Myofascial Release for the Treatment of Tension-Type, Cervicogenic Headache or Migraine: A Systematic Review and Meta-Analysis.

Objective: To assess the effectiveness of myofascial release (MFR) techniques on the intensity of headache pain and associated disability in patients with tension-type headache (TTH), cervicogenic headache (CGH), or migraine. Design: A systematic review and meta-analysis. Methods: Eight databases were searched on September 15, 2023, including PubMed, Scopus, Web of Science, CINAHL, Cochrane Library, Embase, CNKI, and Wanfang Database. The risk of bias was evaluated utilizing the Cochrane Risk of Bias 2 (RoB 2) tool. Results: Pooled results showed that MFR intervention significantly reduces pain intensity [SMD = -2.01, 95% CI (-2.98, -1.03), I2 = 90%, P < 0.001] and improves disability [SMD = -1.3, 95% CI (-1.82, -0.79), I2 = 74%, P < 0.001]. Subgroup analysis based on the type of headache revealed significant reductions in pain intensity for CGH [SMD = -2.01, 95% CI (-2.73, -1.29), I2 = 63%, P < 0.001], TTH [SMD = -0.86, 95% CI (-1.52, -0.20), I2 = 50%, P=0.01] and migraine [SMD = -6.52, 95% CI (-8.15, -4.89), P < 0.001] and in disability for CGH [SMD = -1.45, 95% CI (-2.07, -0.83), I2 = 0%, P < 0.001]; TTH [SMD = -0.98, 95% CI (-1.32, -0.65), I2 = 0%, P < 0.001] but not migraine [SMD = -2.44, 95% CI (-6.04, 1.16), I2 = 97%, P=0.18]. Conclusion: The meta-analysis results indicate that MFR intervention can significantly alleviate pain and disability in TTH and CGH. For migraine, however, the results were inconsistent, and there was only moderate quality evidence of disability improvement for TTH and CGH. In contrast, the quality of other evidence was low or very low.

Massage for neck pain.

BACKGROUND: Massage is widely used for neck pain, but its effectiveness remains unclear. OBJECTIVES: To assess the benefits and harms of massage compared to placebo or sham, no treatment or exercise as an adjuvant to the same co-intervention for acute to chronic persisting neck pain in adults with or without radiculopathy, including whiplash-associated disorders and cervicogenic headache. SEARCH METHODS: We searched multiple databases (CENTRAL, MEDLINE, EMBASE, CINAHL, Index to Chiropractic Literature, trial registries) to 1 October 2023. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing any type of massage with sham or placebo, no treatment or wait-list, or massage as an adjuvant treatment, in adults with acute, subacute or chronic neck pain. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. We transformed outcomes to standardise the direction of the effect (a smaller score is better). We used a partially contextualised approach relative to identified thresholds to report the effect size as slight-small, moderate or large-substantive. MAIN RESULTS: We included 33 studies (1994 participants analysed). Selection (82%) and detection bias (94%) were common; multiple trials had unclear allocation concealment, utilised a placebo that may not be credible and did not test whether blinding to the placebo was effective. Massage was compared with placebo (n = 10) or no treatment (n = 8), or assessed as an adjuvant to the same co-treatment (n = 15). The trials studied adults aged 18 to 70 years, 70% female, with mean pain severity of 51.8 (standard deviation (SD) 14.1) on a visual analogue scale (0 to 100). Neck pain was subacute-chronic and classified as non-specific neck pain (85%, including n = 1 whiplash), radiculopathy (6%) or cervicogenic headache (9%). Trials were conducted in outpatient settings in Asia (n = 11), America (n = 5), Africa (n = 1), Europe (n = 12) and the Middle East (n = 4). Trials received research funding (15%) from research institutes. We report the main results for the comparison of massage versus placebo. Low-certainty evidence indicates that massage probably results in little to no difference in pain, function-disability and health-related quality of life when compared against a placebo for subacute-chronic neck pain at up to 12 weeks follow-up. It may slightly improve participant-reported treatment success. Subgroup analysis by dose showed a clinically important difference favouring a high dose (≥ 8 sessions over four weeks for ≥ 30 minutes duration). There is very low-certainty evidence for total adverse events. Data on patient satisfaction and serious adverse events were not available. Pain was a mean of 20.55 points with placebo and improved by 3.43 points with massage (95% confidence interval (CI) 8.16 better to 1.29 worse) on a 0 to 100 scale, where a lower score indicates less pain (8 studies, 403 participants; I2 = 39%). We downgraded the evidence to low-certainty due to indirectness; most trials in the placebo comparison used suboptimal massage doses (only single sessions). Selection, performance and detection bias were evident as multiple trials had unclear allocation concealment, utilised a placebo that may not be credible and did not test whether blinding was effective, respectively. Function-disability was a mean of 30.90 points with placebo and improved by 9.69 points with massage (95% CI 17.57 better to 1.81 better) on the Neck Disability Index 0 to 100, where a lower score indicates better function (2 studies, 68 participants; I2 = 0%). We downgraded the evidence to low-certainty due to imprecision (the wide CI represents slight to moderate benefit that does not rule in or rule out a clinically important change) and risk of selection, performance and detection biases. Participant-reported treatment success was a mean of 3.1 points with placebo and improved by 0.80 points with massage (95% CI 1.39 better to 0.21 better) on a Global Improvement 1 to 7 scale, where a lower score indicates very much improved (1 study, 54 participants). We downgraded the evidence to low-certainty due to imprecision (single study with a wide CI that does not rule in or rule out a clinically important change) and risk of performance as well as detection bias. Health-related quality of life was a mean of 43.2 points with placebo and improved by 5.30 points with massage (95% CI 8.24 better to 2.36 better) on the SF-12 (physical) 0 to 100 scale, where 0 indicates the lowest level of health (1 study, 54 participants). We downgraded the evidence once for imprecision (a single small study) and risk of performance and detection bias. We are uncertain whether massage results in increased total adverse events, such as treatment soreness, sweating or low blood pressure (RR 0.99, 95% CI 0.08 to 11.55; 2 studies, 175 participants; I2 = 77%). We downgraded the evidence to very low-certainty due to unexplained inconsistency, risk of performance and detection bias, and imprecision (the CI was extremely wide and the total number of events was very small, i.e < 200 events). AUTHORS' CONCLUSIONS: The contribution of massage to the management of neck pain remains uncertain given the predominance of low-certainty evidence in this field. For subacute and chronic neck pain (closest to 12 weeks follow-up), massage may result in a little or no difference in improving pain, function-disability, health-related quality of life and participant-reported treatment success when compared to a placebo. Inadequate reporting on adverse events precluded analysis. Focused planning for larger, adequately dosed, well-designed trials is needed.

Physical Therapist Interventions to Reduce Headache Intensity, Frequency, and Duration in Patients With Cervicogenic Headache: A Systematic Review and Network Meta-Analysis.

OBJECTIVE: The aim of this study was to assess the efficacy of physical therapist interventions on the intensity, frequency, and duration of headaches, as well as on the quality of life of patients with cervicogenic headache. METHODS: The following databases were searched up to October 2022: Physiotherapy Evidence Database, Web of Science, Pubmed, and Cochrane Library. Randomized controlled trials assessing the effect of physical therapist interventions on adults with cervicogenic headache were included. Quality appraisal was conducted using the Cochrane risk of bias 2.0 tool and the Confidence in Network Meta-analysis web app. Synthesis methods were conducted in accordance with the Cochrane Handbook. RESULTS: Of the 28 identified reports, 23 were included in the quantitative synthesis. Manipulation plus dry needling was the highest-ranked intervention to reduce the short-term headache intensity (mean difference [MD] = -4.87; 95% CI = -8.51 to -1.24) and frequency (MD = -3.09; 95% CI = -4.93 to -1.25) when compared to a control intervention. Other high-ranked and clinically effective interventions (when compared to a control intervention) were muscle-energy technique plus exercise (MD = 4.37; 95% CI = -8.01 to -0.74), as well as soft tissue techniques plus exercise (MD = -3.01; 95% CI = -5.1 to -0.92) to reduce short-term headache intensity, and dry needling plus exercise (MD = -2.92; 95% CI = -4.73 to -1.11) to reduce short-term headache frequency. These results were based on a low certainty of evidence. CONCLUSION: The 4 most highly ranked interventions can be considered in clinical practice. However, no conclusive recommendation can be made due to the low certainty of evidence. IMPACT: Combined interventions such as spinal joint manipulation plus dry needling and muscle-energy technique or soft tissue techniques or dry needling plus exercises seem to be the best interventions to reduce short-term cervicogenic headache intensity and/or frequency.

Efficacy and safety of acupuncture in the treatment of post-traumatic headache secondary to mild traumatic brain injury: A systematic evaluation and meta-analysis protocol of randomized controlled trials.

INTRODUCTION: Post-traumatic headache secondary to mild traumatic brain injury in patients has become an important factor in their prognosis. Due to the lack of effective pharmacological treatments, non-pharmacological interventions such as acupuncture are considered to have greater potential. However, the efficacy and safety of acupuncture treatment have not been clearly demonstrated. The purpose of this meta-analysis protocol is to investigate the effectiveness and safety of acupuncture in the treatment of headache secondary to mild traumatic brain injury. METHODS AND ANALYSIS: Seven English and Chinese databases will be selected and searched according to their respective search methods, spanning the period from database creation to April 2022, and the languages will be limited to English and Chinese. Only randomized controlled trials will be included. Study selection, data collection, and risk of bias control will be performed by two independent investigators. Any disagreements will be referred to a third independent investigator for decision and documentation. Revman software will be used to complete our meta-analysis, and risk of bias assessment, subgroup analysis, and sensitivity analysis will be performed to correct the results. Finally we will assess the reliability of our final results using the Recommended Guidelines Development Tool for Assessment. ETHICS AND DISSEMINATION: All data for this study will be obtained from published journals, so no ethical review will be required. The completed review will be published in a peer-reviewed journal and the findings will be further disseminated through presentation at an appropriate forum or conference.

The Efficacy of Manual Therapy and Pressure Biofeedback-Guided Deep Cervical Flexor Muscle Strength Training on Pain and Functional Limitations in Individuals with Cervicogenic Headaches: A Randomized Comparative Study.

Objective: This study aimed to compare the efficacy of manual therapy and pressure biofeedback-guided DCFM strength training on pain intensity and functional limitations in individuals with CGH. Trial Design. A double-blinded, two-arm parallel group randomized comparative design. Methods: After applying the eligibility criteria, sixty out of eighty-nine CGH patients were recruited from King Saud University Medical Center in Riyadh and randomly allocated to intervention groups using simple random sampling. Group 1 underwent pressure biofeedback-guided DCFM strength training and conventional treatment, while Group 2 received manual therapy and conventional treatment for three consecutive weeks. The main outcome measures were scores on the visual analog scale (VAS) and the headache disability index (HDI). One assessor and two physical therapists were blinded to group allocation. Results: Sixty out of eighty participants aged 29-40 years were randomized into intervention groups (n = 30/group; age (mean ± standard deviation): group 1 = 35.0 ± 2.82; group 2 = 34.87 ± 2.60), and their data were analyzed. A significant improvement (95% CI, p < 0.05) was observed within each group when comparing the VAS and HDI scores between baseline and postintervention. In contrast, between-group comparisons for the outcome score of VAS and HDI revealed nonsignificant differences in the first, second, and third weeks after intervention, except for the VAS score, which showed a significant difference in weeks 2 and 3 after intervention. Cohen's d-value indicated that the intervention effect size for reducing pain was larger in group 1 than in group 2 at weeks 2 and 3. Conclusion: Compared with manual therapy, pressure biofeedback-guided DCFM strength training showed a greater reduction in pain intensity (assessed using the VAS) at weeks two and three. However, both treatments were equally effective in lowering headache-related functional limitations in patients with CGH. This trial is registered with ClinicalTrial.gov PRS (Identifier ID: NCT05692232).

The Role of Manual Therapies in the Treatment of Headache Disorders.

PURPOSE OF REVIEW: A comprehensive headache treatment plan typically requires both medication and non-medication treatment strategies. Manual therapies offer another therapeutic approach to headache treatment. This article reviews the evidence for manual therapies in the treatment of headache disorders. RECENT FINDINGS: Current evidence shows potential benefit from myofascial trigger point injections, myofascial release, and massage for the treatment of various headache types. There is also evidence for strain counterstrain technique, ischemic compression, and spinal manipulative therapies for cervicogenic headache. Although larger randomized clinical trials are necessary for many of these modalities, recent findings show that manual therapies could be an important tool for the treatment of some headache disorders.

The cervical spine in tension type headache.

INTRODUCTION: The concept that headaches may originate in the cervical spine has been discussed over decades and is still a matter of debate. The cervical spine has been traditionally linked to cervicogenic headache; however, current evidence supports the presence of cervical musculoskeletal dysfunctions also in tension-type headache. PURPOSE: This position paper discusses the most updated clinical and evidence-based data about the cervical spine in tension-type headache. IMPLICATIONS: Subjects with tension-type headache exhibit concomitant neck pain, cervical spine sensitivity, forward head posture, limited cervical range of motion, positive flexion-rotation test and also cervical motor control disturbances. In addition, the referred pain elicited by manual examination of the upper cervical joints and muscle trigger points reproduces the pain pattern in tension-type headache. Current data supports that the cervical spine can be also involved in tension-type headache, and not just in cervicogenic headache. Several physical therapies including upper cervical spine mobilization or manipulation, soft tissue interventions (including dry needling) and exercises targeting the cervical spine are proposed for managing tension-type headache; however, the effectiveness of these interventions depends on a proper clinical reasoning since not all will be equally effective for all individuals with tension-type headache. Based on current evidence, we propose to use the terms cervical "component" and cervical "source" when discussing about headache. In such a scenario, in cervicogenic headache the neck can be the cause (source) of the headache whereas in tension-type headache the neck will have a component on the pain pattern, but it will be not the cause since it is a primary headache.

Thalamic subfield iron accumulation after acute mild traumatic brain injury as a marker of future post-traumatic headache intensity.

OBJECTIVE: To explore alterations in thalamic subfield volume and iron accumulation in individuals with post-traumatic headache (PTH) relative to healthy controls. BACKGROUND: The thalamus plays a pivotal role in the pathomechanism of pain and headache, yet the role of the thalamus in PTH attributed to mild traumatic brain injury (mTBI) remains unclear. METHODS: A total of 107 participants underwent multimodal T1-weighted and T2* brain magnetic resonance imaging. Using a clinic-based observational study, thalamic subfield volume and thalamic iron accumulation were explored in 52 individuals with acute PTH (mean age = 41.3; standard deviation [SD] = 13.5), imaged on average 24 days post mTBI, and compared to 55 healthy controls (mean age = 38.3; SD = 11.7) without history of mTBI or migraine. Symptoms of mTBI and headache characteristics were assessed at baseline (0-59 days post mTBI) (n = 52) and 3 months later (n = 46) using the Symptom Evaluation of the Sports Concussion Assessment Tool (SCAT-5) and a detailed headache history questionnaire. RESULTS: Relative to controls, individuals with acute PTH had significantly less volume in the lateral geniculate nucleus (LGN) (mean volume: PTH = 254.1, SD = 43.4 vs. controls = 278.2, SD = 39.8; p = 0.003) as well as more iron deposition in the left LGN (PTH: T2* signal = 38.6, SD = 6.5 vs. controls: T2* signal = 45.3, SD = 2.3; p = 0.048). Correlations in individuals with PTH revealed a positive relationship between left LGN T2* iron deposition and SCAT-5 symptom severity score at baseline (r = -0.29, p = 0.019) and maximum headache intensity at the 3-month follow-up (r = -0.47, p = 0.002). CONCLUSION: Relative to healthy controls, individuals with acute PTH had less volume and higher iron deposition in the left LGN. Higher iron deposition in the left LGN might reflect mTBI severity and poor headache recovery.

Efficacy of physiotherapy interventions for the management of adults with cervicogenic headache: A systematic review and meta-analyses.

OBJECTIVE: To update and appraise the efficacy of physiotherapy for adults with cervicogenic headache. LITERATURE SURVEY: Bibliographic searches were conducted up to October 2021 for randomized controlled trials (RCTs), assessing the efficacy of physiotherapy interventions for adults with cervicogenic headache, in five databases: CINAHL, Physiotherapy Evidence Database (PEDro), PubMed, Sage Journals, and Wiley Online Library. METHODOLOGY: Data extraction of included trials was conducted by two reviewers according to a standardized extraction form. The PEDro tool and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach were used for grading evidence. Results from trials with similar interventions and with similar outcome measures were pooled into separate meta-analyses. A qualitative synthesis was performed for studies that were not pooled into meta-analyses. SYNTHESIS: Fourteen trials were included. Moderate-certainty evidence indicates that manual therapy significantly reduces headache frequency (mean difference [MD]: -0.93 episodes/week; 95% confidence interval [CI]: -1.40 to -0.46; 2 RCTs; n = 265) compared to sham manual therapy, and headache frequency (MD: -1.23 episodes/week; 95% CI: -1.55 to -0.91; 3 RCTs; n = 126) and intensity (MD: -1.63/10; 95% CI: -2.15 to -1.10; 4 RCTs; n = 208) compared to no treatment in the short term. At 12-month follow-up, moderate-certainty evidence indicates that manual therapy did not lead to greater reduction in headache intensity (MD Visual Analog Scale 0-10: -0.12; 95% CI: -0.49 to 0.26; 2 RCTs; n = 265) or frequency (MD: -0.32 episodes/week; 95% CI: -0.91 to 0.28; 2 RCTs; n = 265) when compared to a sham manual therapy. In the long-term, in one high quality trial, neck exercise significantly reduced headache intensity compared to no treatment (MD: -1.51/10; 95% CI: -2.52 to -0.50; n = 100) or to aerobic exercises in another trial of moderate quality (MD: -1.15/10; 95% CI: -2.1 to -0.20; n = 180). CONCLUSIONS: Manual therapy in the short term and neck exercise in the long term may be efficacious to treat adults with cervicogenic headache. More high-quality evidence is needed and future results may change the current conclusions. Trial Registration Prospero: #CRD42019135858.

Targeted dietary interventions to reduce pain in persistent post-traumatic headache among service members: Protocol for a randomized, controlled parallel-group trial.

INTRODUCTION: Post-traumatic headache (PTH) is common after traumatic brain injury (TBI), especially among active-duty service members (SMs), affecting up to 35% of patients with chronic TBI. Persistent PTH is disabling and frequently unresponsive to treatment and is often migrainous. Here, we describe a trial assessing whether dietary modifications to increase n-3 eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and reduce n-6 linoleic acid (LA), will alter nociceptive lipid mediators and result in clinical improvements in persistent PTH. METHODS: This prospective, randomized, controlled trial tests the efficacy, safety, and biochemical effects of targeted, controlled alterations in dietary n-3 and n-6 fatty acids in 122 adult SMs and military healthcare beneficiaries with diagnosed TBI associated with actively managed persistent frequent (>8 /month) PTH with migraine. Following a 4-week baseline, participants are randomized to one of two equally intensive dietary regimens for 12 additional weeks: 1) increased n-3 EPA + DHA with low n-6 LA (H3L6); 2) usual US dietary content of n-3 and n-6 fatty acids (Control). During the intervention, participants receive diet arm-specific study oils and foods sufficient for 75% of caloric needs and comprehensive dietary counseling. Participants complete daily headache diaries throughout the intervention. Clinical outcomes, including the Headache Impact Test (HIT-6), headache hours per day, circulating blood fatty acid levels, and bioactive metabolites, are measured pre-randomization and at 6 and 12 weeks. Planned primary analyses include pre-post comparisons of treatment groups on clinical measures using ANCOVA and mixed-effects models. Similar approaches to explore biochemical and exploratory clinical outcomes are planned. CLINICALTRIALS: gov registration: NCT03272399.

Effectiveness of dry needling for headache: A systematic review.

INTRODUCTION: Non-pharmacological treatment of patients with headache, such as dry needling (DN), is associated with less morbidity and mortality and lower costs than pharmacological treatment. Some of these techniques are useful in clinical practice. The aim of this study was to review the level of evidence for DN in patients with headache. METHODS: We performed a systematic review of randomised clinical trials on headache and DN on the PubMed, Web of Science, Scopus, and PEDro databases. Methodological quality was evaluated with the Spanish version of the PEDro scale by 2 independent reviewers. RESULTS: Of a total of 136 studies, we selected 8 randomised clinical trials published between 1994 and 2019, including a total of 577 patients. Two studies evaluated patients with cervicogenic headache, 2 evaluated patients with tension-type headache, one study assessed patients with migraine, and the remaining 3 evaluated patients with mixed-type headache (tension-type headache/migraine). Quality ratings ranged from low (3/10) to high (7/10). The effectiveness of DN was similar to that of the other interventions. DN was associated with significant improvements in functional and sensory outcomes. CONCLUSIONS: Dry needling should be considered for the treatment of headache, and may be applied either alone or in combination with pharmacological treatments.

Effects of acupuncture treatment on posttraumatic headache after traumatic brain injury in patients: A protocol for systematic review.

BACKGROUND: Posttraumatic headache (PTH) after traumatic brain injury (TBI) is a common clinical symptom, which refers to a headache that occurs after TBI. Acupuncture is often used for the treatment of such patients in China, and significant clinical effects have been achieved. However, to date, its efficacy has not been methodically evaluated. The purpose of this systematic review is to provide evidence to prove the effectiveness of acupuncture in the treatment of PTH in patients with TBI. METHODS: This systematic review will be conducted in accordance with the preferred reporting items for systematic review and meta-analysis protocols. The following electronic databases will be searched from their inception to February 2022: PubMed, Web of Science, Embase, PsycINFO, the Cochrane Library, and Chinese databases such as Chinese Biomedical Literature (CBM), Chinese Medical Current Content (CMCC), Chinese Scientific Journal Database (VIP), WanFang Database, and China National Knowledge Infrastructure (CNKI). No language restrictions will be applied to the search strategy. Randomized controlled trials and cohort and case-control studies that met the inclusion and exclusion criteria will be included in this study. The meta-analysis will be performed using RevMan 5.3 software. Each session of this systematic review will be conducted independently by 2 members. RESULTS: This review evaluates the efficacy of acupuncture in the treatment of PTH after TBI. CONCLUSION: This review provides substantial evidence for the clinical application of acupuncture in PTH treatment after TBI. ETHICS AND DISSEMINATION: Since the data in this study will be retrieved from published trials, therefore the Patient Consent Statement and Ethical Approval are not required. We will disseminate our results by publishing the research in a peer-reviewed journal. TRAIL REGISTRATION NUMBER: The protocol was registered in INPLASY (INPLASY 202220073).

Acupuncture plus massage for cervicogenic headache: A protocol for systematic review and meta-analysis.

BACKGROUND: Cervicogenic headache (CGH), one of the most common headaches. It is characterized by pain starting from the neck and gradually involving the eyes, frontal and temporal regions. Acupuncture and massage therapy has been widely used in the treatment of CGH, the purpose of this study was to evaluate the effectiveness and safety of acupuncture combined with massage in the treatment of CGH. METHODS: The databases of PubMed, Embase, Cochrane library, Medicine, Web of Science, China National Knowledge Infrastructure, Wan-Fang Database, China Biomedical Literature Service System, and Chongqing VIP Chinese Science will be searched. This study will include randomized controlled trials of acupuncture combined with massage in the treatment of CGH published before November 2021. The primary outcomes included the overall efficiency, visual simulation score, neck activity score, quality of life score, and adverse reactions as secondary outcomes were assessed. Cochrane bias risk assessment tool will be used for literature data screening and quality evaluation, and using RevMan5.4 to collect data for statistical analysis. We then will use the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the overall quality of evidence supporting the primary outcomes. RESULTS: This systematic review will provide a high-quality synthesis to evaluate the efficacy and safety of acupuncture combined with massage therapy in the treatment of CGH, providing a reference for the safe and effective treatment plan. CONCLUSION: This study provides evidence that acupuncture combined with massage is effective and safe for patients with CGH. SYSTEMATIC REVIEW REGISTRATION: INPLASY2021120049U1.

T2* reduction in patients with acute post-traumatic headache.

OBJECTIVES: Although iron accumulation in pain-processing brain regions has been associated with repeated migraine attacks, brain structural changes associated with post-traumatic headache have yet to be elucidated. To determine whether iron accumulation is associated with acute post-traumatic headache, magnetic resonance transverse relaxation rates (T2*) associated with iron accumulation were investigated between individuals with acute post-traumatic headache attributed to mild traumatic brain injury and healthy controls. METHODS: Twenty individuals with acute post-traumatic headache and 20 age-matched healthy controls underwent 3T brain magnetic resonance imaging including quantitative T2* maps. T2* differences between individuals with post-traumatic headache versus healthy controls were compared using age-matched paired t-tests. Associations of T2* values with headache frequency and number of mild traumatic brain injuries were investigated using multiple linear regression in individuals with post-traumatic headache. Significance was determined using uncorrected p-value and cluster size threshold. RESULTS: Individuals with post-traumatic headache had lower T2* values compared to healthy controls in cortical (bilateral frontal, bilateral anterior and posterior cingulate, right postcentral, bilateral temporal, right supramarginal, right rolandic, left insula, left occipital, right parahippocampal), subcortical (left putamen, bilateral hippocampal) and brainstem regions (pons). Within post-traumatic headache subjects, multiple linear regression showed a negative association between T2* in the right inferior parietal/supramarginal regions and number of mild traumatic brain injuries and a negative association between T2* in bilateral cingulate, bilateral precuneus, bilateral supplementary motor areas, bilateral insula, right middle temporal and right lingual areas and headache frequency. CONCLUSIONS: Acute post-traumatic headache is associated with iron accumulation in multiple brain regions. Correlations with headache frequency and number of lifetime mild traumatic brain injuries suggest that iron accumulation is part of the pathophysiology or a marker of mild traumatic brain injury and post-traumatic headache.

The Effect of Adding Dry Needling to Physical Therapy in the Treatment of Cervicogenic Headache: A Randomized Controlled Trial.

OBJECTIVE: To compare the long-term effect of adding real or sham dry needling with conventional physiotherapy in cervicogenic headache. DESIGN: A randomized controlled trial. SETTING: Physiotherapy Clinic, Rouhani Hospital of Babol University of Medical Sciences, Iran. SUBJECTS: Sixty-nine patients with cervicogenic headache. METHODS: Patients were randomly assigned into a control group (n = 23) receiving conventional physical therapy; a dry needling group (n = 23) receiving conventional physical therapy and dry needling on the cervical muscles; placebo needling group (n = 23) receiving conventional physical therapy and superficial dry needling at a point away from the trigger point. The primary outcome was the headache intensity and frequency. Neck disability, deep cervical flexor performance, and range of motion were secondary outcomes. Outcomes were assessed immediately after treatment and 1, 3, and 6 months later. RESULTS: Sixty-five patients were finally included in the analysis. Headache intensity and neck disability decreased significantly more in the dry needling compared to sham and control groups after treatment and during all follow-ups. The frequency of headaches also reduced more in the dry needling than in control and sham groups, but it did not reach statistical significance. Higher cervical range of motion and enhancement of deep cervical flexors performance was also observed in the dry needling compared to sham and control groups. CONCLUSION: Dry needling has a positive effect on pain and disability reduction, cervical range of motion, and deep cervical flexor muscles performance in patients with cervicogenic headache and active trigger points, although the clinical relevance of the results was small. TRIAL REGISTRATION: The trial design was registered in the Iranian Registry of Clinical Trials (www.irct.ir, IRCT20180721040539N1) before the first patient was enrolled.

Ultrasound-guided interfascial blocks of the trapezius muscle for cervicogenic headache: A report of two cases.

Cervicogenic headache (CEH) is a headache arising from cervical nociceptive structures such as facet joints, disci intervertebrales, muscles and ligaments. Myofascial trigger points (TrPs) are common factors in patients with CEH and contribute to the pain and disability. In this report, we present two patients with CEH who had TrPs in their upper trapezius muscles. Each patient received an ultrasound-guided interfascial block of the trapezius muscle. Case 1 A 79-year-old female patient presented with a complaint of headache due to trigger point in her upper trapezius muscle. Her Numerical Rating Scale (NRS) score for pain intensity was 10. We performed an ultrasound-guided interfascial block of the trapezius muscle. Her NRS score at 30 minutes after the procedure was 2. The patient was pain free during the two months follow-up period. Case 2 A 55-year-old female patient presented with a complaint of headache due to trigger point in her upper trapezius muscle. Her Numerical Rating Scale (NRS) score for pain intensity was 8. We performed an ultrasound-guided interfascial block of the trapezius muscle. Her NRS score at 30 minutes after procedure was 3. The patient was pain free during the two weeks follow-up period. The structure of the fascia can ease diffusion of an injected anaesthetic during diagnostic and therapeutic blocks, and interfascial injections are becoming more common. We suggest that this treatment may produce positive effects for patients with CEH caused by trigger points.

Manual therapy in adults with tension-type headache: A systematic review.

INTRODUCTION: Tension-type headache is the most common primary headache, with a high prevalence and a considerable socioeconomic impact. Manual physical therapy techniques are widely used in the clinical field to treat the symptoms associated with tension-type headache. This systematic review aims to determine the effectiveness of manual and non-invasive therapies in the treatment of patients with tension-type headache. DEVELOPMENT: We conducted a systematic review of randomised controlled trials in the following databases: Brain, PubMed, Web of Science, PEDro, Scopus, CINAHL, and Science Direct. Ten randomised controlled trials were included for analysis. According to these studies, manual therapy improves symptoms, increasing patients' well-being and improving the outcome measures analysed. CONCLUSIONS: Manual therapy has positive effects on pain intensity, pain frequency, disability, overall impact, quality of life, and craniocervical range of motion in adults with tension-type headache. None of the techniques was found to be superior to the others; combining different techniques seems to be the most effective approach.

[Observation on analgesic effect of acupuncture combined with manipulation on cervicogenic headache].

OBJECTIVE: To compare therapeutic effects between nape acupuncture combined with manipulation and simple manipulation in treating cervicogenic headache, and to verify the synergistic effect of manipulation and nape acupuncture. METHODS: Total 60 patients with cervicogenic headache were divided into two groups:nape acupuncture combined with manipulation group (group A) and manipulation group(group B). There were 30 patients in group A, including 12 males and 18 females with an average age of (41.37±12.09) years old, and an average course of disease of (23.73±15.54) months;there were 30 patients in the manipulation group (group B), including 14 males and 16 females with an average age of (42.40±12.05) years old, and an average course of disease of (25.53±14.33) months. In the group A, acupuncture therapy was performed firstly at the bilateral Fengchi (GB20), Wangu (GB12) and Ashi points 2 inches from the left and right sides under C2 and C4 spinous processes, and after retaining the needle for 30 minutes, the manipulation therapy was performed at the above points for 20 minutes. In the group B, manipulation therapy was performed alone. The patients in both groups were treated once a day, every 5 days of treatment interval 2 days, 10 times as a course of treatment, a total of 2 courses of treatment. The average onset time of analgesia and the average maintenance time of analgesia after the first treatment were observed, and the McGill Pain Questionnaire was used to compare the average pain scores between the two groups after the first treatment and two courses of treatment. RESULTS: There was no significant difference in the onset time of analgesia between the two groups[(5.97±3.21) min vs(7.30±3.97) min, P>0.05]. The duration of analgesia in the group A was longer than that in the group B[(12.13±6.34) h vs (8.17±4.36) h, P<0.05]. There was no significant difference in pain rating index (PRI), visual analogue scale (VAS) and present pain intensity (PPI) scores between the two groups after the first treatment (all P>0.05);after the two courses, the scores of three items in the group A were lower than those in the group B(all P<0.05). CONCLUSION: Nape needling can prolong the analgesic time of manipulation and improve the analgesic effect of manipulation.

Assessment of the efficacy of tuina on treating cervicogenic headache: A protocol for systematic review and meta-analysis.

BACKGROUND: Cervicogenic headache is a secondary headache characterized by unilateral headache, symptoms, and signs of neck involvement. It is often worsened by neck movement, sustained awkward head position, or external pressure over the upper cervical or occipital region on the symptomatic side. In this systematic review, we aimed to evaluate the efficacy and safety of massage therapy for the treatment of cervicogenic headache. METHODS: We searched the China National Knowledge Infrastructure, Chinese Scientific Journal Database, Wanfang Database, China Doctoral Dissertations Full-Text Database, China Master's Theses Full-Text Database, Cochrane Central Register of Controlled Trials, PubMed, and Embase. We will select all eligible studies published on or before April 1, 2021. We will use Review Manager 5.4, provided by the Cochrane Collaborative Network for statistical analysis. We then assessed the quality and risk of the included studies and observed the outcome measures. RESULTS: This meta-analysis further confirmed the benefits of tuina in the treatment of cervicogenic headache. CONCLUSION: The purpose of this meta-analysis was to explore the effect of tuina on patients with cervicogenic headache and to provide more options for clinicians and patients to treat cervicogenic headache. ETHICS AND DISSEMINATION: This systematic review will evaluate the efficacy and safety of tuina in the treatment of cervicogenic headache. Since all the data included were published, the systematic review did not require ethical approval. REGISTRATION NUMBER: INPLASY202150053.

Effectiveness of Mulligan manual therapy over exercise on headache frequency, intensity and disability for patients with migraine, tension-type headache and cervicogenic headache - a protocol of a pragmatic randomized controlled trial.

BACKGROUND: Non - pharmacological management of migraine, tension-type headache (TTH), and cervicogenic headache (CGH) may include spinal manual therapy and exercise. Mulligan Manual Therapy (MMT) utilizes a protocol of headache elimination procedures to manage headache parameters and associated disability, but has only been evaluated in CGH. There is little evidence for its effectiveness in migraine and TTH. This study aims to determine the effectiveness of MMT and exercise over exercise and placebo in the management of migraine, TTH, and CGH. METHODS: This pragmatic trial is designed as a prospective, three-armed randomised controlled trial in a clinical setting provided at a general hospital physiotherapy department. Two hundred ninety-seven participants with a diagnosis of migraine, TTH or CGH based on published headache classification guidelines will be included. An assessor blind to group allocation will measure outcomes pre-and post-intervention as well as 3 and 6 months after commencement of treatment. Participants will be allocated to one of the three groups: MMT and exercise; placebo and exercise; and exercise alone. The primary outcome measure is headache frequency. Secondary outcome measures are headache duration and intensity, medication intake, pressure pain threshold (PPT), range of motion recorded with the flexion rotation test, and headache disability recorded with Headache Activities of Daily Living Index (HADLI). The intention-to-treat principle will be followed for statistical analysis. Between groups differences for all outcome measures at baseline and at reassessment points and 95% confidence intervals will be calculated using a mixed model ANOVA. Post hoc tests will be conducted to identify any significant difference between groups and over time. DISCUSSION: This pragmatic study will provide evidence for the effectiveness of MMT when compared with a placebo intervention and exercise on headache frequency, intensity, and disability. Limitations are that baseline evaluation of headache parameters may be affected by recall bias. External validity will be limited to the population with a minimum 1-year history of headache. The HADLI is not yet extensively evaluated for its psychometric properties and association between PPT and headache parameters is lacking. Performance bias is inevitable as a single therapist will be delivering all interventions. TRIAL REGISTRATION: The trial was registered prospectively under the Clinical Trial Registry India (Registration number: CTRI/2019/06/019506 , dated on 03/06/2019). .