after a whiplash injury: a cross-sectional study

AIM

To determine differences in physical examination findings between people with acute whiplash-associated disorders (WAD) with and without headache.

METHODS

In this cross-sectional study, participants with acute WAD were evaluated to assess differences in the presence of physical impairments. The following were assessed: pain intensity on manual palpation the over spinous process of C1-C3, zygapophyseal joints of C0-C4, and trapezius, sternocleidomastoid, suboccipitalis, masseter and temporalis muscles; cervical range of motion (ROM); flexion-rotation test (FRT); forward head posture; cranio-cervical flexion test (CCFT); neck flexor and extensor endurance; pressure-pain thresholds (PPT) over neural structures and upper limb neural tests (ULNT) in addition to median UNLT + CCF. Correlation analyses were performed to assess the association between examination findings and headache intensity. Logistic regression and discriminant analyses were also performed.

RESULTS

Forty-seven participants (26 men and 21 women; mean age = 38.9 years old) were included in the study. 60% of the participants presented with headache. Several examination findings were significantly different between groups. A group of examination findings composed of neck endurance, manual palpation over cervical and muscular structures, PPT, CCFT, ROM and FRT could discriminate between groups with a sensitivity of 86.7% and specificity of 90%.

CONCLUSIONS

Several neuromusculoskeletal features are different between people with acute WAD with or without headache. A combination of features could distinguish between groups with high levels of sensitivity and specificity.

[Non-medical Approaches to Headache Prevention: What is the Evidence?]

Primary headaches can be prevented by medication, exercise, behavioral therapy, or lifestyle changes. It is important to note that if medication is used for prophylaxis, non-drug approaches should also be recommended as a complement. Patients often wish to address their headaches without medication. Except for cognitive behavioral therapy and biofeedback, the evidence for nonmedication approaches to headache management has not been definitively established. This article reviews the current literature on the evidence for endurance exercise, relaxation exercises, physical therapy, lifestyle factors, and complementary procedures. For tension-type headache, there is an increasing number of studies reporting positive results from physical therapy; long-term follow-up, however, are still pending. Aerobic endurance exercise has the best evidence as a measure for prevention of migraine. However, other methods can also be used.

Cervical muscle parameters and allodynia in migraine and cervical pain-A controlled study

BACKGROUND

Neck pain is common among individuals with migraine, but there is a lack of information of how this comorbidity can be associated with cervical muscle function. This controlled cross-sectional study aimed to compare cervical muscle function, activity, and sensitization in women with migraine, neck pain, both, and neither.

METHODS

This study included women, between 18 and 55 years old, with either episodic migraine with or without aura, without any concomitant headache diagnosis; chronic neck pain, with at least moderate intensity and mild disability; or neither headache nor neck pain. Pain pressure threshold, allodynia, muscle strength, and endurance and cervical muscles activity were evaluated.

RESULTS

One hundred subjects, with mean age of 30.4 years old, were stratified by diagnosis (n = 25 per group) and by self-reported pain during tests. Lower endurance during flexion was observed for migraine and neck pain (34s) relative to neck pain alone (45s), migraine (40s), and controls (58s) (p = 0.04). For extensor endurance, means were 142s, 166s, 215s, and 270s, respectively (p < 0.001). Endurance times were impacted by the presence of test-induced pain decreasing about 40%-53% of the performance. Diagnostic groups did not differ significantly in strength (p > 0.05), but all pain groups presented significantly higher proportion of test-induced pain, lower muscle activity during the maximal isometric voluntary contractions, and lower pressure pain thresholds.

CONCLUSION

Patients with migraine, chronic neck pain, and the association of both present altered cervical muscle function and activity. Also, test-induced pain impacts significantly on neck muscles endurance.

SIGNIFICANCE

The diagnosis of migraine and chronic neck pain is associated with altered function and activity of the cervical muscles. However, the test-induced pain had an important contribution to worse cervical muscle endurance. This suggests that the therapeutic approach should focus on de-sensitization of the trigeminal-cervical complex when dealing with the comorbidity of migraine and cervical pain.

Profiling migraine patients according to clinical and psychophysical characteristics: a cluster analysis approach

AIM

This study aims to profile migraine patients according clinical and psychophysical characteristics.

METHOD

In this observational study, two cohorts of migraine patients(episodic/chronic) were included. Cohort-1: ictal/perictal phase; Cohort-2: interictal phase.The following variables were assessed: headache frequency; disability; cervical active range of motion(AROM) in flexion, extension, right/left lateral flexion, right/left rotation; pressure-pain threshold(PPT) over: temporalis, two cervical areas(C1/C4 vertebral segments), and two distal pain-free areas(hand/leg). Cluster analysis was performed using the K-means algorithm. Differences across clusters were investigated.

RESULTS

Cohort-1: 100 patients were included, and two clusters were identified. Cluster-1.1 (19%), Cluster-1.2 (81%). Cluster 1.1 had a higher percentage of men (P = .037) and higher disability (P = .003) compared to Clusters 1.2. Cluster 1.2 had reduced AROM in flexion, extension, and left/right lateral flexion (P < .037), and lower PPT value in all areas (P < .001) compared to Cluster 1.1. Cohort-2: 98 patients were included and three clusters were identified. Cluster-2.1(18%), Cluster-2.2(45%), and Cluster-2.3(37%). Cluster-2.1 had a higher percentage of men compared to clusters-2.2 and 2.3 (P = .009). Cluster-2.3 had higher headache frequency, and disability compared to Cluster-2.2 (P < .006), and higher disability compared to Cluster-2.1 (P = .010). Cluster-2.3 had reduced AROM in all directions compared to Clusters-2.1 and 2.2 (P < .029). Clusters-2.2 and 2.3 have lower PPT values in all areas compared to Cluster-1.1 (P < .001).

CONCLUSION

In the Ictal/perictal phase, two clusters were identified according to clinical and psychophysical characteristics, with one group showing no psychophysical impairment and one with increased pain-sensitivity and cervical musculoskeletal-dysfunctions.In the interictal phase, three clusters could be identified, with one group showing no psychophysical impairment, one increased pain-sensitivity, and one increased pain sensitivity and cervical musculoskeletal-dysfunctions.

A Multimodal Conservative Approach to Treating Migraine: A Physical Therapist's Perspective

PURPOSE OF REVIEW

Migraine is common and interventions to treat or manage it vary. Physical therapists possess a varied skill set that can assess and treat limitations related to migraine and its symptoms. Conservative and non-pharmacological examination and treatment techniques for migraine and headache management are reviewed in terms of efficacy and relevance in order to describe the physical therapist's abilities and clinical reasoning process when confronting a patient with migraine symptoms.

RECENT FINDINGS

A thorough examination is necessary to detect red flags and will reveal a person with migraine's biopsychosocial limitations to manage their symptoms. Strength, endurance, cervical mobility, and visual deficits are common in those reporting headaches and examination techniques, along with patient-reported outcome measures, can elicit objective data for re-assessment during an episode of care. Exercise interventions, manual therapy, biofeedback techniques, and vestibular therapy have become viable and efficacious non-pharmacological interventions in recent years to assist the patient with managing and mitigating their migraine symptoms, along with mindfulness-based exercises. A case study, with individualized treatment approaches based on examination findings, current evidence, and accrued expertise, demonstrates the clinical applicability of a physical therapist's multimodal approach to treating migraine. Psychologically- informed physical therapy with mindfulness-based approaches and biofeedback can help a patient gain more control over their symptoms and their body's response to head pain, while exercise and vestibular therapy can assist the system with recovery and adaptation from deficits related to migraine symptoms. A thorough examination, with an individually- tailored rehabilitation plan incorporating movement and mindfulness-based therapies, is recommended.

Musculoskeletal dysfunctions and physiotherapy treatment strategies in patients with migraine

BACKGROUND

Neck pain is prevalent in patients with migraine but its role for the physiotherapy management is unclear.

METHOD

In this narrative review, results of studies, contributing to the overall understanding of musculoskeletal dysfunctions in patients with migraine are summarized, as are approaches to subgroup migraine and attempts to improve migraine non-pharmacologically.

RESULTS

Our line of research shows that musculoskeletal dysfunctions are prevalent in patients with migraine. Pain provocation during manual palpation of the upper cervical spine might be relevant when referred pain to the head is elicited. This subgroup of patients might benefit from physiotherapy treatment to the neck. Preliminary data from treatment studies shows that a small reduction of headache and migraine days can be achieved when treating the neck. The reduction in migraine days might be enhanced when treating migraine as a chronic pain disease and adding pain neuroscience education to the neck treatment.

CONCLUSIONS

Physiotherapy assessment and treatment plays a role in the management of migraine. The effectiveness of different physiotherapy approaches and pain neuroscience education needs to be evaluated further in randomized controlled trials.

The cervical spine in tension type headache

INTRODUCTION

The concept that headaches may originate in the cervical spine has been discussed over decades and is still a matter of debate. The cervical spine has been traditionally linked to cervicogenic headache; however, current evidence supports the presence of cervical musculoskeletal dysfunctions also in tension-type headache.

PURPOSE

This position paper discusses the most updated clinical and evidence-based data about the cervical spine in tension-type headache.

IMPLICATIONS

Subjects with tension-type headache exhibit concomitant neck pain, cervical spine sensitivity, forward head posture, limited cervical range of motion, positive flexion-rotation test and also cervical motor control disturbances. In addition, the referred pain elicited by manual examination of the upper cervical joints and muscle trigger points reproduces the pain pattern in tension-type headache. Current data supports that the cervical spine can be also involved in tension-type headache, and not just in cervicogenic headache. Several physical therapies including upper cervical spine mobilization or manipulation, soft tissue interventions (including dry needling) and exercises targeting the cervical spine are proposed for managing tension-type headache; however, the effectiveness of these interventions depends on a proper clinical reasoning since not all will be equally effective for all individuals with tension-type headache. Based on current evidence, we propose to use the terms cervical "component" and cervical "source" when discussing about headache. In such a scenario, in cervicogenic headache the neck can be the cause (source) of the headache whereas in tension-type headache the neck will have a component on the pain pattern, but it will be not the cause since it is a primary headache.

Cervical musculoskeletal impairments and pain sensitivity in migraine patients

INTRODUCTION

Currently, examination of migraine patients relies on a clinical interview investigating symptoms characteristics. Despite this, to help identify distinct migraine subtypes and allow a personalized treatment approach, biomarkers to profile distinct migraine subtypes should be utilized in clinical and research settings. Therefore, there is a need to include physical and psychophysical examinations aimed at assessing migraine features quantitatively.

PURPOSE

This paper aimed to discuss if increased pressure pain sensitivity and impaired cervical musculoskeletal function could be considered 1) as quantitative features of migraine and 2) if they could be used as biomarkers to profile migraine patients in distinct subtypes.

IMPLICATION

Increased pain sensitivity and cervical musculoskeletal impairments have been suggested as quantitative biomarkers to phenotype and subgroup migraine patients in clinical and research settings. This could provide the first step for a mechanistically-driven and personalized treatment approach according to migraine phenotypes.

Cervicogenic headache

INTRODUCTION

Cervicogenic headache, first proposed as a distinct headache in 1983, is a secondary headache to a primary cervical musculoskeletal disorder. Research into physical impairments was integral to clinical diagnosis and to develop and test research informed conservative management as the first line approach.

PURPOSE

This narrative presents an overview of the body of cervicogenic headache research from our laboratory which was undertaken in the context of a broad program of research into neck pain disorders.

IMPLICATIONS

Early research validated manual examination of the upper cervical segments against anaesthetic nerve blocks, which was vital to clinical diagnosis of cervicogenic headache. Further studies identified reduced cervical motion, altered motor control of the neck flexors, reduced strength of flexor and extensor muscles, and occasional presentation of mechanosensitivity of the upper cervical dura. Single measures are variable and not reliable in diagnosis. We proved that a pattern of reduced motion, upper cervical joint signs and impaired deep neck flexor function accurately identified cervicogenic headache and differentiated it from migraine and tension-type headache. The pattern was validated against placebo controlled diagnostic nerve blocks. A large multicentre clinical trial determined that a combined program of manipulative therapy and motor control exercise is effective in the management of cervicogenic headache and outcomes are maintained in the long term. More specific research into cervical related sensorimotor controlled is warranted in cervicogenic headache. Further adequately powered clinical trials of current research informed multimodal programs are advocated to further strengthen the evidence base for conservative management of cervicogenic headache.

Women with migraine presents similar altered performance in the craniocervical flexion test than women with chronic nonspecific neck pain: An observational study

BACKGROUND

Although patients with migraine show cervical muscle impairments previous studies investigating motor performance have not characterized the sample of patients with migraine according to the presence/absence of neck pain complaints.

OBJECTIVE

To verify if there are differences in the clinical and muscular performance of the superficial neck flexors and extensors during Craniocervical Flexion Test in women with migraine, considering the presence or absence of concomitant symptoms of neck pain.

METHODS

The cranio-cervical flexion test performance was assessed by its clinical stage test and by the surface electromyographic activity of the sternocleidomastoid, anterior scalene muscles upper trapezius and splenius capitis. It was assessed in 25 women with migraine without neck pain, 25 women with migraine and neck pain, 25 women with chronic neck pain and 25 pain-free control women.

RESULTS

Poorer performance of the cervical muscles was found during the execution of the cranio-cervical flexion test, in addition to higher muscle activity, especially in the sternocleidomastoid, splenius capitis, and upper trapezius muscles in the neck pain, migraine without neck pain, and migraine with neck pain groups in comparison with the results obtained for healthy women in the control group. No difference was observed between the groups of women experiencing pain. Analysis of the extensor/flexor muscle electromyographic ratio showed that there was no difference between the groups.

CONCLUSION

Poor cervical muscle performance was observed in both women with chronic nonspecific neck pain and women with migraine regardless of the presence of neck pain.

Intramuscular Electrical Stimulation for the Treatment of Trigger Points in Patients with Chronic Migraine: A Protocol for a Pilot Study Using a Single-Case Experimental Design

Background and Objectives: Trigger points (TrPs) are prevalent in patients with migraine headaches. Needling interventions targeting TrPs in migraine patients may reduce the intensity and frequency of headaches, yet systematic reviews reveal a lack of robust evidence. Intramuscular electrical stimulation (IMES) is a modality that delivers electrical current into muscles and TrPs, with recent studies suggesting it may amplify the therapeutic effects of dry needling peripherally and centrally. This could be advantageous for patients with migraine and symptomatic TrPs. Materials and Methods: This study will implement a multiple baseline single-case experimental design (SCED). In a clinical setting, a SCED study lends itself to conducting research with only a few patients that each serve as their own controls. In this SCED study, four participants with chronic migraine will be enrolled in a non-concurrent manner and randomized to one of four baseline measurement periods (4, 5, 6 or 7 weeks), leading to four potentially different start dates for each participant in the intervention phase. During the intervention phase, patients will receive five sessions of dry needling with IMES, one session per week for five weeks. The primary outcome measure will be headache frequency, i.e., the reduction in the number of headache days over a one-month period using electronic headache diary data from the Migraine Buddy smartphone application. Secondary outcome measures will be changes in mean migraine pain intensity using a numeric pain rating scale (NPRS), migraine disability using the Migraine Disability Assessment Test (MIDAS), the Headache Impact Test (HIT-6), and changes in selected cervical musculoskeletal impairments including pressure pain thresholds (PPTs) over TrPs, the craniocervical flexion test (CCFT), and cervical active range of motion (AROM). Primary and secondary outcome measures will be analyzed separately using both visual and statistical analyses. Results: Actively recruiting participants. This project was approved by the Mass General Brigham Institutional Review Board (protocol #2023P000931) and is registered with ClinicalTrials.gov (NCT05893914). Conclusions: This study will seek to determine the effects of a five-week intervention period of IMES to TrPs in the posterior cervical muscles of subjects with chronic migraine.

A guide to identify cervical autonomic dysfunctions (and associated conditions) in patients with musculoskeletal disorders in physical therapy practice

BACKGROUND

Differential diagnosis is a hot topic in physical therapy, especially for those working in a direct access setting dealing with neck pain and its associated disorders. All international guidelines agree in recommending to first rule out non-musculoskeletal pathologies as the cause of signs and symptoms in the patient. Although the autonomic nervous system (ANS) has a crucial role and is also involved in pain conditions, coverage of it in neuroscience textbooks and educational programmes is limited and most healthcare professionals are unfamiliar with it. Although autonomic conditions are benign in nature, they are clinically of great importance as they may be a 'red flag' warning of an injury along the sympathetic pathway. Therefore, sound knowledge of the ANS system is essential for clinicians.

OBJECTIVE

To develop physical therapists' knowledge of and confidence in understanding cervical ANS function and dysfunction, thus enhancing clinical reasoning skills and the pattern recognition process, and performing and interpreting objective examinations.

METHODS

This master class provides an introductory guide and essential knowledge to facilitate clinicians to understand cervical autonomic dysfunctions and their clinical evaluation. The optimal referral method is also handled.

CONCLUSIONS

Gaining knowledge and understanding of the ANS, its function, its dysfunction, and the related clinical manifestations is likely to lead to a decision-making process driven by 'science and conscience'. This will empower physical therapists to be aware of subtle clues that may be offered by patients during the interview and history intake leading to the appropriate physical examination and triage.

Effect of aerobic exercises and therapeutic pain neuroscience education on disability, pain, head posture and QOL in migraine patients

Migraine is a type of primary headache with a high degree of associated disability that can present with a variety of indications and co-morbidities. The role of physical therapy treatment in migraine management is largely obscure. To investigate the combine effect of aerobic exercises and therapeutic pain neuroscience education on disability, pain pressure threshold, head posture and quality of life (QoL) in patients having migraine. Subjects were screened by using Migraine Disability Assessment (MIDAS) and after screening total sample of 50 subjects were randomly assigned into two groups: Group A (Experimental, n=25) and Group B (Control, n=25). Migraine disability assessment, pressure algometer, craniovertebral angle (CVA) and migraine specific quality of life were examined before and after 6 weeks of the intervention. Group A were given aerobic exercises and therapeutic pain neuroscience education along with conventional treatment for 45 min 3 days/week for 6 weeks, whereas participants in the Group B performed conventional exercises alone for 20 min 3 days/week for 6 weeks. Significant differences were observed in migraine disability score (P=0.003) and pain pressure threshold (P=0.039, P=0.030 and P=0.025) and improvement in forward head posture (P=0.001) between the groups after the intervention period, signifying greater improvement in the group A. QoL also improved in both the groups after intervention. Main findings of the present study suggest that the therapeutic pain neuroscience education and aerobic exercises combined with conventional treatment together maybe helpful to give better quality of life, reduced disability, increased pain pressure threshold and increased CVA to patients with migraine.

Inter-rater reliability, discriminatory and predictive validity of neck movement control tests in office workers with headache and/or neck pain

BACKGROUND

Movement control tests (MCTs) are clinical tests to evaluate impairment of movement and associated neuromuscular control and are commonly used to evaluate people with neck pain or headache conditions. The aim of this study was to establish inter-rater reliability as well as discriminatory and predictive validity for seven MCTs of the upper (UCS) and lower cervical spine (LCS) in office workers with headache or neck pain.

METHODS

Seven MCTs of the UCS (3) and LCS (4) were performed at baseline on 140 office workers which were included in a cluster randomized controlled trial. The occurrences of headache and neck pain were established at baseline (discriminatory validity) and at a 15-month follow-up (predictive validity). Inter-rater-reliability was established in a separate cross-sectional study.

RESULTS

MCTs showed slight to almost perfect inter-rater reliability but limited discriminatory (baseline) and limited to small predictive validity (15-month follow up) for different subgroups of office workers with headache and/or neck pain. MCTs of the UCS showed limited discriminatory validity, especially for rotation in participants with headache and neck pain compared to those with headache only (Negative Likelihood-ratio: 0.82, 95% CI: 0.69-0.98). Participants with neck pain only and ≥1/4 positive MCTs for the sagittal plane had an increased risk for future neck pain (Relative risk: 3.33, 95% CI: 1.05-10.56).

DISCUSSION

MCTs of the UCS and LCS are reliable but have only limited to small validity to predict future headache events in office workers. Insufficient sagittal plane movement control may predict neck pain relapses in the future.

Flexion-rotation test and C0-C2 axial rotation test. Are they equally reliable for novice clinicians?

OBJECTIVE

To analyse the inter- and intra-examiner reliability for the neck flexion-rotation test and the C0-C2 axial rotation test when applied in asymptomatic subjects by two novice physiotherapists.

DESIGN

Repeated measures reliability study design. The study was approved by the Research Ethics Committee of [X], in compliance with the Declaration of Helsinki (CSEULS-PI: 004/2020).

METHODS

32 asymptomatic adults were included, recruited by convenience sampling. Two sessions were scheduled for each subject, with an intersession break of 30 min. Two inexperienced raters blinded to their own previous and peer results performed three movements to both sides using the flexion-rotation test and the C0-C2 axial rotation test in randomised order of rater, test and direction. A third researcher collected the data measured by inertial sensors and displayed to the Pro Motion Capture software.

RESULTS

Both raters showed good-excellent intra-examiner reliability (ICC_(2,3) ranging from 0.88 to 0.94) and moderate to good inter-examiner reliability (ICC_(2,3) ranging from 0.58 to 0.86) to measure the rotation ROM with the FRT. The C0-C2 axial rotation test resulted in poor to moderate intra-examiner reliability (ICC_(2,3) ranging from 0.33 to 0.74) and poor inter-examiner reliability using (ICC_(2,3) ranging from 0.16 to 0.37).

CONCLUSION

Although performed by novice raters, the FRT showed good to excellent intra and inter-examiner reliability. Results for the C0-C2 axial rotation test were less reliable. We suggest that novice physiotherapists use the FRT instead of the C0-C2 axial rotation test in order to determine C1-C2 dysfunction.

Neck-specific strengthening exercise compared with placebo sham ultrasound in patients with migraine: a randomized controlled trial

Background

Migraine patients have musculoskeletal disorders and pain in the cervical. And, despite the pathophysiology demonstrating the relationship between migraine and the cervical spine, the effectiveness of craniocervical exercises in these patients has not been verified. So, the aimed of this study was verify the effectiveness of craniocervical muscle-strengthening exercise (CMSE) in reducing the frequency and intensity of headache in migraine patients. 

Methods

A two-armed, parallel-group randomized controlled trial with a 3-month follow-up was performed. For eight weeks, the volunteers in the intervention group (n = 21) performed a protocol of CMSE, while those in the sham ultrasound group (n = 21) received the application of disconnected therapeutic ultrasound in the upper trapezius and guideline for home-stretching. The primary outcomes were the frequency and intensity of the headache. The secondary outcomes were questionnaires about migraine and neck disability, and satisfaction with the treatment, cervical range of motion, the pressure pain threshold, craniocervical flexion test (CCFT), cervical muscle strength and endurance test, and the cervical muscle activity during the physical tests.

Results

No differences were observed for the changes observed in primary outcomes after eight weeks and at the 3-months follow up (p > 0.05). For the secondary outcomes, craniocervical exercises improved the sensitivity of the frontal muscle (p = 0.040) and promoted a reduced amplitude of muscle activity of the anterior scalene and upper trapezius in the last stages of CCFT (p ≤ 0.010). There was also reduced muscle activity of the anterior scalene and splenius capitis in the endurance test (p ≤ 0.045), as evaluated by surface electromyography.

Conclusion

CMSE were insufficient in reducing the frequency and intensity of headache, improving the performance of the cervical muscles, or reducing migraine and neck pain-related disabilities. This was found despite a decreased electromyographic activity of the cervical muscles during the last stages of CCFT and increased median frequency during the endurance test.

Trial registration

Accession code RBR-8gfv5j, registered 28/11/2016 in the Registro Brasileiro de Ensaios Clínicos (ReBEC).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02650-0.

Cervical musculoskeletal impairments in the 4 phases of the migraine cycle in episodic migraine patients

OBJECTIVE

To assess cervical musculoskeletal impairments during the 4 phases of a migraine cycle in episodic migraine patients, controlling for the presence of concomitant neck pain.

METHODS

Differences in cervical musculoskeletal impairments were assessed during the 4 migraine phases in episodic migraine patients and compared with healthy controls controlling for concomitant neck pain. Cervical musculoskeletal impairments were assessed as follow: cervical active range of motion; flexion rotation test; craniocervical flexion test and calculation of activation pressure score; the total number of myofascial trigger points in head/neck muscles; the number of positivevertebral segments (headache's reproduction) during passive accessory intervertebral movement; pressure pain thresholds over C1, C2, C4, C6 vertebral segments bilaterally, trigeminal area, hand, and leg. Signs of pain sensitization were assessed by evaluating mechanical pain threshold over trigeminal area and hand, pressure pain thresholds, and the wind-up ratio. The Bonferroni-corrected p-value (05/4 = 0.013) was adopted to assess the difference between groups, while a p-value of 0.05 was considered significant for the correlation analysis.

RESULTS

A total of 159 patients and 52 controls were included. Flexion rotation test and craniocervical flexion test were reduced in all 4 phases of the migraine cycle versus healthy controls (p < 0.001). The number of myofascial trigger points and positive vertebral segments was increased in all 4 phases of the migraine cycle versus healthy controls (p < 0.001). Flexion, extension, and total cervical active range of motion and cervical pressure pain thresholds were reduced in episodic migraine in the ictal phase versus controls (p < 0.007) with no other significant differences. Outside the ictal phase, the total cervical active range of motion was positively correlated with trigeminal and leg pressure pain threshold (p < 0.026), the number of active myofascial trigger points and positive positive vertebral segments were positively correlated with higher headache frequency (p=0.045), longer headache duration (p < 0.008), and with headache-related disability (p = 0.031). Cervical pressure pain thresholds were positively correlated with trigeminal, hand, and leg pressure pain threshold (p < 0.001), and trigeminal and leg mechanical pain thresholds (p < 0.005), and negatively correlated with the wind-up ratio (p < 0.004).

CONCLUSION

In all phases of the migraine cycle, independent of the presence of concomitant neck pain, episodic migraine patients showed reduced flexion rotation test and craniocervical flexion test and an increased number of myofascial trigger points and passive accessory vertebral segments. These impairments are correlated with enhanced headache duration, headache-related disability, and signs of widespread pain sensitization. Reduction in active cervical movement and increased mechanical hyperalgesia of the cervical was consistent in ictal episodic migraine patients and the subgroups of episodic migraine patients with more pronounced widespread sensitization.

Cervical musculoskeletal impairments in migraine

Background

Neck pain is common and disabling amongst individuals with migraine. Cervical musculoskeletal interventions are often sought but there is currently no evidence to support such interventions for this population. Improved understanding of how cervical musculoskeletal impairments present in migraine can elucidate neck pain mechanisms and guide clinicians and researchers in the management of patients with migraine and neck pain.

Main body

Migraine hypersensitivity is a major consideration when assessing for cervical impairments as it can aggravate migraine and confound findings. Current evidence of cervical impairments in migraine is limited by disregard for the different underlying causes of neck pain and possible influence of hypersensitivity. Findings of cervical musculoskeletal impairments are mixed within and across studies, indicating that different forms of neck pain are present in migraine. Some migraineurs have neck pain that is part of the migraine symptom complex and therefore exhibit little or no cervical musculoskeletal impairment. Others have a cervical source of neck pain and therefore exhibit a pattern of cervical musculoskeletal impairments akin to that of cervical disorders. The presence of cervical musculoskeletal dysfunction may or may not be related to migraine but knowledge of this is currently lacking which impacts decision making on management. Cervical musculoskeletal interventions may be indicated for migraineurs with identified cervical dysfunction but other factors requiring further clarification include determination of i) patient specific outcomes, ii) impact of co-existing migraine referred neck pain, and iii) potential moderating effects of migraine hypersensitivity on treatment efficacy.

Conclusions

Physiotherapists should seek a combination of cervical impairments through skilful assessment to identify if cervical musculoskeletal dysfunction is present or not in individual patients. The relevance of cervical dysfunction to migraine and influence of co-existing migraine referred neck pain need to be established through detailed evaluation of pain behaviours and further research. Future clinical trials should define expected treatment outcomes and select individuals with cervical musculoskeletal dysfunction when investigating the efficacy of cervical musculoskeletal interventions.

Psychophysical testing in chronic migraine and chronic tension type headache: An observational study

BACKGROUND

Clinical presentation is the key to the diagnosis of patients with migraine and tension-type headache, but features may overlap when both become chronic. Psychophysical parameters may distinguish both conditions. We aimed to compare psychophysical aspects of patients with chronic migraine, chronic tension-type headache and headache-free controls, and to determine whether these can predict headache frequency.

METHODS

An examiner blinded to the diagnosis assessed 100 participants (chronic migraine (n = 38), chronic tension-type headache (n = 31) and controls (n = 31)). Assessed variables included painful area, pressure pain thresholds, temporal summation, cervical range of motion, neck posture, headache and neck impact, quality of life, and kinesiophobia. Comparison between groups was performed with one-way ANOVA and multiple linear regression was used to assess the headache frequency predictors.

RESULTS

We found differences of both headache groups compared to controls (p < 0.01), but not between headache groups. Neck disability was a significant predictor of headache frequency for chronic tension-type headache (adjusted R² = 0.14; β = 0.43; p = 0.03) and chronic migraine (adjusted R² = 0.18; β = 0.51; p < 0.01).

CONCLUSIONS

Chronic tension-type headache and chronic migraine showed similar psychophysical results, but were significantly worse when compared to controls. The psychophysical examination did not discriminate between headache types. The variable best explaining headache frequency for both headache types was neck disability.

Differentiating migraine, cervicogenic headache and asymptomatic individuals based on physical examination findings: a systematic review and meta-analysis

BACKGROUND

Migraine and cervicogenic headache (CGH) are common headache disorders, although the large overlap of symptoms between them makes differential diagnosis challenging. To strengthen differential diagnosis, physical testing has been used to examine for the presence of musculoskeletal impairments in both conditions. This review aimed to systematically evaluate differences in physical examination findings between people with migraine, CGH and asymptomatic individuals.

METHODS

The databases MEDLINE, PubMed, CINAHL, Web of Science, Scopus, EMBASE were searched from inception until January 2020. Risk of bias was assessed with the Downs and Black Scale for non-randomized controlled trials, and with the Quality Assessment of Diagnostic Accuracy Studies tool for diagnostic accuracy studies. When possible, meta-analyses with random effect models was performed.

RESULTS

From 19,682 articles, 62 studies were included in this review and 41 were included in the meta-analyses. The results revealed: a) decreased range of motion [°] (ROM) on the flexion-rotation test (FRT) (17.67, 95%CI:13.69,21.65) and reduced neck flexion strength [N] (23.81, 95%CI:8.78,38.85) in CGH compared to migraine; b) compared to controls, migraineurs exhibit reduced flexion ROM [°] (- 2.85, 95%CI:-5.12,-0.58), lateral flexion ROM [°] (- 2.17, 95% CI:-3.75,-0.59) and FRT [°] (- 8.96, 95%CI:-13.22,-4.69), reduced cervical lordosis angle [°] (- 0.89, 95%CI:-1.72,-0.07), reduced pressure pain thresholds over the cranio-cervical region [kg/cm²], reduced neck extension strength [N] (- 11.13, 95%CI:-16.66,-5.6) and increased activity [%] of the trapezius (6.18, 95%CI:2.65,9.71) and anterior scalene muscles (2.87, 95%CI:0.81,4.94) during performance of the cranio-cervical flexion test; c) compared to controls, CGH patients exhibit decreased neck flexion (- 33.70, 95%CI:-47.23,-20.16) and extension (- 55.78, 95%CI:-77.56,-34.00) strength [N].

CONCLUSION

The FRT and neck flexion strength could support the differential diagnosis of CGH from migraine. Several physical tests were found to differentiate both headache types from asymptomatic individuals. Nevertheless, additional high-quality studies are required to corroborate these findings.

STUDY REGISTRATION

Following indications of Prisma-P guidelines, this protocol was registered in PROSPERO on 21/05/2019 with the number CRD42019135269 . All amendments performed during the review were registered in PROSPERO, indicating the date and what and why was changed.

Neck Active Movements Assessment in Women with Episodic and Chronic Migraine

We aimed to compare movement parameters and muscle activity during active cervical spine movements between women with episodic or chronic migraine and asymptomatic control. We also assessed the correlations between cervical movement measures with neck-related disability and kinesiophobia. Women with episodic (n = 27; EM) or chronic (n = 27; CM) migraine and headache-free controls (n = 27; CG) performed active cervical movements. Cervical range of motion, angular velocity, and percentage of muscular activation were calculated in a blinded fashion. Compared to CG, the EM and CM groups presented a reduced total range of motion (p < 0.05). Reduced mean angular velocity of cervical movement was also observed in both EM and CM compared to CG (p < 0.05). Total cervical range of motion and mean angular velocity showed weak correlations with disability (r = −0.25 and −0.30, respectively; p < 0.05) and weak-to-moderate correlations with kinesiophobia (r = −0.30 and −0.40, respectively; p < 0.05). No significant correlation was observed between headache features and total cervical range of motion or mean angular velocity (p > 0.05). No differences in the percentage of activation of both flexors and extensors cervical muscles during active neck movements were seen (p > 0.05). In conclusion, episodic and chronic migraines were associated with less mobility and less velocity of neck movements, without differences within muscle activity. Neck disability and kinesiophobia are negative and weakly associated with cervical movement.

Effectiveness of a manual therapy protocol based on articulatory techniques in migraine patients. A randomized controlled trial

BACKGROUND

Physiotherapy is used as a non-pharmacological treatment for migraine. However, controversy exists over whether articulatory manual techniques are effective in some aspects related to migraine.

OBJECTIVES

To assess the effectiveness of a manual therapy protocol based on articulatory techniques in pain intensity, frequency of episodes, migraine disability, quality of life, medication intake and self-reported perceived change after treatment in migraine patients.

DESIGN

Randomized controlled trial.

METHODS

Fifty individuals with migraine were randomized into the experimental group, which received manual therapy based on articulatory techniques (n = 25), or the placebo group (n = 25). The intervention lasted 4 weeks and included 4 sessions. Patients were assessed before (T1), after (T2) and at a one-month follow-up following the intervention (T3). The instruments used were the Migraine Disability Assessment (MIDAS) questionnaire, the Short Form-36 Health Survey (SF-36), the medication intake and The Patients' Global Impression of Change scale.

RESULTS

In comparison with placebo group, manual therapy patients reported significant effects on pain intensity at T2 (p < 0.001; d = 1.15) and at T3 (p < 0.001; d = 1.13), migraine disability at T3 (p < 0.05; d = 0.69), physical quality of life at T2 (p < 0.05; d = 0.72), overall quality of life at T2 (p < 0.05; d = 0.60), decrease in medication intake at T2 (p < 0.001; d = 1.11) and at T3 (p < 0.05; d = 0.77) and self-reported perceived change after treatment at T2 and T3 (p < 0.001). No serious adverse events were reported.

CONCLUSIONS

The application of a manual therapy protocol based on articulatory techniques reduced pain intensity, migraine disability, and medication intake, while improving quality of life in patients with migraine.

Comparison of cervical muscle isometric force between migraine subgroups or migraine-associated neck pain: a controlled study

This study aimed to verify if migraine frequency or migraine-associated neck pain were associated with a reduction of normalized force and altered electromyographic activity during maximal cervical muscle isometric contractions. Additionally, it aimed to assess the correlation of normalized isometric force with years with migraine, headache frequency, headache intensity, migraine-related disability, and severity of cutaneous allodynia. The sample comprises 71 women with migraine (40/31 episodic/chronic, 42/18 with/without neck pain) and 32 women without headache. Cervical muscle isometric force in flexion, extension, and lateral flexion was assessed synchronized with the acquisition of superficial electromyography from the cervical muscles. Women with episodic migraine presented lower normalized isometric force in extension, flexion, and right and left lateral flexions than controls (P < 0.05). Women with migraine and neck pain exhibited lower cervical extension and right/left lateral-flexions normalized isometric force than controls (P < 0.05). No significant differences were observed in antagonist activity. Normalized isometric force in all directions showed weak to moderate correlations with the severity of self-reported symptoms of cutaneous allodynia (- 0.25 ≥ r ≥ - 0.39). No additional linear correlation with clinical migraine features was observed. In conclusion, cervical muscle weakness may be associated with episodic migraine and neck pain concurrent with migraine attacks without altered antagonist activity. Additionally, it may also be related to the severity of cutaneous allodynia.

High concurrent validity between digital and analogue algometers to measure pressure pain thresholds in healthy participants and people with migraine: a cross-sectional study

Background

Pressure pain thresholds (PPTs) are commonly assessed to quantify mechanical sensitivity in various conditions, including migraine. Digital and analogue algometers are used, but the concurrent validity between these algometers is unknown. Therefore, we assessed the concurrent validity between a digital and analogue algometer to determine PPTs in healthy participants and people with migraine.

Methods

Twenty-six healthy participants and twenty-nine people with migraine participated in the study. PPTs were measured interictally and bilaterally at the cephalic region (temporal muscle, C1 paraspinal muscles, and trapezius muscle) and extra-cephalic region (extensor carpi radialis muscle and tibialis anterior muscle). PPTs were first determined with a digital algometer, followed by an analogue algometer. Intraclass correlation coefficients (ICC_3.1) and limits of agreement were calculated to quantify concurrent validity.

Results

The concurrent validity between algometers in both groups was moderate to excellent (ICC_3.1 ranged from 0.82 to 0.99, with 95%CI: 0.65 to 0.99). Although PPTs measured with the analogue algometer were higher at most locations in both groups (p < 0.05), the mean differences between both devices were less than 18.3 kPa. The variation in methods, such as a hand-held switch (digital algometer) versus verbal commands (analogue algometer) to indicate when the threshold was reached, may explain these differences in scores. The limits of agreement varied per location and between healthy participants and people with migraine.

Conclusion

The concurrent validity between the digital and analogue algometer is excellent in healthy participants and moderate in people with migraine. Both types of algometer are well-suited for research and clinical practice but are not exchangeable within a study or patient follow-up.

Neck pain associated with migraine does not necessarily reflect cervical musculoskeletal dysfunction

OBJECTIVE

To identify how frequently the neck pain associated with migraine presents with a pattern of cervical musculoskeletal dysfunction akin to cervical musculoskeletal disorders, and to determine if pain hypersensitivity impacts on cervical musculoskeletal function in persons with migraine.

BACKGROUND

Many persons with migraine experience neck pain and often seek local treatment. Yet neck pain may be part of migraine symptomology and not from a local cervical source. If neck pain is of cervical origin, a pattern of musculoskeletal impairments with characteristics similar to idiopathic neck pain should be present. Some individuals with migraine may have neck pain of cervical origin, whereas others may not. However, previous studies have neglected the disparity in potential origins of neck pain and treated persons with migraine as a homogenous group, which does not assist in identifying the origin of neck pain in individuals with migraine.

METHODS

This cross-sectional, single-blinded study was conducted in a research laboratory at the University of Queensland, Australia. Persons with migraine (total n = 124: episodic migraine n = 106, chronic migraine = 18), healthy controls (n = 32), and persons with idiopathic neck pain (n = 21) were assessed using a set of measures typically used in the assessment of a cervical musculoskeletal disorder, including cervical movement range and accuracy, segmental joint dysfunction, neuromuscular and sensorimotor measures. Pain hypersensitivity was assessed using pressure pain thresholds and the Allodynia Symptom Checklist. People with migraine with diagnoses of comorbid neck disorders were excluded. Cluster analysis was performed to identify how participants grouped on the basis of their performance across cervical musculoskeletal assessments. Post hoc analyses examined the effects of pain hypersensitivity on musculoskeletal function, and if any symptoms experienced during testing were related to musculoskeletal function.

RESULTS

Two distinct clusters of cervical musculoskeletal function were found: (i) neck function similar to healthy controls (n = 108) and (ii) neck dysfunction similar to persons with neck pain disorders (n = 69). Seventy-six of the individuals with migraine (62 with neck pain and 14 without neck pain) were clustered as having normal cervical musculoskeletal function, whereas the remaining 48 with neck pain had cervical dysfunction comparable with a neck disorder. Musculoskeletal dysfunction was not related to pain hypersensitivity or symptoms experienced during testing.

CONCLUSIONS

Neck pain when present with migraine does not necessarily indicate the existence of cervical musculoskeletal dysfunction. Skilled assessment without reliance only on the person reporting symptoms is needed to identify actual cervical dysfunction. Treatments suitable for neck musculoskeletal disorders would seem inappropriate for the individuals without cervical dysfunction. Future studies evaluating any potential effects of such treatments should only select participants with neck pain of cervical origin.

Effects of combining manual therapy, neck muscle exercises, and therapeutic pain neuroscience education in patients with migraine: a study protocol for a randomized clinical trial

BACKGROUND

Non-pharmacological approaches for the management of migraine exhibit low to moderate effectiveness due to a lack of high-quality randomized clinical trials. In fact, previous studies applied isolated techniques, which were not representative of common clinical practice. A multimodal approach for migraine may benefit these patients more than isolated approaches. This randomized clinical trial aims to determine the effectiveness of a multimodal protocol combining manual therapy, exercise, and therapeutic pain neuroscience education versus the application of manual therapy or pain neuroscience education alone in patients with migraine.

METHODS

This clinical trial will include 75 individuals of both sexes, aged between 18 and 55 years, with migraine. Participants will be randomized into three groups: the therapeutic pain neuroscience education (TPNE; n = 25) group, the manual therapy (MT; n = 25) group, and the multimodal (MM; n = 25) group. The TPNE group will receive one orientation session on migraine and pain self-management, and recommendations for daily active stretching and walking, with subsequent therapist monitoring. The MT group will receive manual therapies targeting musculoskeletal disorders of the cervical spine. The MM group will receive manual therapies targeting musculoskeletal disorders of the cervical spine, active neck exercises, and therapeutic pain neuroscience education. The treatment period will last 12 weeks. The primary outcome will be the headache impact, measured using the Headache Impact Test (HIT-6). Secondary outcomes will include migraine frequency and intensity, cervical mobility and strength parameters, neck pain-related disability, kinesiophobia, cutaneous allodynia, pain-related catastrophizing, quality of life, and self-perception of change. All outcomes will be evaluated at the fourth, eighth, and twelfth weeks of the treatment period. Primary and secondary clinical outcomes, such as headache impact, frequency, and intensity, will also be evaluated at the 1-, 2-, and 4-month follow-ups.

DISCUSSION

The results of this randomized clinical trial may provide high-quality clinical evidence of the effects of non-pharmacological treatment options for the management of migraine.

TRIAL REGISTRATION

This study was registered under the access code RBR-7s22c75 in the Registro Brasileiro de Ensaios Clínicos (ReBEC) in December 2020.

Inter and Intra-Rater Reliability of Measuring Photometric Craniovertebral Angle Using a Cloud-Based Video Communication Platform

Objective:

Due to social distancing guidelines during the Coronavirus (COVID-19) pandemic, most providers and patients have wanted to avoid close contact. This makes physical therapy (PT) assessments difficult because of the lack of empirical evidence about the reliability of various clinical measurements performed in a virtual environment. One such procedure is the photometric measurement of craniovertebral (CV) angle. Craniovertebral angle measurement is usually performed in an outpatient setting and is defined as the acute angle formed between a straight line connecting the spinous process of C7 to the tragus of the ear, and the horizontal line passing through the spinous process of the C7. Although the photometric measurement of CV angles is considered both valid and reliable in the clinics, no empirical evidence exists about the CV angle measurement reliability when performed in a virtual environment. Thus, the purpose of this study was to assess the inter- and intra-rater reliability of photometric CV angle measurement using a cloud-based video communication platform. Number of Subjects: 66 subjects (57 females).

Methods:

All measurements were performed by two final year PT students who had completed the musculoskeletal part of the curriculum and were blinded to each other's measurements. Each subject was photographed in two postures over a HIPAA-compliant video-based telehealth platform: (1) normal/relaxed posture and (2) ideal posture (posture the subject considered good). Student researcher 1 measured the CV angle in both the relaxed posture and ideal posture, while student researcher 2 measured the CV angle only in the relaxed posture. Each subject's CV angle measurement was performed three times on three separate days and the means were used for further analysis. The shape of the CV angle frequency distribution was assessed using kurtosis and skewness values. Rater reliability was assessed using intraclass correlation coefficients (ICC), and interpreted based on the guidelines provided by Portney and Watkins (2009).

Results:

The CV angles were normally distributed in both relaxed and ideal postures. The mean and standard deviation (SD) of relaxed posture was 50.7o ± 6.3o with kurtosis and skewness of 0.67 and −0.74 respectively. The mean and SD of ideal posture was 55.5o ± 5.4o, with kurtosis and skewness of 0.1 and −0.54 respectively. The ICC for inter-rater reliability in the relaxed posture was 0.88 and the ICC for intra-rater reliability for relaxed posture was 0.91.

Conclusions:

Craniovertebral angles were normally distributed in the sample. An acceptable level of inter- and intra-rater reliability can be attained when measuring CV angle using a cloud-based video communication platform.

Changes and Associations between Cervical Range of Motion, Pain, Temporomandibular Joint Range of Motion and Quality of Life in Individuals with Migraine Applying Physiotherapy: A Pilot Study

Background and Objectives: The aim of this study was to assess the effects of physiotherapy with aerobic exercise together with temporomandibular joint range of motion exercises (supervised) and physiotherapy with aerobic exercise only (unsupervised), also to review the correlations between neck movements, pain, temporomandibular joint range of motion movements and quality of life in individuals with migraine. Methods: The flexion, extension and lateral flexion of the cervical spine were measured in degrees with a mechanical goniometer and pressure pain thresholds with algometer. Quality of life was assessed with the SF-36 questionnaire and temporomandibular joint range of motion with a centimeter. Results: The study showed statistically significant cervical flexion results in both groups (p < 0.05), masticatory muscle results and temporomandibular joint range of motion between the groups (p < 0.05). A correlation between left upper trapezius muscle pain and cervical lateral flexion was observed in the intervention group. Physical activity correlated with cervical extension, activity limitation due to physical ailments and general health. A correlation between temporomandibular joint and right-side masticatory muscles pain was found. A correlation between upper trapezius muscle pain and left- as well as right-side temporalis muscles were found in the control group. Strong correlations were found between pain and activity limitation due to physical ailments and emotional state. The temporomandibular joint range of motion strongly correlated with activity limitation due to physical ailments. Conclusions: Physiotherapy based on aerobic exercises together with temporomandibular joint exercises was more effective than physiotherapy based on aerobic exercise for decreasing pain, increasing pressure pain thresholds and cervical range of motion.

Chronic Primary Headache Subjects Have Greater Forward Head Posture than Asymptomatic and Episodic Primary Headache Sufferers: Systematic Review and Meta-analysis

OBJECTIVE

To summarize the cervical physical examination characteristics in subjects with chronic primary headache and compare those with a healthy population and a population with episodic primary headache.

DESIGN

Systematic review and meta-analysis.

SUBJECTS

Humans ≥18 years old. At least one of the study groups should be constituted by subjects diagnosed with one of the chronic primary headache subtypes according to the International Classification of Headache Disorders, 3rd Edition.

COMPARISON

Neck physical examination outcomes of subjects with chronic primary headache compared with a healthy population or subjects with episodic primary headache.

OUTCOMES

Forward head posture (FHP), cervical range of movement, motor control, neck muscle activity, and reproduction and resolution of symptoms.

METHODS

Two reviewers assessed independently the MEDLINE, EMBASE, WOS, MEDES, PEDro, and CINAHL databases to select observational studies. First, both implemented an agreement for a search strategy. Then, they screened independently for duplicates, titles, abstracts, and full-text information. A meta-analysis was conducted to compare measures between groups.

RESULTS

Twelve studies (N = 1,083) with moderate quality (mean ± SD = 7.75 ± 1.48 on the Newcastle Ottawa Scale) were selected for the qualitative analysis. The meta-analysis showed that patients with chronic primary headache presented greater forward head posture than asymptomatic participants (N = 275, Hg = 0.68, 95% CI = 0.25-1.1, Z = 3.14, P < 0.01) and patients with episodic primary headache (N = 268, Hg = 0.39, 95% CI = 0.13-0.65, Z = 2.98, P < 0.01).

CONCLUSIONS

There is moderate to strong evidence that patients with chronic primary headache present greater FHP than asymptomatic individuals and moderate evidence that patients with chronic primary headache present greater forward head posture than those with episodic primary headache.

Inter, intra-examiner reliability and validity of inertial sensors to measure the active cervical range of motion in patients with primary headache

We analyzed the inter- and intra-examiner reliability of Werium inertial sensors and the cervical range of motion (CROM) instrument for the measurement of active CROM (AcROM) in patients with primary headache. Another objective is to analyze the validity of the inertial sensors (Werium). The literature has reported symptomatology features in patients diagnosed with primary headache similar to that of patients with cervicogenic headache. The International Classification of Headache (ICHD-III) established the presence of reduced AcROM as a diagnostic criterion for cervicogenic headache. Several instruments are used for this measurement, with limitations in their applicability in daily clinical practice. A prospective longitudinal repeated measures study was conducted to assess the intra- and inter-rater reliability and validity of Werium inertial sensors in 20 adults with chronic primary headache. For the inter-rater analysis, the intraclass correlation coefficient (ICC) values were above 0.75 for all movements, indicating a good level of reliability. For the intra-rater results, the ICC values obtained by the Werium inertial sensors for all cervical movements were good for rater A (ICC >0.80) and rater B (ICC >0.84). For the validity, the ICCs obtained by the Werium inertial sensors compared with the CROM instrument for all cervical movements were moderate for both raters (ICC > 0.70, respectively). Values obtained in the standard error of measurement, minimum detectable change at 90% and limits of agreement also indicated good agreement. Werium inertial sensors have shown good to excellent reliability results, both intra- and inter-examiner (ICC > 0.75). Likewise, when the sensors were compared with another validated instrument (CROM device) they obtained high reliability results (ICC > 0.70). These results plus its relatively low price and ease of use allow us to recommend it in daily clinical practice to measure AcROM in patients with chronic primary headache.

[The Second Short Form of the McGill Pain Questionnaire as the useful additional tool for differential diagnostics of migraine and cervicogenic headache]

OBJECTIVE

To study the effectiveness of the Second Short Form of the McGill Pain Questionnaire (SF-MPQ-2) as an instrument for assessment and comparison of quantitative characteristics of pain in patients with chronic musculoskeletal impairment of the cervical spine and nonspecific neck pain accompanied by chronic migraine or cervicogenic headache (CeH).

MATERIAL AND METHODS

Forty-nine patients, aged from 19 to 60 years (mean age 42.8±10.4), were divided into 2 comparable by age and gender groups with migraine (n=18) and CeH (n=31). Neck pain and headache intensity was measured by the 11-points Numerical Rating Scale (NRS). Quality of pain and related symptoms were measured by SF-MPQ-2. Multidisciplinary and multimodal approaches were applied for treatment, including several modalities of manual therapy.

RESULTS

Headache intensity was higher in the migraine group in comparison with the CeH group (7.8±1.7 vs 6.0±1.5, respectively; p<0.05). No significant differences in neck pain intensity were found (6.2±1.8 vs 5.3±1.7; p=0.08). Patients with migraine usually chose more descriptors than patients with CeH (14 vs 4, respectively) and higher range of their intensity (p<0.001). By the end of treatment session, the number of descriptors and their intensity decreased significantly on all SF=MPQ-2 scales (p<0.001) in both groups. Most patients of migraine and CeH group were satisfied with treatment (83% and 97%, respectively) and marked «much improved» and «very much improved» on the 7-point Patient Global Impression of Change scale.

CONCLUSION

SF-MPQ-2 is a useful tool for differential diagnosis of migraine and CeH, as it contains the sufficient number of descriptors and the scale for measuring their intensity.

Consensus among musculoskeletal experts for the management of patients with headache by physiotherapists? A delphi study

BACKGROUND

Though a large amount of research on the management of headache has been conducted, the clinical effectiveness of these treatments remains unclear.

OBJECTIVES

To reach consensus among international musculoskeletal experts on what the most appropriate management is in patients that suffer from headache.

DESIGN

Expert group and Delphi-study.

METHODS

A total of 11 experts participated in the expert panel groups, where the role of physiotherapy in the management of headache was discussed. Afterwards, 14 of the initial 25 participants in the field of headache completed the whole Delphi study, which was conducted over 4 rounds. The first round aimed to identify clinical indicators and treatments that are useful in patients with headache. These questions were then categorized and ranked during the second, third, and fourth rounds. Consensual agreement was set at ≥ 80%.

RESULTS

After the final round, 9 interventions were rated as useful by the participants. In the final extra round, 14 clinical indicators were retrieved as important to decide whether or not to start one of the consensual treatments. The top 3 management strategies were (1) upper cervical spine mobilisations in cervivogenic headache, (2) active mobilisation exercises of the cervical spine in cervivogenic headache, and (3) lifestyle advice in tension-type headache and migraine.

CONCLUSION

International experts agreed that most scientifically established effective treatments are useful in cervicogenic headache. Consensual agreement on treatments for migraine and tension-type headache were only reached for specific treatments. Their recommendations provide a framework for further research and the clinical management of headache.

Muscle endurance and cervical electromyographic activity during submaximal efforts in women with and without migraine

BACKGROUND

Despite previous reports supporting cervical muscle weakness and altered motor control in migraine, the endurance under standardized submaximal loads has not been investigated. Therefore, this study aimed to assess the endurance and muscle activity of the cervical musculature during submaximal isometric contractions in women with migraine and those without headache.

METHODS

Cervical muscle endurance tests were performed for flexors and extensors at 25%, 50%, and 75% of the output force during maximal isometric contraction using the Multi-Cervical Rehabilitation Unit with customized biofeedback. Initial values and relative rates of changes in root mean square and median frequency were calculated using cervical muscle superficial electromyography.

FINDINGS

Women with chronic migraine presented significantly shorter flexor endurance time in all load tests than controls (25%, P = .001, 50%, P = .005; 75%, P = .013), while episodic migraine only differed from controls at 75% (P = .018). The frequency of neck pain and/or pain referred to the head after the endurance test was up 12% in the control group, 40% in the episodic migraine group and 68% of the chronic migraine group. Few differences between groups were observed in the electromyographic variables and none of them was related to a worse performance in the endurance tests.

INTERPRETATION

Cervical flexor endurance was reduced in women with chronic migraine when independent of the load, whereas it was reduced to 75% of the maximal force in those with episodic migraine. No difference in the electromyographic variables could be related to this reduced flexor endurance. Also, no differences were detected in extensors endurance.

The intersection of COVID-19, school, and headaches: Problems and solutions

OBJECTIVE

To equip clinicians with recommendations specific to concerns related to the novel coronavirus disease 2019 (COVID-19), which impact the physical, emotional, and social health of youth with headache disorders.

BACKGROUND

COVID-19 has affected societies on a global scale including children and youth with chronic headache disorders. Many concerns are predicted to arise in the 2020-2021 school year, whether classes are conducted in-person or virtually.

METHODS

Clinical impressions were combined with a review of the literature, although limited due to the recent nature of this issue.

RESULTS

We describe recommendations to support caregivers and youth as they face changes expected with the return to school in the fall of 2020.

CONCLUSION

Although there are significant concerns for caregivers and youth with migraine given the context of changes related to the pandemic, there are many recommendations that can help minimize exacerbations of the physical, emotional, and social health of youth with chronic migraine.

Muscle endurance training of the neck triggers migraine attacks

BACKGROUND

Most migraine patients report neck pain as part of their migraine symptomatology, but it is unknown whether triggering neck pain would induce migraine attacks. Our aim was to assess the occurrence of headache and/or neck pain after an endurance test of the neck muscles among migraineurs and controls.

METHODS

Sixty-five patients with migraine and 32 headache-free participants underwent a manual examination of the cervical spine by an assessor blinded towards the diagnosis and were sub-classified according to the appearance or absence of neck pain. Subsequently, the endurance of the neck flexors and extensors was tested three times, in a random order. The maximum sustained duration was recorded and the test was terminated when the subject was unable to maintain the position or reported pain. On the day after the assessment, participants were asked to report the potential occurrence of headache or neck symptoms.

RESULTS

None of the controls reported headache after assessment, while migraine-like headache was reported by 42% of the patients with migraine (p < 0.001) after 15.8 h (SD: 10.0). Neck pain was more prevalent in migraineurs compared to controls (45% vs. 16%, p = 0.006). When considering the neck pain subtype, there were no differences among the three profiles regarding neck pain but participants with referred pain to the head reported a migraine attack more often (45%, p = 0.03).

CONCLUSION

Patients with migraine are more likely to report neck pain and migraine attacks following a neck muscle endurance test. Participants with neck pain referred to the head during manual examination had a greater prevalence of migraine attacks than those without or with only local pain.

Predicting the outcome of the greater occipital nerve block - an observational study on migraine patients with and without musculoskeletal cervical impairment

BACKGROUND AND OBJECTIVE

The importance of neck pain and the trigeminocervical complex in migraine is of high pathophysiological interest since a block to the greater occipital nerve is more effective for some primary headaches than others. This observational study hypothesised that the response to manual palpation of the upper cervical spine predicts the efficacy of the greater occipital nerve-block.

METHODS

We divided patients, scheduled by a neurologist to receive a greater occipital nerve-block to reduce their migraine symptoms, into three groups: Patients with no pain response to manual palpation of the neck, patients with local pain, and those with referred pain to the head. Primary outcome was the percentage change in headache frequency. Additionally, items from the quantitative sensory testing protocol were included.

RESULTS

Eighty-seven chronic migraine patients were recruited consecutively from a specialised outpatient clinic and 71 were included for analyses and stratified into the three groups: No pain (n = 11), local pain (n = 28), and referred pain to the head (n = 32). Overall, patients experienced a reduction of 1.9 headache days per month (SD 3.4, p < 0,0001). The groups differed significantly in the percentage change of headache frequency (p = 0.041) with the "no pain" group showing the largest reduction. The pressure-pain-threshold over C2 and headache on the day of the intervention influenced the outcome significantly (R² 0,27, p = 0,00078). No serious adverse events occurred. Sixty-five percent of the patients had headaches during the examination. The groups did not differ regarding the distribution of patients with neck-pain in absence of migraine at baseline (p = 0.618).

CONCLUSION

Patients that were less sensitive to palpation in the cervical region and headache-free on the day of the intervention improved more after the greater occipital nerve-block.Registration: Registered a priori at the German Clinical Trials Register (DRKS00015995).

Clinical Reasoning Behind Non-Pharmacological Interventions for the Management of Headaches: A Narrative Literature Review

Headache is the clinical syndrome most commonly observed by neurologists in daily practice. Pharmacological and non-pharmacological treatments are commonly used for the management of headaches; however, the clinical reasoning behind these interventions is not properly applied. We conducted a narrative literature review using as data sources for academic PubMed, MEDLINE, EMBASE, AMED, CINAHL, EBSCO, PEDro, Cochrane Database of Systematic Reviews, Cochrane Collaboration Trials Register, and SCOPUS. This narrative literature review mainly considered systematic reviews, meta-analyses, randomised clinical trials, and expert opinions published after the year 2000 discussing clinical reasoning for application of non-pharmacological interventions in individuals with tension-type, migraine, and cervicogenic headaches. After the data extraction, we organized the literature thematically as follows: (1) mapping of theoretical aspects of non-pharmacological interventions; (2) summarizing most updated literature about effectiveness of non-pharmacological interventions grouped by targeted tissue and headache; (3) identifying research gaps in the existing literature and proposing hypotheses for better understanding of current clinical reasoning. We found that there are many non-pharmacological treatment strategies used for headaches, including beyond the tissue-based impairment treatments (bottom-up) and strategies targeting the central nervous system (top down). Bottom-up strategies include joint-biased, soft-tissue biased, or needling interventions, whereas top-down strategies include exercise and cognitive interventions. Evidence shows that the effectiveness of these interventions depends on the application of proper clinical reasoning, since not all strategies are effective for all headaches. For instance, evidence of non-pharmacological interventions is more controversial for migraines than for tension-type or cervicogenic headaches, since migraine pathogenesis involves activation of sub-cortical structures and the trigemino- vascular system, whereas pathogenesis of tension-type or cervicogenic headaches is most associated to musculoskeletal impairments of the cervical spine. We conclude that current literature suggests that not all non-pharmacological interventions are effective for all headaches, and that multimodal, not isolated, approaches seem to be more effective for patients with headaches. Most published studies have reported small clinical effects in the short term. This narrative literature review provides some hypotheses for discrepancies in the available literature and future research. Clinical reasoning should be applied to better understand the effects of non-pharmacological interventions.

Involvement of cervical disability in migraine: a literature review

Background

The trigeminal nerve theory has been proposed as a pathophysiological mechanism of migraine; however, its association with the triggers of migraine remains unclear. Cervical disability such as neck pain and restricted cervical rotation, have been associated with not only cervicogenic headaches but also migraine. The presence of cervical disability could worsen of the migraine, and also the response to pharmacologic treatment may be reduced. The aim in this review is to highlight the involvement of cervical disability in migraine, considering contributing factors.

Findings

In recent years, evidence of neck pain complaints in migraine has been increasing. In addition, there is some recent evidence of cervical musculoskeletal impairments in migraine, as detected by physical assessment. However, the main question of whether neck pain or an associated cervical disability can act as an initial factor leading to migraine attacks still remains. Daily life imposes heavy loads on cervical structures (i.e. muscles, joints and ligaments), for instance, in the forward head position. The repetitive nociceptive stimulation initiating those cervical skeletal muscle positions may amplify the susceptibility to central migraine and contribute to chronicity via the trigeminal cervical complex.

Conclusion

Further studies are needed to explain the association between cervical disability as a source of pain and the development of migraine. However, evidence suggests that cervical disability needs to be considered in the prevention and treatment of migraine.

Fluctuations in local and widespread mechanical sensitivity throughout the migraine cycle: a prospective longitudinal study

BACKGROUND

People with migraine have localised (i.e., cephalic) mechanical sensitivity. There is uncertainty regarding widespread (i.e., extra-cephalic) mechanical sensitivity and variations in mechanical sensitivity throughout the migraine cycle. Therefore, this study aimed (1) to comprehensively assess mechanical sensitivity in both cephalic and extra-cephalic regions during the preictal, ictal, postictal and interictal phases; and (2) to compare these findings with mechanical sensitivity at corresponding time-points and locations in healthy participants.

METHODS

According to sample size calculations, 19 people with migraine and 19 matched healthy volunteers participated in a prospective longitudinal study. Pressure pain thresholds were evaluated in three cephalic regions (temporalis, upper trapezius and C1 paraspinal muscles) and two extra-cephalic regions (extensor carpi radialis and tibialis anterior muscle) with a digital algometer during the four phases of the migraine cycle in people with migraine and at corresponding intervals and locations in healthy participants. Linear mixed model analyses with a random intercept were used.

RESULTS

People with migraine had increased mechanical sensitivity in cephalic and extra-cephalic regions in all phases of the migraine cycle compared to healthy participants. Furthermore, this mechanical sensitivity was more severe in the preictal, ictal and postictal phase compared to the interictal phase in cephalic and extra-cephalic regions.

CONCLUSION

People with migraine have localised as well as widespread mechanical sensitivity compared to healthy participants. This sensitivity is even more pronounced immediately before, during and after a migraine attack.

Physical therapy and migraine: musculoskeletal and balance dysfunctions and their relevance for clinical practice

BACKGROUND

Migraine is a primary headache with high levels of associated disability that can be related to a variety of symptoms and comorbidities. The role of physical therapy in the management of migraine is largely unknown. Therefore, the aim of this review is to highlight and critically discuss the current literature and evidence for physical therapy interventions in individuals with migraines.

METHODS

A narrative review of the literature was performed.

RESULTS

Physical therapists assessing and treating patients with migraine should focus on two primary aspects: (1) musculoskeletal dysfunctions, and (2) vestibular symptoms/postural control impairment. Signs and symptoms of musculoskeletal and/or vestibular dysfunctions are prevalent among individuals with migraines and different disability levels can be observed depending on the presence of aura or increment of the migraine attacks.

CONCLUSION

A proper physical examination and interview of the patients will lead to a tailored treatment plan. The primary aim regarding musculoskeletal dysfunctions is to reduce pain and sensitization, and physical therapy interventions may include a combination of manual therapy, exercise therapy, and education. The aim regarding postural control impairment is to optimize function and reduce vestibular symptoms, and interventions should include balance exercises and vestibular rehabilitation. However, consistent evidence of benefits is still lacking due to the lack of and therefore need for tailored and pragmatic clinical trials with high methodological quality.

Can physical testing be used to distinguish between migraine and cervicogenic headache sufferers? A protocol for a systematic review

INTRODUCTION

Differential diagnosis of migraine and cervicogenic headache (CGH) can be challenging given the large overlap of symptoms, commonly leading to misdiagnosis and ineffective treatment. In order to strengthen the differential diagnosis of headache, previous studies have evaluated the utility of physical tests to examine for musculoskeletal impairment, mainly in the cervical spine, which could be provoking or triggering headache. However, no systematic review has attempted to evaluate whether physical tests can differentiate CGH from migraine or both conditions from asymptomatic subjects.

METHODS/ANALYSIS

A systematic review protocol has been designed and is reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P). A sensitive topic-based search strategy is planned which will include databases, hand searching of key journals and consultation of relevant leading authors in this field. Terms and keywords will be selected after discussion and agreement. Two independent reviewers will perform the search and select studies according to inclusion and exclusion criteria, including any cohort or observational studies evaluating the topic of this review; a third reviewer will confirm accuracy. A narrative synthesis will be developed for all included studies and, if possible, a meta-analysis will be conducted. The overall quality of the evidence will be assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) checklist for diagnostic accuracy studies and the Downs and Black scale for those studies where the QUADAS-2 checklist cannot be applied.

ETHICS AND DISSEMINATION

Ethical approval is not required since no patient information will be collected. The results will provide a deeper understanding about the possibility of using physical tests to differentiate cervicogenic headache from migraine and from asymptomatic subjects, which has direct relevance for clinicians managing people with headache. The results will be published in a peer-reviewed journal and presented at scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42019135269.

Extensor/flexor ratio of neck muscle strength and electromyographic activity of individuals with migraine: a cross-sectional study

PURPOSE

Neck pain is considered a common characteristic of migraine attacks. The relationship between neck pain and migraine can be explained by central sensitization of the trigeminocervical complex, where superior cervical afferents and the trigeminal nerve converge. However, few studies have evaluated motor control of cervical muscles in individuals with migraine. Thus, the purpose of the present study was to determine the extensor/flexor ratio of neck muscle strength and electromyographic activity during a test of maximal voluntary isometric contraction and craniocervical flexion in individuals with migraine and individuals without history of migraine or other headaches.

METHODS

Fifty-two women with the disease and 52 women with neither a history of migraine nor neck pain, between 18 and 55 years old, were included in the study. The electromyographic activities of the sternocleidomastoid, anterior scalene, splenius capitis, and upper trapezius muscles were evaluated during a test of maximal voluntary isometric contraction and craniocervical flexion.

RESULTS

The migraine group presented lower flexor muscle strength and a higher extensor/flexor muscle strength ratio than the control group. In addition, the migraine group showed a reduced electromyographic extensor/flexor muscle ratio during maximal voluntary isometric contraction in flexion. The results demonstrated worse performance in the craniocervical flexion test of the migraine group and a lower electromyographic ratio of extensor/flexor neck muscles in the last stage of the test.

CONCLUSION

Altogether, the migraine group presented an imbalance in cervical muscles verified not only during force production, but also during muscle activity. These slides can be retrieved under Electronic Supplementary Material.

A Neuroscience Perspective of Physical Treatment of Headache and Neck Pain

The most prevalent primary headaches tension-type headache and migraine are frequently associated with neck pain. A wide variety of treatment options is available for people with headache and neck pain. Some of these interventions are recommended in guidelines on headache: self-management strategies, pharmacological and non-pharmacological interventions. Physical treatment is a frequently applied treatment for headache. Although this treatment for headache is predominantly targeted on the cervical spine, the neurophysiological background of this intervention remains unclear. Recent knowledge from neuroscience will enhance clinical reasoning in physical treatment of headache. Therefore, we summarize the neuro- anatomical and—physiological findings on headache and neck pain from experimental research in both animals and humans. Several neurophysiological models (referred pain, central sensitization) are proposed to understand the co-occurrence of headache and neck pain. This information can be of added value in understanding the use of physical treatment as a treatment option for patients with headache and neck pain.