How many and which type of patients did you enrol in the study?

Our study included 99 patients with cervicogenic headache (CGH), diagnosed as per the International Classification of Headache Disorders.

CGH is a non-throbbing, unilateral, side-locked headache that originates in the cervical spine and gradually spreads to the occipital, temporal and orbital areas.

The patients were aged 18–60 years with moderate to severe headache present for at least one year and clinical evidence of upper cervical spine dysfunction.

Patients with contraindications to manual therapy were excluded.

What were the primary and secondary outcome measures?

The primary outcome was headache frequency measured as headache days/month.

Secondary outcomes were headache- related parameters including headache intensity, headache duration, medication intake, disability and patient satisfaction as well as some parameters related to cervical musculoskeletal dysfunction including upper cervical rotation range of motion and pressure pain thresholds.

Outcome measures were collected at baseline and at four, 13 and 26 weeks.

What interventions were they randomised to?

Patients were randomised to either group exercise alone, Mulligan manual therapy (MMT) added to exercise or sham MMT added to exercise.

The exercise protocol comprised cervical flexion loading, scapular retraction and stretching of sternocleidomastoid, trapezius and scalene muscles as well as cervical active mobility in cardinal planes.

MMT is a pragmatic symptom-modification approach.

Sustained pressure is applied to selected vertebrae of the upper cervical spine to modify or eliminate the headache.

In addition to MMT or sham MMT, patients performed an unsupervised home exercise program similar to that undertaken by the exercise-only group.

What was the effect of adding MMT to exercise on the primary outcome?

Professor Kiran Satpute

All three groups showed a reduction in headache frequency in patients with CGH.

However, patients who received the additional MMT reported that their headache frequency was reduced by two days per month more than those who received only exercise and three days per month more than those given sham MMT.

This additional reduction in headache frequency was maintained for at least 26 weeks.

Did any secondary outcomes also show benefits from adding MMT to exercise?

All secondary outcomes demonstrated benefits at all time points favouring the addition of MMT to exercise.

The improvements were observed for headache-related parameters as well as for parameters related to cervical dysfunction, with the exception of pressure pain thresholds measured at the upper trapezius muscle area.

MMT plus exercise was more clinically beneficial in reducing headache intensity than exercise only or exercise and sham MMT, by an additional 2.1 and 2.4 points respectively.

Patients who received MMT reported that their headache-related disability was reduced by four points more compared to the other two groups and this effect was eight and seven points more compared with the sham MMT and exercise groups at the 26-week follow-up.

With the application of MMT and exercise, headache duration and medication intake were reduced more compared with exercise alone or with the sham MMT procedure. No side effects were observed.

Did having three groups help you to distinguish whether the effects were due to placebo?

Comparison between exercise only and sham MMT with exercise helped to distinguish whether the effects were attributable to placebo.

The sham MMT with exercise intervention showed benefits similar to exercise alone, suggesting that these benefits were not due to placebo effects.

Where does research in this area need to go now?

Because headache disorders place a substantial economic burden on the person and, in turn, on society, further research should explore the cost-effectiveness of adding MMT to exercise compared to other forms of management.

Research could also focus on combinations of multimodal management in addition to MMT and exercise.

This may yield greater and more rapid improvement in CGH management, with long-lasting effects.

>> Kiran Satpute is a professor of physiotherapy at Maharashtra University of Health Sciences in Nashik, India. Kiran is a PhD scholar and has undertaken extensive postgraduate training in
manual therapy. He is also an accredited Mulligan Concept Teacher. Kiran’s research interest is in musculoskeletal physiotherapy.

>> Click here to read the paper.