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Therapeutic Exercise and Manual Therapy for Treating Cervicogenic Headaches


It can be estimated that approximately 7 million Americans suffer from headaches on a basis of at least every other day, with a considerable amount of these headaches being cervicogenic in origin where the pain originates in thecervical spine and refers to the head. According to the International Headache Society, the following criteria for a cervicogenic headache must be fulfilled:localized unilateral pain originating in the posterior neck and occipital region that spreads to oculofrontotemporal areas on the symptomatic side, pain aggravated by neck movements and sustained postures, reduced cervical passive range of motion, and tenderness to palpation over at least one of the upper cervical vertebrae (Dunning et al., 2016; Haas et al., 2004; Jull et al.,2002). Tenderness in neck musculature and altered response to stretching is often also present.

Evidence provides support for positive outcomes with neuromuscular retraining exercises and cervical spine mobilization. Jull et al. (2002) found exercise and manual therapy were successful in reducing headache frequency and intensity and decreasing neck pain and disability immediately after treatment sessions and at 12 month follow-ups for patients with cervicogenic headaches. These results were clinically relevant as the International Headache Society defines clinical relevance as a 50% reduction in headache frequency, and 72% of patients reported such improvement within 8-12 visits over the course of 6weeks. Exercises consisted of low load endurance exercises targeting the deep 11 neck flexor muscles and the longus capitus and colli, which play an important role in stabilizing the cervical spine, where patients had to hold controlled ranges of craniocervical flexion in supine against an air-filled pressure sensor able to monitor flattening of the cervical spine that occurs with longuscolli contraction. Isometric exercises for the co-contraction of neck flexors and extensors against low level rotary resistance were also used. Manual therapy consisted of low-velocity cervical joint mobilizations as well ashigh-velocity manipulation techniques.

Uthaikhup et al. (2017) also provides support for exercise and manual therapy for treating cervicogenic headaches. The researchers found significant reductions in headache frequency, intensity, and duration, neck pain and disability, cervical range of motion, and quality of life immediately post treatment and at 6 month and 9 month follow-ups. Compared to controls, 60% of patients in the intervention group reported complete headache relief after completing fourteen 45-minute sessions over the course of 10 weeks where treatment consisted of low load craniocervical flexor strengthening, postural correction,and low-velocity cervical mobilizations.

While manual therapy is effective for improving symptoms of cervicogenic headaches, it is of particular interest whether high-velocity cervical manipulation is any more effective than low-velocity cervical mobilization.Research suggests that manipulative therapy may activate descending inhibitory pathways from the midbrain and stimulate neural inhibition at various levels of the spinal cord, resulting in an analgesic effect. Decreased electrical activity in the suboccipital muscles, often found to be overstimulated in those suffering from cervicogenic headaches, can also result from high-velocity cervical manipulation (Jull et al., 2002). Manipulation may also better stimulate mechanoreceptors and proprioceptors in deeper paraspinal muscles that can alter alpha motor neuron excitability and muscle activity, where as mobilization may be more likely to target more superficial structures (Dunninget al., 2016).

When comparing different treatment options for patients suffering from cervicogenic headaches, Dunning et al. (2016) found greater improvements in headache intensity, frequency, and duration, disability, and medication intake in patients that received manipulation in comparison to those whose treatment consisted of combined mobilization and exercises. Patients in the combined treatment grouped received one 30 second unilateral grade IV posterior-anterior joint mobilization to both sides of the C1-2 motion segment and one 30 second centrally focuses grade IV posterior-anterior joint mobilization to the T1-2 motion segment in prone, coupled with craniocervical flexion exercises in supine against an air-filled pressure sensor and lower trapezius and serratus anterior theraband strengthening. Patients in the manipulation group received unilateral high-velocity low-amplitude thrust manipulations to the left and right C1-C2 articulations as well as an anterior-posterior thrust manipulation to T1-T2 in supine. All patients received treatment for 6-8 sessions over the course of 4 weeks, and those in the manipulation group experienced less frequent headaches of shorter duration at 1 week, 4 week, and 3 month followups after the initial treatment session. Haas et al. (2004) provides further support for high-velocity low-amplitude cervical manipulations yielding favorable results in those suffering from cervicogenic headaches.

Kristen Gasnick, SPT

Dr.Brandon Cruz PT,DPT

Board Certified in Orthopedics

Board Certified in Sports

Fellow in Training

Certified Strength & Conditioning Specialist

Dunning, JR, Butts, R, Mourad, F, Young, I, Fernandez-de-las Peñas, C, Hagins,M, Stanislawski, T, Donley, J, Buck, D, Hooks, TR, & Cleland, JA.(2016).Upper cervical and upper thoracic manipulation versus mobilization andexercise in patients with cervicogenic headache: a multi-center randomizedclinical trial. BMC Musculoskeletal Disorders;17(64):1-12.

Haas, M, Aickin, M, Fairweather, A, Ganger, B, Attwood, M, Cummins, C, &Baffes, L. (2004). Dose response for chiropractic care of chronic cervicogenicheadache and associated neck pain: a randomized pilot study. Journal ofManipulative and Physiological Therapeutics;27(9):547-553.

Jull, G, Trott, P, Potter, H, Zito, G, Niere, K, Shirley, D, Emberson, J,Marschner, I, & Richardson, C. (2002). A Randomized Controlled Trial ofExercise and Manipulative Therapy for Cervicogenic Headache.SPINE;27,(17):1835–1843.

Uthaikhup, S, Assapun, J, Watcharasaksilp, K, & Jull, G. (2017).Effectiveness of physiotherapy for seniors with recurrent headaches associatedwith neck pain and dysfunction: a randomized controlled trial. The SpineJournal;17:46-55.