Physiotherapy is often involved in the management of headaches, but how do we know if it is effective?
Two important things to consider when answering this question are, how is effectiveness defined, and does the headache type impact the effectiveness of physiotherapy treatment?
There are many different variables to consider when determining if treatment is effective. These may include headache intensity, duration, frequency, as well as response or need for medication. Ultimately, these variables are trying to capture if treatment has had a meaningful effect on the individual.
Research evidence shows us that:
The main aims of an initial assessment with a Physiotherapist, are to:
Headache type is diagnosed based on symptoms, and the findings from a clinical physical examination. (2) During a physical examination, the recreation and resolve of a headache when applying sustained pressure over the upper neck segments, would suggest a link between the neck and the headache. (6, 11)
Additional signs of neck dysfunction identified during an assessment may include, poor movement control, muscle weakness, hypomobility, or ‘stiffness’ of the upper neck joints and the presence of trigger points. (2, 6)
These findings, together with triggers identified in the your history, provide potential targets for treatment.
Treatment will depend on several factors including:
For some, managing a headache may consist of just avoiding triggers — weighing up if that extra glass of red wine is worth the headache in the morning — while for others, a multi-disciplinary approach involving a GP, Consultant, Physiotherapist, Psychologist, Neurologist or Pain Specialist may be required to achieve the best result.
As discussed in Headaches Part 1: Are They All the Same? sensitisation of pain pathways, or increased responsiveness of the nervous system, is a common underlying mechanism in cervicogenic headache, TTH and migraine. Treatment should therefore be aimed at factors contributing to sensitisation such as neck dysfunction, stress and poor sleep. (6, 8, 12)
An individualised headache ‘profile’, which identifies and weights various factors contributing to sensitisation, could be established to help direct the most appropriate treatment(s). (6)
Below is an example of two different headache profiles — symptomatic and asymptomatic — and how different contributing factors may direct the treatment that follows.
As you can see, an increase in any one factor might contribute towards reaching the threshold, but often it is a combination of different factors which results in exceeding the headache threshold. (6, 8, 11) In this example, addressing the neck component which is contributing to the headache may drop an individual below the symptomatic threshold.
If neck dysfunction is identified during the assessment, manual therapy and specific neck exercises are recommended. (6) Manual therapy, such as sustained joint mobilisations, is used to try and desensitise the structures in the neck which may be causing the headache symptoms. (6, 8, 11)
Poor control of deep neck flexor muscles has been reported in individuals with cervicogenic headache, tension-type headache and migraine. (6, 8) Furthermore, strengthening these muscles has shown to decrease symptoms in individuals with cervicogenic and TTH. (6, 10, 13)
If similar signs of weakness are found to be present in individuals with migraine, a neck strengthening program may also be beneficial. (6) Further research is needed however to determine this effect.
Psychological factors such as stress and anxiety may also contribute to sensitisation of pain pathways and the generation of headache symptoms. (12) Cognitive behavioural therapy (CBT) and mindfulness meditation are two psychological interventions which may be used to try and calm the central nervous system. (7, 14)
Sleep is essential for health and well-being and plays an important role in physical development, emotional regulation, cognitive performance and quality of life. (15)
Poor sleep is associated with increased sensitivity to pain and is often experienced by individuals living with chronic pain. (12) In athletes, better sleep may improve performance as well as reduce the risk of injury and illness. (15) Implementing good sleep habits to improve sleep quantity or quality should therefore be considered in management.
Although outside the scope of this blog, medication can also play an important role in addressing the increased responsiveness of the nervous system. Medications should only be taken when prescribed by a medical professional and may be used in combination with Physiotherapy in some cases.
To summarise, sensitisation of pain pathways (the nervous system) is a common feature in migraine, tension-type and cervicogenic headaches. Furthermore, neck dysfunction may be present in all three types.
Individualised Physiotherapy treatment can identify factors which may be contributing to sensitisation, as well as develop a rehabilitation program in order to address impairments, like neck dysfunction, that may be driving headache symptoms.