Headache symptom modification: the relevance of appropriate manual therapy assessment and management of a patient with features of migraine and cervicogenic headache – a case report

ABSTRACT

Objectives

People who suffer from headache frequently present with multiple headache forms and the precise diagnosis of the dominant headache form can be challenging. This case report describes a headache symptom modification approach in the diagnosis and management of a patient presenting with combined features of chronic migraine and cervicogenic headache (CGH).

Methods

A 28-year-old female presented with combined features of chronic migraine and CGH diagnosed according to guidelines published by the International Headache Society. Her main complaints were frequent and severe headache along with frequent neck pain and disability. Symptom modification based on the Mulligan Concept was utilized for assessment of musculoskeletal dysfunction associated with headache which identified upper cervical articular impairment. Impairments were also identified in craniocervical muscle control and endurance. Interventions comprised six sessions of Mulligan manual therapy to address cervical spine impairments, exercise for craniocervical control and endurance, as well as patient education.

Results

Headache frequency at 6 months follow up was reduced from 16 to 3 days per month and intensity from 72 to 23 on Visual Analogue Scale. Clinically relevant improvements were also found in headache duration, pressure pain thresholds, medication intake and Headache Activities of Daily Living Index post-treatment and continued up to 6 months follow-up without adverse events.

Discussion

This case report illustrates the use of a manual therapy symptom modification approach in the management of headache. Improvement in headache symptoms and disability suggests that the musculoskeletal impairments and headache symptoms were more a feature of CGH rather than migraine. The mechanisms underlying these changes in symptoms and impairments are discussed.

Introduction

Headache is both a symptom and disease and is considered one of the most common disorders globally, causing major disability and economic burden [1]. Migraine is one form of primary headache, without identifiable cause, with 1 year prevalence between 14% and 18% [2–4]. In contrast, cervicogenic headache (CGH) is classified as a secondary headache arising from pathology in the cervical spine (International Headache Society) with prevalence 4.1% [5].

The typical features of CGH are referred pain from the cervical spine to the head together with a consistent pattern of cervical musculoskeletal dysfunction which is considered as important diagnostic criteria for CGH [6]. Musculoskeletal dysfunction associated with CGH includes poor motor control, tightness of cervical muscles [7,8], reduced relative cross-sectional areas of sub occipital extensors [9], hypomobility of upper cervical spine joints [10,11], pain on palpation of the upper cervical spine [12], and the presence of cervical myofascial trigger points [13].

Though migraine is a distinct form of headache separate to CGH without origin from the cervical spine, neck pain [14,15] with associated disability [16] together with features of cervical musculoskeletal dysfunction common to CGH have been reported in a migraine population [17–21]. However, there is a low level of evidence for such findings [22].

The presence of neck pain has been reported as the most common trigger for migraine [23] and it has been suggested that eliminating triggers plays an important role in migraine management [23]. However, the presence of neck pain is considered by many to be an associated feature of migraine and does not necessarily indicate that the cervical spine is the cause [19,24] or that treatment to the cervical spine will reduce migraine symptoms.

Multiple headache forms are reported in 55% of people who suffer from headache according to one community survey [25]. This suggests that although migraine and CGH are distinct entities both may coexist in the same individual [26]. Hence, overlap of symptoms between migraine and CGH are common, with as much as 82% of people with CGH fulfilling criteria for migraine [27] creating a diagnostic challenge [28]. Moreover, there is similarity between migraine and CGH in the mechanisms sub-serving symptom generation [24]. Musculoskeletal dysfunction is considered as a potential source for the development of both peripheral sensitisation as well as sensitisation of the trigeminocervical nucleus (TCN). Both peripheral and central sensitization may be involved in headache symptoms [13,29,30] due to the convergence of afferents from the trigeminal system and upper three cervical nerve roots in the TCN. Thus, managing musculoskeletal triggers through the reduction of peripheral and central sensitization may be considered in the management of migraine.

One method of identifying whether cervical musculoskeletal dysfunction is associated with headache is through manual therapy symptom modification, including headache reproduction [17,24] and elimination [31] using sustained pressures applied to the upper cervical spine. If symptoms can be modified this would suggest a link between the cervical spine and the headache and therefore the potential for treatment directed to the cervical spine in management. This method of assessment may circumvent the difficulty in determining whether cervical spine musculoskeletal impairments are causative in headache or not.

The purpose of this case report is to describe an evidence-based approach to the assessment and management of a patient with migraine and associated cervical musculoskeletal dysfunction based on symptom modification.

Patient information

A 28-year-old female full-time academic and manager in a University hospital presented with a main concern of right side dominant headache with a pulsating quality together with a feeling of a tight band across the occipital area. The headache intensity was 72 mm on the 100 mm visual analogue scale (VAS) with an average of 16 attacks per month, lasting an average 6 hours. However, in recent months the frequency had increased and was triggered more easily. She also has constant mild to moderate neck pain which was aggravated by neck movements, particularly cervical rotation and extension. The intensity of neck pain increased in severity during the headache attacks. Common triggers for headache were bus travel with sustained neck positions particularly rotation, as well as sustained neck extension, lack of sleep, carrying a heavy shoulder bag, and use of contact lenses. For management, she had tried increasing sleep duration but this had no impact on her symptoms. She avoided analgesics as she was concerned about potential side effects. She believed that her headache may have been due to a cessation of exercise, as she was now sitting for prolonged periods during her commute and work. Travel to work by bus took 2 hours each day. At work, she managed an intensive care unit, inpatients, an outpatient department as well as delivering 6–8 lectures per week. She was married and lived with her husband and his parents.

She thought her headache might have been related to her vision but an ophthalmic specialist negated any specific eye abnormality.

Her episodes of headache began 5 years previously with no apparent cause, usually commencing after an episode of vertigo, occurring twice per week for 4 hours, with some relief after sleep. She consulted many physicians and a neurologist who ordered computed tomography (CT) scans and magnetic resonance imaging (MRI) of the brain, all of which were reported as normal. The initial diagnosis was migranous vertigo and she was prescribed Sibelium medication. In the last 3 years, her episodes of vertigo had reduced however she reported an increase in headache frequency. Sixty percent of her total headache attacks were associated with phonophobia and or nausea, but she never reported episodes of photophobia or vomiting. Her goal for physical therapy was to eliminate headache during work activity to enable her to work without interruption.

Clinical findings

At the initial consultation the patient presented with headache.  Her vital signs were stable and within normal physiological range (as reported by her medical practitioner) without in recent months of any dizziness, diplopia, dysphagia, or signs of nystagmus. Disability was assessed with the Headache and Disability Index (HADLI) [32] and was 17 out of 45 indicating a moderate level of disability.

Observation

Postural examination revealed an exaggerated lumbar lordosis, and forward head posture (FHP) in sitting as well as in standing. Scapular position was normal. Correcting the FHP and thus reducing upper cervical extension gave some relief from temporal area headache but not affecting other headache areas.

Range of motion

Examination of whole cervical spine active range of motion revealed neck pain at end range left rotation and flexion. Localization of upper cervical extension movement by protraction of the head [33] revealed neck pain, while retraction [upper cervical flexion] temporarily reduced her headache. Upper cervical rotation was evaluated in sitting with the C0-C2 rotation test [34] and in supine with the flexion-rotation test (FRT) using the compass application of an iPhone. For the C0-C2 rotation test, the spinous process of C2 is fixed while the head is rotated to the left and right. Range was 15° to each side and was within normal limits [34]. For the FRT test, upper cervical rotation range to the left was 43° and to the right 46° and did not provoke pain.

Manual assessment

Palpation of subcranial soft tissues and muscles revealed tenderness on the right trapezius muscle to firm pressure. Pressure pain thresholds were measured using an algometer on two maximally tender points, one at the right trapezius muscle located centrally and the second at the C2/C3 articular pillar on the left side. Palpation over the left articular pillar of C2 and C3 provoked headache and neck pain and was hypomobile compared to the contralateral side and adjacent segments below. Palpation over the C7 and T1 spinous process reproduced neck pain which was also provoked during unilateral palpation on the articular pillar of C7 on the right side.

Muscle testing

Muscle length tests revealed mild tightness of the left upper trapezius. The craniocervical flexion test [7] was abnormal, with reduced isolation of the deep neck flexors and increased activation of the sternocleidomastoid muscles. This was apparent during a single 5-s hold, at end range upper cervical flexion. The neck flexor endurance test [35] was also abnormal, she could only sustain a head lift for 5 s before fatiguing. Manual muscle testing of the upper limb revealed scapular retractor and shoulder rotator muscle weakness.

Tests to assess cervical arterial dysfunction were not performed while no abnormality was found on testing the integrity of the alar and transverse ligaments.

As the patient had headache at the time of consultation further symptom provocative assessment was not performed, rather a symptom elimination approach as suggested by Mulligan [31] was utilized. A Headache SNAG (Sustained Natural Apophyseal Glide) [31] was trialed first with posteroanterior sustained pressure applied to the C2 spinous process, which immediately provoked headache. Following this, a 10-s Reverse Headache SNAG [31] was trialed where the C2 vertebra was stabilized while pressure was applied to translate the cranium horizontally forward. Again there was no change in headache symptoms.

Based on the pain response and hypomobility to palpation on the C2 and C3 vertebrae, lack of impairment and pain response to testing ROM above C2, and no effect on symptom modification using the Headache SNAG and Reverse Headache SNAG, a third symptom modification test was trialed with a Modified headache SNAG at C3 level, which immediately reduced her headache (Figure 1(a)).

Figure 1.

Modified headache SNAG (a) and self headache SNAG (b) at C3 level.

Diagnosis based on examination

The examination findings including predominant unilateral location, throbbing quality, chronicity, age at onset, frequency of attacks and associated nausea with phonophobia with no history of trauma suggest a diagnosis of chronic migraine [36]. However, there are also features of CGH due to the presence of cervical musculoskeletal dysfunction which justified the use of physiotherapy in management [19,37]. Furthermore, amelioration of symptoms with manual therapy justifies its use as a part of a multimodal treatment approach.

Interventions

The patient was seen for a total of six visits over a 6-week period. Treatment consisted of manual therapy, postural re-education, specific and general exercise as well as patient education. The goal was to increase tolerance for functional and work activities without triggering headache (see Table 1 for summary of treatment sessions). There were no adverse events during or after each treatment session in terms of dizziness, increase in pain intensity, or induction of other symptoms.

Table 1.

Summary of treatment sessions.

Session	Subjective report	Manual therapy	Exercise	Reassessment after intervention
1 (day 0)	HA intensity of 72/100 on VAS Neck pain intensity of 60/100 on VAS Restricted left rotation HADLI- 17	Modified HA- SNAG C3	Self Modified HA- SNAG C3 DNF Strengthening Neck flexor Endurance training Trapezius stretching exercises	No HA No adverse events No difference in neck pain intensity or mobility
2 (day 3)	HA intensity of 55/100 on VAS Neck pain intensity of 55/100 on VAS Restricted left rotation	Modified HA- SNAG C3	Self Modified HA- SNAG C3 DNF Strengthening Neck flexor Endurance training	No HA
3 (day 6)	HA intensity of 40/100 on VAS Neck pain intensity of 60/100 on VAS Reduced cervical rotation to left	Modified HA- SNAG C3 C7 SNAGs	Self Modified HA- SNAG C3 DNF Strengthening Neck flexor Endurance training Self C7 SNAGs Upper Quadrant Strengthening Stretching	No HA No neck pain Increased ROM of cervical rotation to left
4 (day 14)	No HA at the time of presentation. Average HA of intensity 30/100 on VAS Average Neck pain of intensity 40/100 on VAS Reduced cervical rotation to left GROC- 3	C7 SNAGs	DNF Strengthening Neck flexor Endurance training Self C7 SNAGs Upper Quadrant Strengthening Stretching	No neck pain Increased cervical rotation to left
5 (1.5 month after initial visit)	No HA at the time of presentation. Average HA of intensity 25/100 on VAS Average neck pain of intensity – 35/100 on VAS HADLI-8		DNF Strengthening Neck flexor Endurance training Upper Quadrant Strengthening Stretching	Reduced frequency of HA
6 (3 months after initial visit)	No headache at the time of presentation. Average HA of intensity 23/100 on VAS HADLI – 6 Poor compliance with exercises GROC-4		DNF Strengthening Neck flexor Endurance training Upper Quadrant Strengthening Stretching	Reduced frequency of HA

HA – Headache, VAS – 100 mm Visual Analogue Scale, SNAGs – Sustained Natural Apophysial Glides, DNF – Deep neck flexors, GROC – Global rate of change scale (11 point), HADLI – Headache Activities of Daily Living

Manual therapy

Modified headache SNAG at C3

Based on the positive response in assessment a Modified Headache SNAG at C3 (Figure 1(a)) was used in the first session. Postero-anterior pressure was applied obliquely along the plane of the C2-C3 facet joint sustained for 30 s. After four repetitions the patient’s headache symptoms were completely relieved. This modified SNAG at C3 was delivered for the first three treatment sessions only as she presented without headache on the 4th consultation. Due to the positive response to the technique in the clinic, she was advised to perform a home exercise self Modified Headache SNAG at C3 (Figure 1(b)) replicating the clinic technique using a towel (while retracting the head) with a maximum of five repetitions of 10 s holds performed daily.

Snags at C7

Symptom modification for neck pain was incorporated on the third session as neck movement was still painful. With the patient in a sitting position, a SNAG was applied to the right articular pillar of C7 during left cervical rotation, which enabled pain free movement. Pain-free overpressure was applied on each of six repetitions, with a further two sets delivered. A home exercise was prescribed involving a C7 self SNAGs using a small towel with two sets of six repetitions daily.

Exercise

Deep neck flexor strengthening exercise was performed as described by Jull et al. [1998, ⁷]. The emphasis was to activate isometrically the deep neck flexor muscles by controlled and graded craniocervical flexion, and to avoid substitution by sternocleidomastoid while performing upper cervical flexion. She was advised to do this as a home exercise at least 5 times per day for 3–5 repetitions with 5 s holds. Progression was based on her comfort level.

Endurance training for the neck flexor muscles [35] involved a controlled sustained head lift movement in supine for as long as she could maintain the upper cervical spine in a neutral flexion/extension position. This was 5 s on the first day. She was advised to perform three sets of 5 s holds twice per day progressing gradually to three sets of 10 s holds over the treatment period.

Upper quadrant muscle strengthening exercises was also prescribed. For the shoulder rotator and scapular retractor muscles strengthening exercises were performed against the resistance of yellow elastic band. Five repetitions of 10 to 15-s holds were advised twice a day. Passive static stretching exercises [therapist delivered plus self stretching] for the tight upper trapezius muscle were performed with stretch maintained for 30 s, for three repetitions once daily.

The chief outcome measures are listed in Table 2 and supported by Figure 2. All outcome measures were assessed at baseline, at the end of the 4th and 6th treatment session as well as after 3rd- and 6th-months following the completion of the final treatment session.

Table 2.

Chief outcome measures with time points.

Outcome measures	Baseline	After 2 weeks	After 6 weeks	After 3 Months	After 6 Months
Frequency of HA days per month	16	-	7	3	3
Duration of HA(mean hours/week)	22	-	15	11	9
Medication intake (tablets per week) (paracetamol)	3		1	.5	0.5
Intensity of HA on VAS (100mm)	72	40	36	25	23
Intensity of neck pain on VAS (100mm)	60	10	35	0	0
Pressure pain threshold (N) C2/C3 Left facet joint Right upper trapezius	17.6 24.7	23.6 35.5	31 40.6	30 41	31 40
Cervical flexor endurance test (sec)	5		23	34	40
HADLI(out of 45)	17	-	8	6	5

HA – headache, VAS – visual analogue scale, HADLI – Headache Activities of Daily Living

Figure 2.

Session wise change in main outcome measures at the end of the treatment, and after 3- and 6-months. Including pressure pain thresholds (PPT) and Headache Activities of Daily Living Index (HADLI)..

Discussion

This case report describes the successful use of a manual therapy based symptom modification approach [31] in the assessment and management of a patient with mixed headache forms including chronic migraine with associated signs of musculoskeletal dysfunction suggestive of CGH. Various reports have explored the possible mechanism of action for the beneficial effects of manual therapy to the cervical spine in the management of headache [30,38,39]. Migraine headache has been shown to be reduced by upper cervical spine palpation which was associated with a reduction in TCN sensitization determined by the blink reflex [24]. This might suggest that manual therapy modifies headache through changes in central sensitization. As the treatment method used in this case sought to eliminate headache, it is likely that the mechanism of action involves a combination of changes to the central and peripheral nervous system.

The diagnosis of chronic migraine was based on guidelines developed by the IHS[2018] [36]. Chronic migraine is diagnosed if 8/15 headaches per month are attributable to migraine. However, the remaining seven headaches do not have to fulfill migraine criteria, and may be in the form of CGH, which might be associated with cervical musculoskeletal impairments [37]. A recent meta-analysis by Liang et al. [2019, ²²] indicates low-level evidence for the presence of musculoskeletal dysfunction ina population with migraine, but which are common features of CGH. Thus, the symptom profile of the patient in this case study probably indicates overlapping features of migraine and CGH, or more likely dual forms of headache, which is a common presentation in the community [25]. Despite this duality, the presence of migraine features did not prevent management from being effective in reducing headache burden in this case. Importantly, however, headache was not completely eliminated following management possibly indicating that migraine headache may not be completely responsive to the management employed in this case.

In the manual therapy assessment, we used a symptom modification approach developed by Mulligan [31] to identify the potential for this as treatment. In this method, headache elimination was considered as a positive outcome which provides potential evidence for the link between the presence of cervical musculoskeletal dysfunction and headache. If neck pain, impairments and associated neck disability were not associated with the headache then no symptom reduction would be expected with the application of manual techniques. The finding of no response to a headache and Reverse Headache SNAG, with headache elimination following modified Headache SNAG at C3 suggests a specific segmental level of cervical spine involvement in the headache. Indication of a C2/3 segmental level origin for headache was also confirmed by the painful response and hypomobility on palpation at this level.

Once musculoskeletal dysfunction is identified in headache, manual therapy and specific neck exercises are recommended [40] as a part of physiotherapy management. A systematic review provides only limited low-level evidence in support of the use of manual therapy in the management of migraine [41]. Previous research provides some evidence for Mulligan manual therapy in the management of patients with CGH [42–44]. We believe this case report provides preliminary evidence for the use of a manual therapy symptom modification approach in the management of people with mixed headache forms including migraine.

Poor control of craniocervical flexor muscles is a common feature seen in patients with migraine and a self reported neck pain [21], a profile similar to the patient in this case study. Strengthening these muscles has previously been shown to be effective in the management of CGH [45]. Moreover a recent meta analysis indicates that these exercises can effectively reduce neck pain and associated disability [46] which supports our hypothesis of using these exercises to address the impairments in craniocervical flexor muscles in our patient.

It is important to note that no adverse events were reported in using this manual therapy symptom modification approach, which is also in accordance with previous reports using similar procedures for the treatment of dizziness [47]. This suggests clinical safety in the use of symptom modification in the management of a cervical disorder.

Limitations

There are a number of potential limitations to this study. Firstly, a longer follow up period may have been appropriate considering the chronic nature of migraine. Secondly, a single case report demands caution as a cause and effect relationship in headache improvement cannot be established from a single case study. Generalization of these findings to larger populations and other forms of headache such as migraine with aura, or with more pure forms of migraine need further investigation.

Conclusion

This case report utilized a manual therapy symptom modification approach in the assessment and management of a patient with multiple headache forms including migraine and CGH with associated cervical musculoskeletal dysfunction. Clinically relevant improvement in headache parameters were seen which were sustained over a 6-month follow up period without adverse events.

Biographies

Kiran Satpute [M.P.Th. Musculoskeletal, C.O.M.T.] is a Associate Professor and Head of Musculoskeletal Department at Smt. Kashibai Navale College of Physiotherapy, India. He is a PhD Scholor at Sancheti College of Physiotherapy.

Dr. Nilima Bedekar [Msc PT (UK) PhD PT, MCSP] is a Phd Guide, Professor and Head of Musculoskeletal Department at Sancheti College of Physiotherpy, India.

Dr. Toby Hall [PhD, FACP] is a Specialist Musculoskeletal Physiotherapist and Adjunct Associate Professor at Curtin University Australia.

Disclosure statement

Kiran Satpute and Toby Hall are Accredited Mulligan Concept teachers and gain a teaching fees when running these courses.