Comparative Safety and Efficacy of Manual Therapy Interventions for Cervicogenic Headache: A Systematic Review and Network Meta-Analysis
Article Summary
This is a recent systematic review/meta-analysis looking at treatment for cervicogenic headache (CHA). They included 16 RCTs and a total of 769 subjects to determine the efficacy of manipulation, mobilization using SNAGs, exercise, and massage for improving CHA using a visual analog scale (VAS) and NDI outcome score.
They used something called the surface under the cumulative ranking (SUCRA) curve to determine which intervention was best. A SUCRA curve ranks each intervention on its likelihood of being the best option. Each is ranked from 0 to 100%, meaning that if an intervention has a SUCRA score of 75%, it means that there is a 75% chance that this intervention will be the most helpful for a patient. The higher the SUCRA score, the more effective the intervention.
- Manipulation: performed to either the upper cervical (OA/AA joints) or the upper thoracic spine.
- In the short term (0-4 weeks)
- For VAS improvement, SUCRA score was 98.9%
- For NDI improvement, SUCRA score was 82.2%
- In the short term (0-4 weeks)
- SNAGs: at AA joint to improve rotation.
- Improvement up to 24 weeks
- VAS 67.3%
- NDI 57.2%
- Improvement up to 24 weeks
- Exercise: unspecified what exercises were performed.
- Up to 24 weeks
- VAS 21.0%
- NDI 6.7%
- Up to 24 weeks
- Massage: also unspecified.
- Up to 24 weeks
- VAS 12.8%
- NDI 53.9%
- Up to 24 weeks
Takeaways
- Manipulative treatment was the most effective in the short-term, but we know that any passive treatment we do (whether it’s manipulation, mobilization, MFR, etc.) will only provide short-term relief unless we combine it with exercise.
- If I passively release a muscle without doing anything to retrain the patient’s brain, at best, the muscle will stay relaxed for 2-4 hours. At worst, 5-40 minutes.
- This is why our exercise is so important – it makes the improvement last much longer because we retrain the proper motor pattern in the brain.
- If I passively release a muscle without doing anything to retrain the patient’s brain, at best, the muscle will stay relaxed for 2-4 hours. At worst, 5-40 minutes.
- The authors conclude that SNAGs are the best option for patients with CHA because of the long-term improvement (from retraining proper movement) and because of the low risk of adverse events.
- They argue that manipulation is the best treatment for short-term improvement, but had a significantly higher amount of adverse events from the upper cervical manipulation group, and therefore requires more clinical expertise.
- HOWEVER, there was still significant improvement in the thoracic manipulation group, with much less risk for adverse events.
- They argue that manipulation is the best treatment for short-term improvement, but had a significantly higher amount of adverse events from the upper cervical manipulation group, and therefore requires more clinical expertise.
Conclusion
My conclusion from this is that I want to use SNAGs with everyone experiencing CHA, and give early thoracic manipulation to the appropriate patients. I may use cervical manipulation with a select few (younger, no red flag symptoms, no obvious hypermobility/instability, no traumatic injury, no anxiety around the idea of manipulation, etc.).
We also know that many HAs are caused by spasms of neck muscles (take Stacy’s Manual Therapy Approach to Treatment of Headaches course!). The study didn’t specify the type of “massage” the subjects received, but we know MFR to neck/face muscles can be very effective for all types of HAs.
