Clinical reasoning for manual therapy management of tension type and cervicogenic headache

Abstract

In recent years, there has been an increasing knowledge in the pathogenesis and better management of chronic headaches. Current scientific evidence supports the role of manual therapies in the management of tension type and cervicogenic headache, but the results are still conflicting. These inconsistent results can be related to the fact that maybe not all manual therapies are appropriate for all types of headaches; or maybe not all patients with headache will benefit from manual therapies. There are preliminary data suggesting that patients with a lower degree of sensitization will benefit to a greater extent from manual therapies, although more studies are needed. In fact, there is evidence demonstrating the presence of peripheral and central sensitization in chronic headaches, particularly in tension type. Clinical management of patients with headache needs to extend beyond local tissue-based pathology, to incorporate strategies directed at normalizing central nervous system sensitivity. In such a scenario, this paper exposes some examples of manual therapies for tension type and cervicogenic headache, based on a nociceptive pain rationale, for modulating central nervous system hypersensitivity: trigger point therapy, joint mobilization, joint manipulation, exercise, and cognitive pain approaches.

Keywords: Cervicogenic headache; Manual therapy; Pain; Sensitization; Spine; Tension type headache; Trigger points.

Figure 1

Manual therapy addressing trigger points in the sternocleidomastoid muscle. The fingers of the therapist grasp the taut band from both sides with a pincer palpation, and stroke centrifugally away from the TrP.

Figure 2

Manual therapy addressing trigger points in the suboccipital musculature. The fingers of the therapist are placed in the space between the occipital bone and C1–C2 vertebrae. The metacarpophalangeal joints are flexed 90° and the interphalangeal joints are extended. This position induces a pressure over the suboccipital musculature.

Figure 3

Manual therapy addressing trigger points in the extra-ocular muscles. One hand of the therapist grasps the eye of the patient and the other one grasps the frontal bone. A manual stretching of the extra-ocular muscles is applied by moving the eye into the opposite direction.

Figure 4

Posterior-anterior upper cervical spine joint mobilization. The thumbs of the therapist make contact over zygapophyseal joint of C1/C2. A posterior-anterior glide of the C1/C2 joint is applied.

Figure 5

Upper cervical spine joint manipulation. The therapist uses the manipulative hand to localize the motion segment targeted (C1/C2) in rotation motion and uses the hand to perform a high-velocity, low-amplitude thrust into rotation, which is directed up towards the patient’s contra-lateral eye.

Figure 6

Supine upper thoracic on mid-thoracic spine manipulation. The therapist uses the manipulative hand to stabilize the inferior vertebra of the motion segment targeted and uses the body to push down through the patient’s arms, to perform a high-velocity, low-amplitude thrust.

Figure 7

Deep cervical flexor exercise. The patient is asked to gently nod the head as he/she was saying ‘yes’ without restoring to retraction, without strictly involvement of superficial flexors, and without a quick, jerky cervical flexion movement.