The effect of physical therapy integrated with pharmacotherapy on tension-type headache and migraine in children and adolescents

Abstract

Background: Tension-type headache (TTH) and migraine are prevalent neurological conditions in children and adolescents that significantly impact activity of daily living (ADL) and quality of life (QOL). Although physical therapy targeting cervical myofascial trigger points (MTrPs) on TTH and migraine has been extensively studied in adults, the efficacy in pediatric patients remains unexplored. The aim of this study is to reveal the effect of physical therapy integrated with pharmacotherapy on TTH and migraine in children and adolescents.

Methods: We conducted a prospective, observational cohort study recruiting consecutive patients aged 6 to 18 years with TTH and migraine with cervical MTrPs. They were classified into 4 types of headaches: frequent episodic TTH (FRTTH), chronic TTH (CTTH), episodic migraine (EM) and chronic migraine (CM). The once-weekly 40-minutes physical therapy session integrated with pharmacotherapy (integrated physical therapy) was continued until the treatment goals (headache days per week less than 2 days, headache impact test-6 (HIT-6) score to below of 50, and the ability to attend school daily) was achieved. Multifaceted assessments including headache frequency (headache days per week), headache intensity using the Visual Analogue Scale (VAS), pain catastrophizing score (PCS), hospital anxiety and depression scale (HADS) score, HIT-6 scores, and EuroQol 5 dimensions 5-level questionnaire (EQ-5D-5 L) scores, were conducted to evaluate the treatment effects.

Results: 161 patients were enrolled in this study. 106 patients (65.8%) were diagnosed with TTH: 70 (66.8%) with FETHH, 36 (34.0%) with CTTH, and 55 patients (34.2%) were diagnosed with migraine: 43 patients (78.2%) with EM, 12 patients (21.8%) with CM. We observed significant improvements in headache frequency, headache intensity, PCS, HADS score, HIT-6 scores, and EQ-5D-5 L scores before and after the treatment in all 4 types of headaches. The average number of sessions required to achieve the treatment goals was 4 times (weeks) for patients with FETTH and EM, 5.5 for those with CTTH, and 7.5 for those with chronic migraine.

Conclusion: The integrated physical therapy on pediatric TTH and migraine patients with the cervical MTrPs was significantly effective in reducing headache symptoms and improving ADL and QOL.

Keywords: Adolescents; Children; Headache; Migraine; Myofascial trigger points; Pediatric; Physical therapy; Physiotherapy; Tension-type headache.

Fig. 1

Multifaceted assessments. #1) Assessing cervical myofascial Trigger points (MTrP): Applying manual compression to MTrP to determine the presence or absence of referred pain. #2) Assessing headache locations: instructing patients to illustrate the areas in which they experienced headache on a diagram of the human body. #3) Assessing the range of motion of the cervical spine using the Easy-Angle Digital Goniometer (Ito Ultrashortwave Co., Ltd.). The device is positioned on the head to measure the mobility of the cervical region

Fig. 2

Integrated physical therapy. The figure illustrates the concept of integrated physical therapy, which combines various physical therapy techniques and methodologies into a cohesive treatment plan. This approach includes a blend of manual therapies, exercise, different modalities, and patient education. The integration of different strategies results in a tailored therapy program designed to address the multifaceted needs of the patient for optimal rehabilitation outcomes

Fig. 3

Neck and shoulder stretch exercises. The figure illustrates the neck and shoulder stretch exercises, which include cervical MTrP massage, scapular training, pectoral stretching and shouder exercise. These exercises are designed to alleviate muscle tension, improve flexibility, and reduce the frequency and intensity of headaches

Fig. 4

Flow chart of the study process based on International Classification of Headache, 3rd ed (ICHD-3). TTH: Tension-type headache; FETH: Frequent episodic tension-type headache; CTTH: Chronic tension-type headache; EM: Episodic migraine; CM: Chronic migraine

Fig. 5

Comparison of the effectiveness of integrative physical therapy at 3 different time points (pre-treatment, 1 month after treatment, and at the last treatment). We used the Kruskal-Wallis test. For multiple comparisons, a Bonferroni correction was applied to adjust the significance level. In addition, the Friedman test was applied to evaluate the treatment effect at 3 different time points. A post-hoc analysis with Wilcoxon’s signed-rank test was then performed. TTH: Tension-type headache; FETTH: Frequent episodic tension-type headache; CTTH: Chronic tension-type headache; EM: Epsodic migraine; CM: Chronic migraine; *p < 0.05; **p < 0.01

Fig. 6

Frequency of integrated physical therapy sessions. A; The Kruskal-Wallis test; FETTH: Frequent episodic tension-type headache; CTTH: Chronic tension-type headache; EM: Episodic migraine; CM: Chronic migraine. B; Percentage of headache patients requiring 5 or more integrated physical therapy sessions to improve headache; FETTH: Frequent episodic tension-type headache; CTTH: Chronic tension-type headache; EM: Episodic migraine; CM: Chronic migraine