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Physical therapy intervention for cervicogenic headache: an overview of

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 European Journal of Physiotherapy

ISSN: 2167-9169 (Print) 2167-9177 (Online) Journal homepage: https://www.tandfonline.com/loi/iejp20

Physical therapy intervention for cervicogenic

headache: an overview of systematic reviews

Monika Rani, Sivachidambaram Kulandaivelan, Arpit Bansal & Alka Pawalia

To cite this article: Monika Rani, Sivachidambaram Kulandaivelan, Arpit Bansal & Alka Pawalia
(2019): Physical therapy intervention for cervicogenic headache: an overview of systematic
reviews, European Journal of Physiotherapy, DOI: 10.1080/21679169.2018.1523460

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EUROPEAN JOURNAL OF PHYSIOTHERAPY
https://doi.org/10.1080/21679169.2018.1523460

REVIEW ARTICLE

Physical therapy intervention for cervicogenic headache: an overview of

systematic reviews
Monika Rania, Sivachidambaram Kulandaivelana, Arpit Bansalb and Alka Pawaliaa
a
Department of Physiotherapy, Guru Jambheshwar University of Science and Technology, Hisar, India; bDepartment of Physiotherapy, Asha
School, Military Station, Hisar, India

ABSTRACT ARTICLE HISTORY

Background and Objective: There are many systematic reviews that investigate the effectiveness of Received 7 June 2018
physical therapy (PT) interventions on cervicogenic headache (CGH) with inconclusive findings which Revised 29 August 2018
is because of either the quantity or quality of the included studies. Thus the aim of this overview was Accepted 8 September 2018
to evaluate the evidence of various PT interventions on CGH from relevant systematic reviews.
KEYWORDS
Methods: We included systematic reviews based entirely on randomised controlled trials (RCTs) that Cervicogenic headache;
were concerned with PT interventions and CGH. They were selected from PubMed and Web of manipulation; manual
Science databases in December, 2017. Quality of reviews was checked by Assessment of Multiple therapy; pain; occipital
Systematic Reviews criteria (AMSTAR). Conclusions were generated from a narrative synthesis based on
conclusions from reviews as well as individual original RCTs.
Results: Six systematic reviews (34 RCTs) were selected for this overview. Overall, the methodological
quality was moderate to high. Evidence from reviews says that spinal manipulation therapy (n ¼ 4), mobil-
isation (n ¼ 2) and other conservative PT management (n ¼ 2) were effective in the management of CGH.
Conclusion: Based on six moderate to high quality systematic reviews, it can be concluded that PT
management particularly manipulation and mobilisation are effective in reducing pain and functional
disability in patients having CGH.

Abbreviations: AMSTAR: Assessment of Multiple Systematic Reviews criteria; CGH: cervicogenic head-
ache; PAVM: posteroanterior vertebral mobilization; PEDro: physiotherapy evidence database; PT: phys-
ical therapy; RCTs: randomised controlled trials; SMT: spinal manipulation therapy; SNAG: sustained
natural apophyseal glide; TMJ: temporomandibular joint

Introduction [5]. Among all headaches, CGH prevalence ranged between

Cervicogenic headache (CGH) is a type of pain originating
from cervical (neck) region. It disables people and diverts
them from their normal daily activities including work. So it
has to be managed at early stage. The term CGH was first
introduced in 1983 [1]. About 97% of patients with CGH
have pain starting from neck and occipital region [2]. The
common clinical presentation of a CGH patient is dull ache
pain or tightening/pressing headache sensation in occipital
region [3]. International headache society (IHS) has classified
the different headache types in which some are similar to
CGH (i.e. tension type headache and migraine) [4]. The fea-
tures which distinguish the CGH from other headaches are
side locking pain, pain aggravated on applying pressure on
neck muscles and movement of head [4]. In CGH, pain radi-
ates from posterior to anterior part of head. Some of the
migrainous features such as nausea, photophobia/phonopho-
bia, vomiting etc. might also be present, but these are pre-
sent at a lesser extent as compared to migraine [4].
Headache/migraine is most common condition which
ranked 15th in terms of disability adjusted life year in 2016
4.1% and 21.4% (21.4% in 2017, 21% in 2013, 4.1–4.8% in
2008) in general population [2,3,6]. Seven percent of patients
present with pain on one side (unilateral) of head and face
out of overall prevalence [7]. In India, CGH accounts for
15.6% of population suffering from all types of headaches
[8]. CGH could create heavy economic burden on individual
as well as the society as a whole due to functional limita-
tions caused by CGH to the individual which leads to signifi-
cant disability.
Although there is pharmacological management for CGH,
patients are often not satisfied with conventional medical
therapy approaches and turn to complementary therapies,
among which physical therapy (PT) is one of the most popu-
lar option. There are many PT approaches such as manipula-
tion, mobilisation and exercises which are used for treating
CGH pain. Literature search showed several RCTs reporting
the effect of these PT approaches on CGH. Many systematic
reviews analysed the effectiveness of PT interventions based
on these RCTs. However, they have contradictory conclusions
and their conclusion was limited by the quality of the

CONTACT Monika Rani monikarani802@gmail.com Department of Physiotherapy, Guru Jambheshwar University of Science & Technology, Hisar 125001,
Haryana, India
Supplemental data for this article can be accessed here.
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
2 M. RANI ET AL.
included studies. Thus, synthesis of existing reviews would
provide a better interpretation of study area by overcoming
limitations from a single review, allowing for the systematic
assessment of current evidence, along with strengths and
limitations of existing systematic reviews.
In health care literature “overview” becomes a new
approach for evidence synthesis [9]. It has particular rele-
vance for reporting of areas which have overlapping reviews
such as manipulation, manual therapy (mobilisation), PT etc.
Though, systematic reviews are a gold standard for reporting
evidence based research, they lack in reporting comparative
data from different domains such as combined treatment
approaches, various conditions, their outcomes and popula-
tions etc [9,10].
Methods
Searching strategy
Two electronic databases, PubMed and Web of Science, were
used to search review articles starting from the beginning till
the date of search (i.e.) May 2018. The search strategies used
in both databases were same. Cervicogenic headache [Title/
Abstract] AND ((physical therapy[Title/Abstract] OR
physiotherapy[Title/Abstract]) OR manual therapy[Title/
Abstract]). Limits or filters were used in order to obtain sys-
tematic reviews. The number of articles found at each stage
is enlisted in Table 1 for both Pubmed and Web of Science.
Selection criteria
Two reviewers (MR and AP) screened the articles independ-
ently from these two databases. After removing the dupli-
cates, they screened the articles by their title and abstract.
Only those full-text studies were selected in which PT was
used to treat CGH. Systematic reviews were selected as per
the predefined inclusion and exclusion criteria as listed
below. Inclusion criteria: Only those systematic reviews were
included which were in English language, based solely on
RCTs that evaluated the effectiveness of PT interventions
with control or sham intervention (e.g. low level laser
Table 1. Searching strategy.
Search steps Query (PubMed) Items found (PubMed)
#1 Search cervicogenic
headache[Title/Abstract]
#2 Search ((physiotherapy[Title/Abstract])
OR physical therapy[Title/Abstract])
OR manual therapy[Title/Abstract]
#3 Search (cervicogenic headache[Title/
Abstract]) AND
(((physiotherapy[Title/Abstract]) OR
physical therapy[Title/Abstract]) OR
manual therapy[Title/Abstract])
#4 Search (((cervicogenic headache[Title/
Abstract]) AND
(((physiotherapy[Title/Abstract]) OR
physical therapy[Title/Abstract]) OR
manual therapy[Title/Abstract])))
AND review[Filter]
therapy, light massage, stimulated trigger point therapy) or
other PT interventions in CGH. Systematic reviews must have
measured pain as an outcome measure. Exclusion criteria:
Non-systematic reviews; reviews in which PT treatment was
not used; reviews that included case reports were excluded.
The strength of selection of eligible studies was expressed
by Cohen’s kappa coefficient [11] and if there was any dis-
agreement, third reviewer (SK) resolved that. After applying
the inclusion and exclusion criteria, there was a main dis-
agreement between two authors about the number of
included studies [one author (AP) wanted to include articles
that were purely on CGH (n ¼ 3); another author (MR) wanted
to include articles that were based on other headaches
including CGH (n ¼ 6)]. This disagreement was resolved by a
third reviewer who decided to include articles that were
based on other headache types, but only the results of RCTs
that were on CGH were used to draw final conclusion.
Data extraction
Data were independently extracted by two reviewers (MR
and AP) from the included reviews by using a spreadsheet to
record descriptive characteristics (author, year, country, num-
ber of studies included), outcome measures used, type of PT
interventions used and conclusion of study.
Quality assessment
Assessment of multiple systematic reviews (AMSTAR) criteria
was used to assess the quality of included systematic
reviews, which is a valid instrument having good construct
validity and reliability [12]. It comprises of 11 items, scored
as ‘yes’, ‘no’, ‘cannot answer’ or ‘not applicable’ as in the
checklist. Two authors MR and AB independently rated the
methodological quality by calculating the overall score for all
included reviews by adding one point for ‘yes’. Agreement
level between two reviewers was measured by Kappa index.
For poor agreement kappa index was less than 0.4, for fair
agreement it was 0.4–0.75 and for excellent agreement it
was over 0.75 [13].
Items found
Query (Web of Science) (Web of Science)
498 Search (cervicogenic headache) AND 2863
(physical therapy) OR (physiother-
apy) OR (manual therapy)
34,284 Refine Search Book Review 167
67 Subject cervicogenic Headache 34
32

We considered the review as low quality if the total score
was four or lower, moderate quality if the score was between
5 and 7, high quality if the score was 8 or higher [14].
Data synthesis
A full synthesis of the findings was compiled to draw conclu-
sion—(i.e.) checking for their methodological quality, out-
comes and total number of systematic reviews reporting
consistent results. Individual RCTs results were also used to
form the final conclusion.
Result
Selection of systematic review
Our search strategy identified 66 reviews out of which five
were duplicates; thus making it to be 61 at stage I. Forty-five
reviews were discarded by screening titles at stage II.
Remaining 16 reviews with full-text were examined and
finally 6 were selected at stage III. Ten reviews were
excluded with following reason: eight were non-systematic
reviews, one used case reports, one did not use PT interven-
tions. Figure 1 schematically shows the flow diagram for lit-
erature search. A detailed description of the excluded studies
is listed in Appendix 1 (Supplementary file).
Figure 1. Flow diagram of literature search.
EUROPEAN JOURNAL OF PHYSIOTHERAPY 3
Characteristics of included reviews
Table 2 shows the main characteristic features of the
included systematic reviews. Three out of six reviews were
purely on CGH [15–17]. One review was based on two types
of headache i.e. CGH and tension type headache [18];
another two based on three types of headache i.e. CGH, ten-
sion type headache and migraine [19,20].
All the included reviews were published between 1999
and 2016. They were originated from five countries (i.e.) USA,
Germany, Norway, Canada and UK.
Outcome measures details
Pain was used as a primary outcome measures in all six
included reviews. In one study, functional disability and
neck pain was used as a secondary outcome measure.
Among all six included reviews, pain intensity was used to
measure findings in four reviews [15–17,19]; headache fre-
quency was used in five reviews [15–19] and duration of
headache was noted in three reviews [16,17,19]. Headache
index was used to measure pain in two reviews [18,20];
severity of headache and medication use were measured in
one review [18]; one review reported neck pain intensity
and disability [16].
4 M. RANI ET AL.

Table 2. Main characteristics of systematic reviews.

Reported result
Author No of RCTs Pain Functional
(year) Country included (patients) Outcome measures Intervention compared relief disability Author conclusion/comments
Garcia et al. 10 (685) Pain intensity SMT or mobilisation com- þ NR Mobilisation and manipula-
[15] USA and frequency pare to placebo, no tion of cervical spine may
treatment or control be beneficial for patients
having other physio- having CGH but hetero-
therapy interventio- geneity of study make
n(eg electrotherapy, difficulty to find
soft tissue therapy, the conclusion
light massage)
Luedtke et al. Out of 26, Pain, intensity, Physiotherapy interven- þ NR Manual therapy resulted in
[16] Germany 7 on CGH frequency and tion compare to pla- reduction in intensity, fre-
duration cebo or other physical quency and duration
therapy interventions. of CGH
Racicki et al. 6 (457) Pain, function SMT or mobilisation com- þ þ Conservative physical ther-
[17] USA disability pare to placebo, no apy intervention are
treatment or control effective for CGH but
having other physio- mobilisation and manipu-
therapy intervention lation alone do not show
(eg electrotherapy, soft significant result but com-
tissue therapy, bination of manipulation,
light massage) mobilisation and cervico
scapular strengthening
exercises was most effect-
ive for treating CGH
Chiabi et al. 7 (492) Headache intensity, SMT compared with con- þ NR Physiotherapy and SMT
[18] Norway frequency, duration trol group might be an effective
treatment for CGH
Astin et al. [19] UK Out of 8, Headache Index SMT compared with pla- þ NR Manipulation is effective in
1 on CGH cebo having soft tis- treating CGH
sue massage
Vernon et al. Out of 24, Headache index, SMT compare with con- þ NR Manipulation is effective in
[20] Canada 2 on CGH severity, frequency trol having soft tis- treating CGH
sue technique
CGH: cervicogenic headache; þ: more effective than; NR: not reported; SMT: spinal manipulation therapy.

Table 3. Methodological quality assessment of systematic reviews (AMSTAR).

Author (year) 1 2 3 4 5 6 7 8 9 10 11 Total
Garcid et al. [15] N N Y Y N Y Y N N N N 4
Luedtk et al. [16] N Y Y Y N Y Y Y Y Y Y 9
Racicki et al. [17] N Y Y Y Y Y Y Y Y N N 8
Chiabi et al. [18] N N Y Y N Y Y Y N N Y 6
Astin et al. [19] N Y Y Y N Y Y N N N N 5
Vernon et al. [20] N Y Y Y N Y Y Y N N N 6
Score 0 4 6 6 1 6 6 4 2 1 2 Mean ¼ 6.33
(1) Was an ‘a priori’ design provided? (2) Was there duplicate study selection and data abstraction? (3) Was a comprehensive literature search performed? (4)
Was the status of publication (i.e. grey literature) used as inclusion criteria? (5) Was a list of studies (included and excluded) provided? (6) Were the characteris-
tics of the included studies provided? (7) Was the scientific quality of the included studies assessed and documented? (8) Was the scientific quality of the
included studies used appropriately in formulating conclusions? (9) Were the methods used to combine the findings of studies appropriate? (10) Was the likeli-
hood of publication bias assessed? (11) Was the conflict of interests stated?.
Y: Yes; N: No; CA: cannot answer; NA: not applicable.

Intervention detail
Among all six included reviews, four reviews compared the
effect of cervical spine manipulation over control or sham
treatment [15,17,18,20]; two reviews compared the effect of
conservative PT intervention over control [16,19] and one
review compared the effect of both cervical spine mobilisa-
tion and manipulation [15].
Methodological quality detail
Out of the six included reviews, only four reported quality
control over selected RCTs. PEDro score [16], Jadad Scale
[20], criteria list of methodological quality assessment of
RCTs [17] and quality review protocol [18] were used as
quality control check over included RCTs. Two reviews does
not report any kind of quality checking in their
review [15,19].
Methodological quality assessed for
included reviews
Agreement of quality assessment of included systematic
reviews using AMSTAR was excellent (kappa index 1.0)
between two reviewers.
An overview of AMSTAR assessment result is shown in
Table 3. Overall score ranged from 4 to 9 out of possible 11
points. One review was of low quality [15], three of moderate
quality [17,18,20] and two of high quality [16,19]. Item 1 i.e. a
 EUROPEAN JOURNAL OF PHYSIOTHERAPY 5

Table 4. Intervention detail of RCTs included in original systematic reviews.

Systematic
review Repeated Experimental
Author (year) references number intervention Control intervention Result/conclusion
Von Piekartz et al. [21] 17,19 2 TMJ manipulation control Manipulation reduces head pain symptoms
Dunning et al. [22] 16 1 SMT mobilisation Manipulation was more effective than mobilisation
Khan et al. [23] 16 1 Mulligan SNAG PAVM mobilisation Mulligan SNAG shows better result
Shin and Lee [24] 16,17 2 Mulligan SNAG Placebo (control) SNAG shows improvement
Youssef and Shanb [25] 16,17 2 SMT Massage Spinal manipulation effective
Bodes-Pardo et al. [26] 17 1 Trigger point therapy Stimulate trigger Trigger point therapy shows improvement
point therapy
Borusiak et al. [27] 16,18,19 3 SMT Placebo (control) No significant difference found
Haas et al. [28] 16,18,19 3 SMT Placebo (control) SMT shows better improvement
Ylien et al. [29] 17 1 Strength training Aerobic training Strengthening exercise shows improvement
Hall et al. [30] 16,17,18 3 Mulligan self SNAG Placebo (control) SNAG shows better improvement
Hass et al. [31] 16,19 2 SMT Soft tissue therapy SMT shows improvement
Jull et al. [32] 16,17,18,19 4 SMT þ Mobilization þ Control Combination of manipulation, mobilisation and
Exercise exercise shows improvement
Nilsson et al. [33] 16,18,19,20,21 5 SMT Placebo (control) SMT shows improvement
Nilsson et al. [34] 16,18,19,21 4 SMT Placebo (control) No significant difference found
PAVM: posteroanterior vertebral mobilization; SMT: spinal manipulation therapy; SNAG: sustained natural apophyseal glide. 16: Garcia et al 2016; 17: Luedtke
et al 2015; 18: Racicki et al 2013; 19: Chiabi et al 2012; 20: Astin et al 2002; 21: Vernon et al 1999.

‘priori design’ requirement was not present in any of the six
included systematic reviews, whereas item 5, i.e. presenting a
list of included and excluded studies; item 9, i.e. the appropri-
ate method of meta analysis; item 10 i.e. assessment of publi-
cation bias and item 11, i.e. Was the conflict of interests
stated? were rarely present amongst six included reviews.
Synthesis of results
From included systematic reviews
Among all six included systematic reviews, four compared
the effect of spinal manipulative therapy and two compared
the effect of conservative PT management over other group
as follows:
Garcia et al. [15] in their low quality (AMSTAR score 4/11)
review concluded that manipulation improved symptoms
including pain intensity and frequency based on the results
of six out of seven included RCTs. There was heterogeneity
found in interventions used and outcome measured as well,
which makes it difficult to draw any conclusion from the
findings of this review.
Luedtke et al. [19] in their high-quality review (AMSTAR
score 9/11) concluded that PT interventions (manual therapy)
significantly reduce intensity, frequency and duration of
headache while the trigger point therapy too reduced the
intensity of CGH.
Racicki et al. [16] in their high quality (AMSTAR score 8/
11) review assessed the effectiveness of conservative PT
management on CGH. Four out of six studies reported
manipulative therapies like mobilisation, manipulation to be
effective in CGH while two did not report any clinical or stat-
istically significant findings. Based on effect size, conservative
PT technique were found to be effective treatment for CGH
and combination of cervical manipulation and mobilisation
along with exercise were most effective conservative inter-
vention for decreasing CGH intensity, frequency and
neck pain.
Chiabi et al. [17] in their review of moderate quality
(AMSTAR score 6/11) reported that both physiotherapy and
spinal manipulative therapy might be an effective treatment
in the management of CGH; but these results were difficult
to evaluate, because only one study included control group
that did not receive treatment. Most of RCTs included in this
review used participants with infrequent CGH.
Astin et al. [20] in their review of moderate quality
(AMSTAR score 5/11) showed that significant reduction in
headache hours and intensity by spinal manipulation when
compared to placebo group. Only one out of eight studies
was on CGH, which was treated by spinal manipulation.
Vernon et al. [18] in their review of moderate quality (6/
11) in which they included two studies on CGH. One study
showed spinal manipulation to be effective and other
showed no clinical significant improvement.
From included RCTs in the included systematic reviews
There were 34 RCTs found in all six included systematic
reviews. Among them, 14 RCTs were repeated in the six
included systematic reviews. Hence, for better understanding
of these RCTs and their results, specific characteristics of
these RCTs are listed in Table 4. Eight out of 14 used spinal
manipulation for treating CGH [21–28]. Out of these eight
RCTs, six showed significant improvement [21–23,25–27]
while two showed statistically non significant results [24,28].
Out of eight RCTs, one compared the effect of mobilisation
with manipulation that showed manipulation more effective
than mobilisation [22]. Three RCTs (3/14) used spinal mobil-
isation for treating CGH and all showed significant improve-
ment in favour of mobilisation group [29–31]. One RCT out
of 14 used trigger point therapy and showed improvement
in favour of experimental group [32] while another RCT used
exercises specifically strength training and showed exercises
to be more effective [33]. Another RCT concluded that com-
bination of manipulation, mobilisation and exercise are more
effective than any of these given alone [34].
Discussion
Main findings
The purpose of the present overview was to critically evalu-
ate the evidence from systematic reviews and to provide the
6 M. RANI ET AL.
summary of evidence concerning the effectiveness of PT
interventions on CGH. We overviewed six systematic reviews
and the findings are in favour of PT interventions. All
included reviews showed positive improvement in pain
reduction, frequency and duration of headaches. One review
also showed improvement in neck pain and disability along
with pain reduction. All six reviews showed that PT interven-
tion is an effective treatment approach for treating CGH in
terms of pain and disability. The quality range varies from
low to high. Five out of six reviews were of moderate-to-
high quality so overall quality of our review is moderate.
Two high quality reviews and one moderate quality review
showed that conservative PT treatment especially manipula-
tion and mobilisation are effective in treating CGH pain and
disability. Another two moderate quality and one low quality
study showed manipulation to be more effective in treating
CGH. The result RCTs included in six systematic reviews
showed that combination of manipulation, mobilisation and
exercise is an effective treatment for CGH. Among manipula-
tion and mobilisation, manipulation is found to be more
effective than mobilisation.
Hence, we conclude that PT interventions might be an
effective treatment approach for treating CGH. According to
current literature among all PT interventions, mobilisation
and manipulation are found to be the best treatment
approaches for CGH management with manipulation is more
effective than mobilisation.
The positive point of our overview is that there is homo-
geneity found in the outcome measure with all six reviews
used parameters of pain as a major outcome for CGH.
Heterogeneity was found in the study quality and interven-
tion used. Although most of the studies used manipulation
in their experimental group, other PT interventions like
mobilisation, trigger point therapy, exercises etc also used by
investigators albeit very less number of studies. This requires
a need for more studies on these PT approaches other than
manipulation for better representation and evaluation
between various PT treatments.
Internal validity of included studies
The methodological quality assessment of included system-
atic reviews revealed that out of six systematic reviews only
one was of low quality. Majority of included systematic
reviews were of moderate to high quality. The methodo-
logical quality of the 14 RCTs in the six included reviews is
reported to be high. Sensitivity analysis was not performed
for the low-quality review and we included that in this
review due to lack of enough research on PT intervention in
CGH management.
The clinical importance of this overview is that it has pro-
vided a comprehensive review of the conservative PT treat-
ment approaches for patients diagnosed with CGH.
Strength of this overview
We have made efforts to minimise the bias of study by fol-
lowing methods. (1) Independent reviewers searched and
selected the relevant literature (2) Independent reviewers
checked the quality of included systematic reviews. (3) The
conclusion is not only based on the collective systematic
reviews but also from the individual RCTs included in each
review. RCTs are included in this overview in order to show
better understanding of CGH treatment options.
Limitation of study
(1) Some of included studies based on other headache types
too. (2) Used one low quality study for drawing conclusion.
(3) Limited literature search to English language only. (4)
Used only two databases to search relevant literature.
Conclusion
Based on five moderate quality systematic reviews, we con-
clude that PT interventions are effective in CGH treatment.
Manipulation and mobilisation (particularly SNAG) are the
most effective treatment options among all available physical
therapy interventions. More research is needed on the other
physiotherapy interventions in the management of CGH.
Disclosure statement
No potential conflict of interest was reported by the authors.
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