The Role of Manual Therapy

in Headache Management
Alison Sentance
Headache Physiotherapy Practitioner
St Georges Healthcare NHS Trust
 Plan
• Define manual therapy
• Manual therapy to the upper cervical spine
• Manual therapy to the thoracic spine
• The role of a neutral posture
• Conservative treatment contribution to tension
type headache
• Contribution to management of migraine
 Manual Therapy
• Encompasses the treatment of health
ailments of various aetiologies through
‘hands on’ physical intervention.
• This form of physical treatment includes
soft tissue mobilisation, various soft tissue
techniques, myofascial release,
craniosacral techniques, mobilisation of
the joints, joint manipulation, neural tissue
mobilisation and visceral mobilisation
• Ref:Wickipedia
 Conservative management
includes:
• Manual therapy – to the joints
– Upper cervical spine
– Thoracic spine
• Myofascial treatment
• Postural correction and ergonomic advice
• Relaxation techniques
• Recognition of triggers
 C0-3
• Headache can arise from dysfunction in
the structures comprising C0-1,1-2 or 2-3.
• Joint dysfunction gives rise to a typical site
of symptoms for each level.
• Reproducing symptoms from any joint and
sustaining the pressure can help to relieve
symptoms.
C0-1 typical distribution
C1-2 typical distribution
C2-3 typical distribution
 We can palpate:
• The central – intervertebral – joint
• The facet joints
• Angle force cephalad or caudad to
implicate a specific level
• Add cervical spine rotation to implicate a
specific culprit level
• Palpate in prone or supine lying or sitting
• Extend palpation techniques to treatment
 Pathophysiology of headache
• The neuroanatomical basis for
cervicogenic headache is convergence in
the trigeminocervical nucleus (TCN) of
nococeptive afferents from the receptive
fields of cervical nerves 1-3 and from the
field of the trigeminal nerve
• There is failure of the CNS to differentiate
the source of pain and misinterpretation of
afferent information
 More Neurophysiology..
• Plus serotinergic inhibition of nociceptive
information in the TCN
• Acceptance of the continuum model rather
than separate headache forms
• A move to encompass the vascular theory
into the neuronal theory of abnormal
nociceptive processing in the TCN
 Why is this important?
• If the TCN is oversensitive and sensitised, any
means that lowers this hypersensitivity will result
in improvement in headache, what ever the
headache type, triggers and aetiology.
• Cady,R et al Primary Headaches: a Convergence
Hypothesis.Headache 2002 42 204-16
• Kaube,H et al Acute Migraine Headache. Possible
Sensitisation of Neurons in the Spinal Trigeminal
Nucleus? Neurology 2002 58 1234-1238
 Red Flags in Headache
• New onset of new headache in middle age
or significant change to existing headache
• Constant, unremitting headache
• Headache associated with pyrexia,
vomiting not explained by systemic
disease eg ‘flu
• Recent headache following trauma
 More red flags
• New headache with distal spinal pain
• New headache with a family history of
vascular anomalies
• New headache with a past history of
malignancy
• New onset of migrainous headache in
pregnancy
 Differential diagnosis
• Subarachnoid
haemorrhage
• Cerebral metastasis
• Intracranial tumour
• Hypertension (BIH)
• Temporal arteritis
 Headache SNAG
• Sustained natural apophyseal glide
• Directed towards C1-2 dysfunction
• Patient must be experiencing symptoms at
the time of treatment
• Symptoms must be reduced immediately
for technique to be effective
• Patient can learn to self apply technique
Treatment of the Thoracic spine
• Generally higher levels hypomobile and
dysfunctional
• Can address the intervertebral, facet and
rib joints
• May be dysfunction in the autonomic
nervous system that can be improved by
spinal mobilisation
• Aim to restore upper thoracic mobility and
a neutral thoracic kyphosis in sitting
Neutral Posture
 Aim to
• Give patients an awareness of
sitting/standing in a neutral posture
• Explain why they should aspire to this
• Teach them the means by which they can
achieve this
• Encourage and motivate for at least 3
months
 Cranio cervical flexor training
• Evidence shows that low load endurance
exercises can retrain muscle control of the
cervicoscapular and craniocervical
regions.
• This addresses the impairment in the neck
flexor synergy found in headache
originating in the cervical spine and in
tension type headache.
 Deep Neck Flexor retraining
• Start in lying, teach carefully, small
amplitude movement

• Avoid overuse of Sternocleidomastoid and

other substitution strategies
• Progress to training in weight bearing,
more functional positions
 Evidence for CCF retraining
• Non invasive physical treatments for
chronic/recurrent headache
• G Bronfort, N Nilsson, R Evans, Ch Goldsmith, WJJ Assendelft, LM Boulter
• Cochrane Database of Systematic Reviews 2007 Issue 1

• For cervicogenic headache, there is

evidence that both low intensity endurance
training and spinal manipulation are
effective in the short and long term
 Cephalalgia Vol 26 Page 983 August 2006
H van Ettekoven & C Lucas

• Efficacy of physiotherapy including a

craniocervical training programme for
tension type headache: a randomised
clinical trial
• At 6 months follow up, the CCF training
group showed significantly reduced
headache frequency, intensity & duration.
 Role in management of TTH
• Myogenic rehabilitation
• Postural advice
• Stress management advice
• Advocating relaxation techniques –
• Visualisation
• Contract relax techniques
• yoga / pilates
 Evaluating muscle lengths
• Look at :
• Upper Trapezius
• Levator scapulae
• Scalenes
• Relative strength of Lower Trapezius, Pec
major > minor
 Techniques include
• Self stretches
• Muscle energy techniques
• Trigger point treatment
• Scapular myofascial rehabilitation
 Upper Trapezius
• Stretch by anchoring arm
• Contralateral side flexion
• Hold 15-30 seconds
• Maintain a neutral posture
 Scalenes
• Anterior – contralateral side flexion plus
ipsilateral rotation
• Middle – contralateral side flexion only
• Posterior – contralateral side flexion plus
contralateral rotation
 Levator scapulae
• Evaluate length and teach patient to
stretch by adding
• Neck flexion to
• Contralateral rotation
 Contribution to management of
migraine
• Discussion of relevant triggers
• Stress management
• Role of cardio – vascular fitness and
importance of exercise
• Must be tailored to patients lifestyle and
capability
 Common Migraine Triggers
• Stress or tension
• Dietary – alcohol, caffeine, dairy, citrus
• Hormonal variations – in women
• Sleeping pattern
• Visual factors – harsh strip lights, flickering
• Head or neck pain
 In summary
• This is a fascinating clinical area
• Consider treating headache patients who
don’t appear to have a frank
musculoskeletal cervical component
• Be aware of cervical arterial dysfunction
 Thank you
• Any questions?
• Useful websites;
• www.bash.org.uk
• www.migrainetrust.org.uk
• www.ouchuk.org
• www.worldheadachealliance.org
• www.i-h-s.org
 References
• Recruitment of Deep Cervical Flexor
Muscles During a Postural Correction
Exercise Performed in Sitting Falla,D et al
Man Ther 12(07) 139-143
• Management of Cervicogenic Headache
Jull,G Man Ther 1997 2(4) 182-190
 References
• Cervical Arterial Dysfunction Assessment and Manual Therapy
Kerry,R & Taylor A Man Ther 11 2006 243-253
• Muscle Specificity in Tests of Cervical Flexor Muscle Performance
O’Leary,S et al J Electromyography & Kinesiology Feb 07 Vol 17
Issue 1 35-40
• Specificity in Retraining Craniocervical Muscle Performance
O’Leary,S J Orth Sports Phys Ther Vol 37 No1 Jan 2007 3-9
• Craniocervical Muscle Impairment at Maximal, Moderate and Low
Loads as a Feature of Neck Pain O’Leary,S et al Man Ther 12 2007
34-39
• Myofascial Trigger Points in Subjects Presenting with Mechanical
Neck Pain – a Blinded, Controlled Study. Fernandez-de-las-penas,F
et al Man Ther 12 2007 29-33
• Myofascial Trigger Points in Suboccipital Muscles in Episodic
Tension Type Headache. Fernandez-de-las-penas,C et al Man Ther
11 2006 225-230
 References
• Abstract 2816 Special Interest Report Platform
Presentation No 2816 Physio 2007 93 (51)
• Cervicotrigeminal Pain – Mechanisms and
Management. Valori,A BASH Newsletter Vol1
Issue3 4-5
• Clinical Tests of Musculoskeletal Dysfunction in
the Diagnosis of Cervicogenic Headache. Zito,G
et al Man Ther 11 2006 118-129