The Impact of Soft Tissue Techniques in the Management of Migraine Headache: A Randomized Controlled Trial

Abstract

Objective

Individuals with migraine often present with postural faults and muscle tension that are associated with myofascial trigger points (MTrPs). These trigger points may be a contributory factor to the development of migraine headaches. There are many treatments aimed at eliminating MTrPs, such as soft tissue techniques, laser therapy, and needling therapies. Thus, we performed a randomized controlled trial study to investigate the efficacy of soft tissue techniques in the management of migraine headache.

Methods

This study was conducted among individuals with migraine headache in Shiraz in 2018. Forty participants were randomly divided into 2 groups: the soft tissue techniques (treatment) group and the placebo control group. Participants in the treatment group were treated over 6 sessions in 2 weeks (combined MTrP therapy and stretching). Headache parameters, drug consumption, score on the Headache Disability Index, and pressure pain threshold (PPT) were measured before and after the intervention and after a 1-month follow-up period. Data were analyzed with 2 × 3 repeated-measures analyses of variance to investigate the differences in variables between the 2 groups.

Results

Compared with baseline and the control group, the treatment group showed a significant reduction in headache parameters (P < .001), drug consumption (P < .001), and Headache Disability Index score (P < .001) immediately after the intervention and after a 1-month follow-up period (all Ps < .001). PPT levels increased in the treatment group in comparison with the control group (P < .001).

Conclusion

The soft tissue techniques were helpful for improving certain aspects of migraine, such as headache parameters, drug consumption, functional disability, and PPT levels of cervical muscles.

Introduction

Headaches are one of the most frequent conditions, affecting at least 47% of adults in their lifetime.¹ The International Headache Society (IHS) has divided headaches into primary (in which the pain is caused by independent pathologic mechanisms) and secondary (in which the pain is a consequence of some other process).² Migraine is a neurologic condition and accounts for 69% of primary headaches.¹ It has a substantial impact on daily life and is associated with functional impairments such as physical and emotional dysfunction.³ The origin of migraines is potentially multifactorial; contributions have been identified from the vascular system, central nervous system, peripheral nervous system,^4,5 and nociceptive inputs of myofascial origin.⁶ Myofascial trigger points in the neck and craniofacial areas may contribute to global pain burden and facilitate migraine pain expression.⁷ Specifically, myofascial trigger points and painful tension in the upper trapezius (UT), sternocleidomastoid (SCM), and suboccipital muscles have been suggested as contributory.⁸ The development of these trigger points may be due to postural faults or the underlying migraine headache disorder.⁹ Trigger points (TrPs) might be an initiating or perpetuating factor for migraine headaches. Nociceptive inputs of myofascial TrP (MTrP) origin might potentially contribute to certain head and neck symptoms found in individuals with migraine.⁶ Deactivation of these trigger points through soft tissue techniques may increase the pressure pain threshold (PPT) and reduce frequency, severity, and duration of headache events.¹⁰

There are various approaches for the management of migraine headaches, including pharmacologic and nonpharmacologic interventions. Although pharmacologic treatments provide some relief, they are associated with side effects such as low blood pressure, nausea, depression, and renal damage.¹¹ Thus, many therapists use alternative treatments for migraine. These nondrug approaches often focus on musculoskeletal disorders¹² using physical therapy techniques including posture correction, exercise therapy, spinal manipulation, massage therapy, and relaxation techniques.^13,14

Although migraine is a neurovascular disorder, the high prevalence of pericranial sensitization and trigger points of neck muscles indicates that manual therapy used for the reduction of trigger points may be useful in reducing migraine headaches and their associated disability. For example, manual therapy of the SCM muscle may be beneficial in reducing headache and neck pain during migraine episodes. Prior studies have applied this technique in individuals with cervicogenic headache and found positive results with manual therapy on the pain intensity, headache parameters, PPT, and range of motion (ROM).¹⁵ John et al¹⁶ conducted a study to compare the effect of yoga therapy with a control group in the treatment of migraine patients. Yoga focused on stretching the neck, shoulder, and back muscles. The results showed that migraine headache parameters and psychological parameters improved in the yoga group. We hypothesized that soft tissue techniques, such as ischemic pressure and muscle stretching, would improve symptoms, such as headache parameters and headache disability, in individuals with migraine. To the best of our knowledge, there is insufficient evidence about the effect of soft tissue techniques in the management of migraine. Only a pilot study with limited variables (frequency, severity of pain, and quality of life) has been conducted in this field,¹⁷ so the purpose of this study was to investigate the effectiveness of 2 soft tissue techniques in the treatment of myofascial trigger points and their subsequent impact on migraine headaches.

Materials and Methods

Participants

This study was a randomized controlled trial done at the research center of the Shiraz University of Medical Sciences in Iran from August 2017 to February 2018. The sample consisted of 40 participants aged 25 to 55 years (mean ± SD: 38.92 ± 10.15 years), diagnosed with migraine, considering CONSORT guidelines. They were referred to a neurology clinic in the hospital of the Shiraz University of Medical Sciences, Iran, that was invited to participate in this study (Fig 1).

Fig 1.

CONSORT flow diagram of the study.

Participants were included if they presented a diagnosis of migraine headache according to International Headache Society criteria as assessed by a neurologist (Table 1). In addition, they showed active TrPs in the UT, suboccipital, and SCM muscles reproducing their headache. The presence of active trigger points was confirmed if (1) “there was an area of focal muscle tenderness that was activated by palpation and that, when activated, referred pain replicating the patient's headache complaint” and (2) “there was a jump sign that was the characteristic behavioral response to pressure on a trigger point.”¹⁸

Table 1.

Diagnostic Criteria for “Migraine Without Aura” According to the Most Recent International Classification of Headache Disorders²

AAt least five attacks fulfilling B-D BHeadache attacks lasting 4-72 h (untreated or unsuccessfully treated) C Headache has at least two of the following characteristics: 1 Unilateral location 2 Pulsating quality 3 Moderate or severe pain intensity 4 Aggravation by or causing avoidance of routine physical activity D During headache at least one of the following: 1 Nausea and/or vomiting 2 Photophobia and phonophobia ENot attributed to another disorder

MO is defined by headache with specific features and associated symptoms, which must be present (A-E).

Participants were excluded if they had a history of neck trauma; cervical radiculopathy; previous surgery in the neck or shoulder area; diagnosed other headaches and unusual migraine (basilar migraine, migraine with aura, hemiplegic migraine); physiotherapy and treatment in the neck area within the past 6 months; evidence of cognitive deficits; or pregnancy.

To determine the sample size, a pilot study was first performed on 10 individuals with migraine; the results were then used in PASS 11 software to calculate the sample size with a type I error of 0.05 and type II error of 0.20 (expected power 80%). According to the statistical formula, it was estimated that 20 participants in each group were required.

Study Protocol

In this randomized, controlled trial study, block randomization was performed by a statistical expert using Excel, and the block sizes were random, so participants were randomly divided into the treatment and control groups.

Participants were requested to complete a daily headache diary for 2 weeks (baseline phase). At the end of the baseline phase, both groups were assessed for disability due to headache and pressure pain threshold. Then the treatment was carried out over 2 weeks, involving 6 sessions (3 sessions every week) with a duration of 20 minutes per session in the treatment group. At the end of the treatment phase, the participants were asked to continue completing a daily headache diary, and both groups were assessed again for disability due to headache and pressure pain threshold. This assessment of disability due to headache and pressure pain threshold was repeated at the end of a 1-month follow-up, and participants in both groups were asked to complete the daily headache diary again.

All participants signed an informed consent form approved by the Ethics Committee of the Social Welfare and Rehabilitation Sciences (ethics code no: IR.USWR.REC.1395.192). The study process and the individual's role were clearly explained. Participants were free to leave the study at any stage. This article was extracted from Iranian Register of Clinical Trials number 20171219037956N1.

Therapy Group (Soft Tissue Techniques)

All the interventions were performed by a trained physical therapist ipsilateral to migraine headaches and with the participants placed in the supine position, and all the stretches were held for 30 seconds.^15,19

UT Muscle

The therapist first identified the TrPs within the muscle. The participant's arm was placed in slight shoulder abduction with elbow flexion and the hand resting on the body. The therapist again applied a pincer grasp, placing the thumb and index finger over the active TrP. Constant pressure was used at the maximum tolerable level before reproducing headache. When the participant reported 50% relief of pain, the pressure was increased again. In each treatment session, this process was performed 3 times for 30 to 60 seconds, with a 30-second interval between repetitions (Fig 2). In addition, participants received a stretching of the UT muscle; the therapist performed passive contralateral lateral flexion and ipsilateral rotation of the head. The therapist placed 1 hand over the participant's acromion process and the other over the participant's occiput and stretched and separated the origin and the insertion of the upper fibers of the trapezius (Fig 3).²⁰

Fig 2.

Soft tissue techniques (ischemic compression): upper trapezius muscle (A), suboccipital muscle (B), and sternocleidomastoid muscle (C).

Fig 3.

Soft tissue techniques (stretching): Upper trapezius muscle (A), suboccipital muscle (B), and sternocleidomastoid muscle (C).

Suboccipital Muscle

The therapist first identified the TrPs within the muscle, then contacted the bony attachment of the suboccipital region with the fingertips of each hand. By flexing the distal interphalangeal joints, the therapist put sustained deep pressure over the musculature attachment to the occipital bone (Fig 2).²⁰ Following this technique, the therapist cradled the skull with the index finger and thumb in contact with the occiput and held the chin with the other hand. By the use of body weight, the therapist put long-axis traction in a cephalic direction and released the suboccipital region (Fig 3).²¹

Sternocleidomastoid Muscle

The therapist first identified the TrPs within the muscle, then applied ischemic pressure over them. The MTrP was grasped between the therapist's thumb and index fingers, and the pressure increased over it to the maximum tolerable level before reproducing headache. When the participant stated 50% relief of pain, the pressure was increased to the maximum tolerable level. In each treatment session, this process was applied 3 times for 30 to 60 seconds, with a 30-second interval between repetitions (Fig 2).²² In addition, participants received a stretching of the SCM muscle; the therapist performed passive contralateral lateral flexion and ipsilateral rotation of the head. The therapist placed 1 hand on the sternal insertion of the muscle and the other on the mastoid process, separating the origin and the insertion of this muscle (Fig 3).¹⁷

Control Group (Placebo)

After the trigger points were determined, the physiotherapist gave a soft and superficial massage while participants were in the supine position. The fingertips of each of the therapist's hands contacted the attachment of the relevant muscle region for this superficial massage of the related muscle.²³ Measurement of variables was done at the beginning of the study. As in the intervention group, measurement of variables was performed immediately after the treatment and after 1 month of follow-up. Of course, treatment was carried out to consider ethical issues immediately at the end of the plan.

Participants were asked not to take any nonsteroidal anti-inflammatory or muscle-relaxing drugs. They were only allowed to take acetaminophen, and the number of tablets used was recorded.

Outcome Measures

Headache frequency, intensity, duration, drug consumption, headache-related disability, and PPT were evaluated at 2 weeks before the intervention, at the end of the intervention, and 30 days after the intervention.

Daily Headache Diary

Participants completed a daily headache diary recording headache frequency, intensity, and duration, and drug consumption:

• • •
    Headache frequency was defined as the number of days (2 weeks baseline, at the end of treatment, and at 1-month follow-up) that participants experienced a headache.
  • •
    Headache intensity was rated on a scale of 0 to 5 (0, no pain; 1, there is pain only when considered; 2, there is pain but it doesn't interfere with daily work; 3, there is pain and the individual cannot do work that needs concentration; 4, there is pain and it interferes with most daily work, so that the individual can do only necessary tasks; 5, there is maximum pain and the individual can't do anything). This was again recorded at 2 weeks baseline, at the end of treatment, and at 1-month follow-up.²⁴
  • •
    Headache duration was defined as the number of hours per day (2 weeks baseline, at the end of treatment, and at 1-month follow-up) that participants experienced a headache.
  • •
    Drug consumption was defined as the number of pain rescue tablets used on days with headache (2 weeks baseline, at the end of treatment, and at 1-month follow-up).

Pressure Pain Threshold (PPT)

An electronic pressure algometer (FG-5005, RS-232, Lutron Electronic Enterprise) was used to measure the PPT of a TrP of the UT, SCM, and suboccipital muscles. Its reliability and validity have been proven previously.²⁵ The algometer was used with perpendicular compression to the skin surface. The compression was stopped when the subject reported pain. The average value of the 3 measurements (expressed as kilograms per square centimeter) was used for data analysis.²⁶

Headache Disability Index

Subjects completed the Headache Disability Index (HDI) questionnaire, designed to assess disability due to headache. It consists of 25 items measuring the effect of headache on daily activities. Items are scored, and the total score can range from 0 to 100. Headache disability is classified as follows: 10% to 28%, mild; 30% to 48%, moderate; 50% to 68%, severe; 72% or higher, complete. The Persian version of the HDI has been shown to be a reliable and valid instrument in Persian-speaking individuals with headache disorders.^27,28

Blinding

The physiotherapist who administered the treatment was unaware of the objectives of the investigation. Another physiotherapist was responsible for the assessments. Patients were unaware of the group allocation. In addition, a researcher who was unaware of the objectives of the study performed the data analysis.

Statistical Analysis

Descriptive statistics were performed on the demographic characteristics of the samples. Potential differences in baseline characteristics between the soft tissue group and the control group were assessed using independent t tests. Differences in outcomes between the groups were analyzed with 2 × 3 repeated-measures analyses of variance. When the main effect of time (before, immediately after, and after 1-month follow-up) was significant, the differences in the variables between the two groups were assessed before and after treatment and follow-up period. Significant findings from the 2 × 3 repeated-measures analysis of variance were followed with 2 × 2 pairwise post-hoc analysis of each time point. Significance was considered at P < .05. Statistical analysis was done using IBM SPSS Statistics, version 23 (IBM, Armonk, New York).

Results

Sixty-five participants were screened but only 46 were enrolled in the study, with 23 participants allocated to the soft tissue group and 23 to the placebo group. The flow diagram for participants in the study is presented in Figure 1. There was no significant difference in demographic data for the participants between the two groups (Table 2). Each group had 8 men and 12 women. The mean (± SD) age of participants was 40.4 ± 11.2 and 37.45 ± 8.9 years, respectively, in the soft tissue group and the control group.

Table 2.

Demographic Data of the Participants

Variable	Control Group (n = 20)	Soft Tissue Therapy Group (n = 20)	P
Age (y)	37.45 ± 8.9	40.40 ± 11.27	.36 (t = 0.91)
Weight (kg)	70.25 ± 6.71	70.20 ± 9.15	.98 (t = 0.02)
Height (cm)	1.70 ± 0.1	1.68 ± 0.09	.60 (t = 0.52)
BMI (kg/m2)	24.37 ± 2.46	25.07 ± 3.40	.46 (t = 0.73)
Headache frequency (d)	3.50 ± 0.76	3.85 ± 1.18	.27 (t = −1.11)
Headache intensity	3.35 ± 0.74	3.65 ± 1.08	.31 (t = −1.01)
Headache duration (h/d)	31.30 ± 12.33	29.30 ± 11.64	.60 (t = 0.52)
Drug consumption	6.50 ± 1.46	6.70 ± 1.21	.64 (t = −0.46)
HDI (score)	40.90 ± 9.32	45.20 ± 14.47	.27 (t = −1.11)
PPT of UT muscle (kg/cm2)	11.75 ± 0.57	11.48 ± 0.58	.15 (t = 1.46)
PPT of suboccipital muscle (kg/cm2)	5.91 ± 0.70	5.58 ± 0.61	.12 (t = 1.56)
PPT of SCM muscle (kg/cm2)	6.72 ± 0.77	6.50 ± 0.87	.42 (t = 0.80)
Gender (female/male)	12/8	12/8

Data are presented as mean ± SD.

BMI, body mass index; HDI, Headache Disability Index; PPT, pressure pain threshold; SCM, sternocleidomastoid; UT, upper trapezius.

In the treatment group, the mean scores of headache frequency, headache intensity, headache duration, and drug consumption decreased after the intervention (P < .001) and at 1-month follow-up (P < .001). There was no change in these scores for the control group. The difference between groups was significant (P < .001; Table 3).

Table 3.

Comparison of Outcome Measures Between the Two Experimental Groups in Different Phases

Variable	Phase	Control Group	Soft Tissue Group	P1	P2 Control Group		P2 Soft Tissue Group		P3 (95% CI)
					Before-after (95% CI)	Before-follow-up (95% CI)	Before-after (95% CI)	Before-follow-up (95% CI)
Headache frequency (d)	Before Immediately afterward Follow-up	3.50 ± 0.76 3.20 ± 0.83 3.30 ± 0.92	3.85 ± 1.18 1.30 ± 0.73 1.20 ± 0.69	<.001	.41 (−20 to 0.80)	1.00 (−0.39, 0.79)	<.001 (2.02–3.07)	<.001 (2.10–3.19)	<.001 (0.75–1.67)
Headache intensity	Before Immediately afterward Follow-up	3.35 ± 0.74 3.20 ± 0.61 3.15 ± 0.48	3.65 ± 1.08 1.80 ± 0.76 1.45 ± 0.68	<.001	1.00 (−0.36 to 0.66)	1.00 (−0.35 to 0.75)	<.001 (1.50–2.19)	<.001 (1.71–2.68)	<.001 (0.53–1.32)
Headache duration (h/d)	Before Immediately afterward Follow-up	31.30 ± 12.33 28.95 ± 12.15 29.60 ± 10.92	29.30 ± 11.64 15.15 ± 7.90 9.05 ± 5.37	<.001	.82 (−3.15 to 7.85)	1.00 (−3.09 to 6.49)	<.001 (10.87–17.42)	<.001 (10.87–17.42)	<.001 (6.02–18.21)
Drug consumption	Before Immediately afterward Follow-up	6.50 ± 1.46 5.95 ± 1.09 6.15 ± 1.22	6.70 ± 1.21 1.75 ± 0.63 1.15 ± 0.48	<.001	.06 (0.19–1.29)	.18 (−3.56 to −1.47)	<.001 (4.27–5.62)	<.001 (4.87–6.22)	<.001 (3.51–4.39)
HDI (score)	Before Immediately afterward Follow-up	40.90 ± 9.32 42.70 ± 9.67 44.10 ± 9.41	45.20 ± 14.47 28.90 ± 7.71 21.00 ± 8.64	<.001	.008 (−3.16 to −0.43)	<.001 (−4.78 to −1.61)	<.001 (11.02–21.57)	<.001 (18.75–29.64)	.001 (4.76–16.96)
PPT of UT muscle (kg/cm2)	Before Immediately afterward Follow-up	11.75 ± 0.57 11.48 ± 0.57 11.26 ± 0.57	11.48 ± 0.58 13.11 ± 0.78 14.24 ± 1.06	<.001	<.001 (0.22–0.31)	<.001 (0.44–0.54)	<.001 (−1.90 to −1.36)	<.001 (−3.23 to −2.27)	<.001 (−1.87 to −1.01)
PPT of suboccipital muscle (kg/cm2)	Before Immediately afterward Follow-up	5.91 ± 0.70 5.62 ± 0.70 5.41 ± 0.71	5.58 ± 0.61 7.16 ± 0.59 8.07 ± 0.72	<.001	<.001 (0.24–0.34)	<.001 (0.44–0.57)	<.001 (−1.86 to −1.29)	<.001 (−2.85 to −2.12)	<.001 (−1.71 to −0.88)
PPT of SCM muscle (kg/cm2)	Before Immediately afterward Follow-up	6.72 ± 0.77 6.40 ± 0.76 6.20 ± 0.77	6.50 ± 0.87 7.82 ± 0.66 8.60 ± 0.76	<.001	<.001 (0.26–0.35)	<.001 (0.45–0.58)	<.001 (−1.53 to −1.09)	<.001 (−2.43 to −1.75)	<.001 (−1.68 to −0.72)

Data are presented as mean ± SD.

Before-after, before intervention and after intervention; Before-follow-up, before intervntion and at follow-up; CI, confidence interval; HDI, Headache Disability Index; P1, P value for repeated measurement; P2, P value for within-group comparison; P3, P value for between-groups comparison; PPT, pressure pain threshold; SCM, sternocleidomastoid; UT, upper trapezius.

The mean HDI score decreased in the treatment group after the intervention (P < .001) and at 1-month follow-up (P < .001), but increased in the control group (P < .001). The results of the main effect of time revealed significant reduction in the HDI score immediately after intervention (P < .001) and at 1-month follow-up of treatment (P < .001), as compared with the baseline in the soft tissue group (P < .001). The post hoc test revealed that the difference between groups was significant (P < .001; Table 3).

Finally, the mean PPT scores for UT, suboccipital, and SCM muscles increased in the soft tissue group as compared to the control group (P < .001). In the control group, the mean scores decreased (P < .001). The results of the main effect of time revealed significant improvement in PPT immediately after the intervention and at 1-month follow-up of the treatment, as compared with the baseline in the soft tissue group (P < .001). The difference between the two groups was significant (P < .001; Table 3).

Discussion

This randomized controlled trial showed that soft tissue techniques used for the reduction of trigger points may be useful in reducing migraine headaches and their associated disability, as measured by headache parameters, drug consumption, disability, and PPT of the cervical muscles.

These findings support previous studies that have identified soft tissue techniques as 1 of the therapeutic options to improve symptoms in individuals with migraine^17,29 and other types of headache.^23,30 In line with the current study, Hanten et al³¹ examined the effect of manual pressure release and stretching in patients with TrPs in their neck or upper back and found reduction of pain and increased PPT in the treatment groups.³¹ Also, Ghanbari et al³² investigated the effect of TrP treatment by positional release therapy in individuals with migraine, and found increased PPT and ROM.

Another study evaluated the short-term effectiveness of combined acupuncture and stretching in individuals with cervical myofascial pain. Results indicated that these techniques could be a suitable treatment option to improve ROM and reduce pain in the short term.³³ Singh and Chauhan³⁴ evaluated the efficacy of myofascial release and positional release therapy in tension-type headache. They reported that both techniques were effective in improving pain and disability in these individuals, but myofascial release was a better choice of treatment in improving symptoms.

Oliveira-Campelo et al³⁵ investigated the effect of various manual techniques in individuals with TrP of the UT muscle. Manual techniques such as the muscle energy technique, passive stretching, and ischemic compression were found to be effective in improving cervical ROM and pressure pain sensitivity.

Various theories have attempted to explain the pathophysiology of trigger points. Muscle overload as a result of repeated and prolonged activity and low levels of muscle contraction may cause changes in muscle fiber, local stiffness, and blood-flow properties of the biochemical environment.³⁶ Also, more acidic biochemical environments have been shown in trigger points, along with high levels of inflammatory mediators which typically produce pain and tenderness.³⁶

According to Simons,³⁷ the use of slow, prolonged passive stretching with a progressive increase in ROM, as used in the current study, appears to inhibit alpha motor neuron response and shortened muscle fibers. These techniques restore the normal length of the muscle sarcomeres, elongating the muscle fiber. Hence, appropriate treatment of MTrPs causes lengthening of the sarcomeres (as might be created with stretching or sustained manual pressure), which reduces energy consumption and improves ischemia, hypoxia, and the presence of analgesic substances such as substance P in the site of TrPs.³⁸

Our findings suggest that stretching of the affected muscle should be considered as an important part of TrP therapy. A mechanism supporting the use of soft tissue techniques in individuals with migraine headache may be related to the alteration in the sensitization state of the trigeminocervical nucleus. Because soft tissue techniques may influence the trigeminocervical nucleus, they also have the potential to change neck muscle tone through alteration of the trigeminoreticular pathway.³⁹ Another possible relation is an anatomical connection between the cervical musculature and the spinal dura. A connective tissue bridge connects the suboccipital muscle with the spinal dura. It has been hypothesized that hypertonicity of this muscle may cause a traction force on the dura through the connective tissue bridge and produce headache pain.⁴⁰ In line with this hypothesis, our results indicated that symptoms of individuals with migraine headache were reduced after treatment of trigger points of the cervical muscles.

Study Limitations

In this study, the effect of other treatments such as medications and other nondrug interventions were not investigated. In addition, this study included participants with migraine originating from MTrPs of the UT, suboccipital, and SCM muscles; the results shouldn't be generalized to all individuals with migraine. The short duration of therapy was a limitation of this study. In future research, it is recommended that the effect of soft tissue techniques with other techniques be studied with a longer treatment period.

Conclusion

According to the present study, soft tissue techniques used for the reduction of trigger points may be useful in reducing certain aspects of migraine headache such as headache parameters, drug consumption, functional disability, and the pressure pain threshold of cervical muscles. Therefore, these techniques may be prescribed for treating individuals with migraine with myofascial trigger points in cervical muscles.

Funding Sources and Conflicts of Interest

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. There are no conflicts of interest; none of the authors has commercial or financial relationships with any entity.

Contributorship Information

Concept development (provided idea for the research): T.R., Z.M.

Design (planned the methods to generate the results): T.R., Z.M., M.R.N.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): T.R., Z.M., M.A.

Data collection/processing (responsible for experiments, patient management, organization, or reporting data): T.R., M.A.

Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): T.R., M.A., M.N.

Literature search (performed the literature search): T.R., Z.M.

Writing (responsible for writing a substantive part of the manuscript): T.R., Z.M., M.R.N., M.A.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): T.R., Z.M., M.R.N., M.A.

Practical Applications:

• •Manual therapy techniques were helpful at improving symptoms of migraine.
• •Stretching the neck muscle after trigger-point treatment is necessary to create longer-lasting pain relief in migraine patients.
• •The high prevalence of pericranial sensitization and trigger points of neck muscles suggests that manual therapy may relieve pain in these individuals.

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