International consensus on the most useful physical examination tests used by physiotherapists for patients with headache: A Delphi study

Involvement of cervical disability in migraine: a literature review

Background

The trigeminal nerve theory has been proposed as a pathophysiological mechanism of migraine; however, its association with the triggers of migraine remains unclear. Cervical disability such as neck pain and restricted cervical rotation, have been associated with not only cervicogenic headaches but also migraine. The presence of cervical disability could worsen of the migraine, and also the response to pharmacologic treatment may be reduced. The aim in this review is to highlight the involvement of cervical disability in migraine, considering contributing factors.

Findings

In recent years, evidence of neck pain complaints in migraine has been increasing. In addition, there is some recent evidence of cervical musculoskeletal impairments in migraine, as detected by physical assessment. However, the main question of whether neck pain or an associated cervical disability can act as an initial factor leading to migraine attacks still remains. Daily life imposes heavy loads on cervical structures (i.e. muscles, joints and ligaments), for instance, in the forward head position. The repetitive nociceptive stimulation initiating those cervical skeletal muscle positions may amplify the susceptibility to central migraine and contribute to chronicity via the trigeminal cervical complex.

Conclusion

Further studies are needed to explain the association between cervical disability as a source of pain and the development of migraine. However, evidence suggests that cervical disability needs to be considered in the prevention and treatment of migraine.

International consensus on the most useful assessments used by physical therapists to evaluate patients with temporomandibular disorders: A Delphi study

OBJECTIVE

To identify assessment tools used to evaluate patients with temporomandibular disorders (TMD) considered to be clinically most useful by a panel of international experts in TMD physical therapy (PT).

METHODS

A Delphi survey method administered to a panel of international experts in TMD PT was conducted over three rounds from October 2017 to June 2018. The initial contact was made by email. Participation was voluntary. An e-survey, according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES), was posted using SurveyMonkey for each round. Percentages of responses were analysed for each question from each round of the Delphi survey administrations.

RESULTS

Twenty-three experts (completion rate: 23/25) completed all three rounds of the survey for three clinical test categories: 1) questionnaires, 2) pain screening tools and 3) physical examination tests. The following was the consensus-based decision regarding the identification of the clinically most useful assessments. (1) Four of 9 questionnaires were identified: Jaw Functional Limitation (JFL-8), Mandibular Function Impairment Questionnaire (MFIQ), Tampa Scale for Kinesiophobia for Temporomandibular disorders (TSK/TMD) and the neck disability index (NDI). (2) Three of 8 identified pain screening tests: visual analog scale (VAS), numeric pain rating scale (NRS) and pain during mandibular movements. (3) Eight of 18 identified physical examination tests: physiological temporomandibular joint (TMJ) movements, trigger point (TrP) palpation of the masticatory muscles, TrP palpation away from the masticatory system, accessory movements, articular palpation, noise detection during movement, manual screening of the cervical spine and the Neck Flexor Muscle Endurance Test.

CONCLUSION

After three rounds in this Delphi survey, the results of the most used assessment tools by TMD PT experts were established. They proved to be founded on test construct, test psychometric properties (reliability/validity) and expert preference for test clusters. A concordance with the screening tools of the diagnostic criteria of TMD consortium was noted. Findings may be used to guide policymaking purposes and future diagnostic research.

What is the minimal important difference of pain intensity, mandibular function, and headache impact in patients with temporomandibular disorders? Clinical significance analysis of a randomized controlled trial

BACKGROUND

There are insufficient studies providing Minimal Clinically Important Difference (MCID) for outcomes related to temporomandibular disorders (TMD).

OBJECTIVES

(1) To provide the MCID of outcomes related to TMD using the Global Rating of Change Scale (GRCS) as an anchor. (2) To verify which outcomes can predict a moderate or large response to the treatment.

STUDY DESIGN

Secondary analysis of a randomized controlled trial in subjects with TMD.

METHODS

Sixty-one women with TMD were divided into intervention and control groups. Visual Analogue Scale (VAS), Headache Impact Test (HIT-6), pressure pain thresholds (PPTs) of masticatory muscles, Mandibular Function Impairment Questionnaire (MFIQ), and Craniocervical Flexion Test (CCFT) were collected at baseline and 5-weeks follow-up.

RESULTS

Participants were divided based on their response to the treatment, according to the GRCS. MCID values were provided for subjects that moderately or largely improved to the treatment. MCID was between 0 and 1.90 for orofacial pain, around 2 points for the MFIQ, between 3 and 6.26 points for the HIT-6, around 0.2 kg/cm2 for the PPTs on masticatory muscles, around 2.5 mm for MMO and between 60 and 68 points for CCFT. Orofacial pain and HIT-6 were the most discriminative variables at determining whether patients would largely/moderately improve or would not improve after treatment.

CONCLUSIONS

The values of MCID could be used as guidance for both clinical practice and research. Pain intensity and headache impact were the most predictive outcomes for improvement of the general health status of women with TMD.

Outcome measures for assessing the effectiveness of non-pharmacological interventions in frequent episodic or chronic migraine: a Delphi study

OBJECTIVES

The aim of this Delphi survey was to establish an international consensus on the most useful outcome measures for research on the effectiveness of non-pharmacological interventions for migraine. This is important, since guidelines for pharmacological trials recommend measuring the frequency of headaches with 50% reduction considered a clinically meaningful effect. It is unclear whether the same recommendations apply to complementary (or adjunct) non-pharmacological approaches, whether the same cut-off levels need to be considered for effectiveness when used as an adjunct or stand-alone intervention, and what is meaningful to patients.

SETTING

University-initiated international survey.

PARTICIPANTS

The expert panel was chosen based on publications on non-pharmacological interventions in migraine populations and from personal contacts. 35 eligible researchers were contacted, 12 agreed to participate and 10 completed all 3 rounds of the survey. To further explore how migraine patients viewed potential outcome measures, four migraine patients were interviewed and presented with the same measurement tools as the researchers.

PROCEDURES

The initial Delphi round was based on a systematic search of the literature for outcome measures used in non-pharmacological interventions for headache. Suggested outcome measures were rated by each expert, blinded towards the other members of the panel, for its usefulness on a 5-point Likert scale ranging from definitely not useful to extremely useful. Results were combined using median values and IQRs. Tools rated overall as definitely or probably not useful were excluded from subsequent rounds. Experts further suggested additional outcome measures that were presented to the panel in subsequent rounds. Additionally, experts were asked to rank the most useful tools and provide information on feasible cut-off levels for effectiveness for the three highest ranked tools.

RESULTS

Results suggest the use of the Migraine Disability Assessment (MIDAS), Headache Impact Test (HIT-6) and headache frequency as primary outcome measures. Patient experts suggested the inclusion of a measure of quality of life and evaluation of associated symptoms and fear of attacks.

CONCLUSIONS

Recommendations are for the use of the MIDAS, the HIT-6 and headache frequency, in combination with an outcome measure for quality of life. Associated symptoms and fear of attacks should also be considered as secondary outcomes, if relevant for the individual target population. The cut-off level for effectiveness should be lower for non-pharmacological interventions, especially when used as an adjunct to medication.

TRIAL REGISTRATION NUMBER

German Register of Clinical Trials (DRKS00011777).

Operationalization of the new Pain and Disability Drivers Management model: A modified Delphi survey of multidisciplinary pain management experts

BACKGROUND

We recently proposed the Pain and Disability Drivers Management (PDDM) model, which was designed to outline comprehensive factors driving pain and disability in low back pain (LBP). Although we have hypothesized and proposed 41 elements, which make up the model's five domains, we have yet to assess the external validity of the PDDM's elements by expert consensus.

RESEARCH OBJECTIVES

This study aimed to reach consensus among experts regarding the different elements that should be included in each domain of the PDDM model.

RELEVANCE

The PDDM may assist clinicians and researchers in the delivery of targeted care and ultimately enhance treatment outcomes in LBP.

METHODS

Using a modified Delphi survey, a two-round online questionnaire was administered to a group of experts in musculoskeletal pain management. Participants were asked to rate the relevance of each element proposed within the model. Participants were also invited to add and rate new elements. Consensus was defined by a greater than or equal to 75% level of agreement.

RESULTS

A total of 47 (round 1) and 33 (round 2) participants completed the survey. Following the first round, 38 of 41 of the former model elements reached consensus, and 10 new elements were proposed and later rated in the second round. Following this second round, consensus was reached for all elements (10 new + 3 from first round), generating a final model composed of 51 elements.

CONCLUSION

This expert consensus-derived list of clinical elements related to the management of LBP represents a first step in the validation of the PDDM model.

Subgrouping Factors Influencing Migraine Intensity in Women: A Semi-automatic Methodology Based on Machine Learning and Information Geometry

BACKGROUND

Migraine is a heterogeneous condition with multiple clinical manifestations. Machine learning algorithms permit the identification of population groups, providing analytical advantages over other modeling techniques.

OBJECTIVE

The aim of this study was to analyze critical features that permit the differentiation of subgroups of patients with migraine according to the intensity and frequency of attacks by using machine learning algorithms.

METHODS

Sixty-seven women with migraine participated. Clinical features of migraine, related disability (Migraine Disability Assessment Scale), anxiety/depressive levels (Hospital Anxiety and Depression Scale), anxiety state/trait levels (State-Trait Anxiety Inventory), and pressure pain thresholds (PPTs) over the temporalis, neck, second metacarpal, and tibialis anterior were collected. Physical examination included the flexion-rotation test, cervical range of cervical motion, forward head position while sitting and standing, passive accessory intervertebral movements (PAIVMs) with headache reproduction, and joint positioning sense error. Subgrouping was based on machine learning algorithms by using the nearest neighbors algorithm, multisource variability assessment, and random forest model.

RESULTS

For migraine intensity, group 2 (women with a regular migraine headache intensity score of 7 on an 11-point Numeric Pain Rating Scale [where 0 = no pain and 10 = maximum pain]) were younger and had lower joint positioning sense error in cervical rotation, greater cervical mobility in rotation and flexion, lower flexion-rotation test scores, positive PAIVMs reproducing migraine, normal PPTs over the tibialis anterior, shorter migraine history, and lower cranio-vertebral angles while standing than the remaining migraine intensity subgroups. The most discriminative variable was the flexion-rotation test score of the symptomatic side. For migraine frequency, no model was able to identify differences between groups (ie, patients with episodic or chronic migraine).

CONCLUSIONS

A subgroup of women with migraine who had common migraine intensity was identified with machine learning algorithms.

Physical therapy and migraine: musculoskeletal and balance dysfunctions and their relevance for clinical practice

BACKGROUND

Migraine is a primary headache with high levels of associated disability that can be related to a variety of symptoms and comorbidities. The role of physical therapy in the management of migraine is largely unknown. Therefore, the aim of this review is to highlight and critically discuss the current literature and evidence for physical therapy interventions in individuals with migraines.

METHODS

A narrative review of the literature was performed.

RESULTS

Physical therapists assessing and treating patients with migraine should focus on two primary aspects: (1) musculoskeletal dysfunctions, and (2) vestibular symptoms/postural control impairment. Signs and symptoms of musculoskeletal and/or vestibular dysfunctions are prevalent among individuals with migraines and different disability levels can be observed depending on the presence of aura or increment of the migraine attacks.

CONCLUSION

A proper physical examination and interview of the patients will lead to a tailored treatment plan. The primary aim regarding musculoskeletal dysfunctions is to reduce pain and sensitization, and physical therapy interventions may include a combination of manual therapy, exercise therapy, and education. The aim regarding postural control impairment is to optimize function and reduce vestibular symptoms, and interventions should include balance exercises and vestibular rehabilitation. However, consistent evidence of benefits is still lacking due to the lack of and therefore need for tailored and pragmatic clinical trials with high methodological quality.

Cervical Muscular Endurance Performance in Women With and Without Migraine

BACKGROUND

Despite previous evidence, the association between migraines and cervical muscular performance is unclear.

OBJECTIVE

To compare the differences in neck flexor and extensor muscle endurance between women with and without migraine.

METHODS

In this cross-sectional, controlled laboratory study, 26 women with migraine and 26 age-matched women without migraine or headache were assessed using clinical tests of neck flexor and extensor muscle endurance. Holding times were compared between groups using the Mann-Whitney U test for independent samples.

RESULTS

Patients with migraine exhibited a lower holding time for both neck extensor endurance (P = .001) and neck flexor endurance (P<.001) than did the controls. The median neck flexor holding time was 35.0 seconds for the migraine group and 60.5 seconds for the control group. The migraine group held the neck extensor endurance test position for a median of 166.5 seconds compared to 290.5 seconds held by the control group. Both groups reported a similar level of neck pain during the endurance tests (P>.05); however, only individuals in the migraine group reported pain referred to the head during testing.

CONCLUSION

Women with migraine demonstrated decreased neck flexor and extensor endurance compared to women without migraine, which may indicate an association between migraine and reduced performance of the neck muscles. J Orthop Sports Phys Ther 2019;49(5):330-336. Epub 26 Mar 2019. doi:10.2519/jospt.2019.8816.

Which Examination Tests Detect Differences in Cervical Musculoskeletal Impairments in People With Migraine? A Systematic Review and Meta-Analysis

BACKGROUND

Most patients with migraine report associated neck pain. Whether neck pain is a symptom of migraine or an indicator for associated cervical musculoskeletal impairment has not yet been determined. Physical examination tests to detect cervical impairments in people with headache have been suggested, but results have not been evaluated systematically and combined in meta-analyses.

PURPOSE

The purpose of this study was to identify musculoskeletal impairments in people with migraine and people who were healthy (healthy controls) by reviewing published data on physical examination results.

DATA SOURCES

PubMed, CINAHL, Web of Science, and the Cochrane Register of Clinical Trials were searched for studies published prior to December 2017.

STUDY SELECTION

Publications investigating physical examination procedures that are feasible for use in a physical therapy setting for patients with migraine and healthy controls were independently selected by 2 researchers.

DATA EXTRACTION

One researcher extracted the data into predesigned data extraction tables. Entries were checked for correctness by a second researcher. The Downs and Black Scale was used for risk-of-bias assessment by 2 reviewers independently.

DATA SYNTHESIS

Thirty-five studies (involving 1033 participants who were healthy [healthy controls] and 1371 participants with migraine) were included in the qualitative synthesis, and 18 were included in the meta-analyses (544 healthy controls and 603 participants with migraine). Overall, studies were rated as having a low to moderate risk of bias. Included studies reported 20 different test procedures. Combined mean effects indicated that 4 of the tests included in the meta-analyses distinguished between patients and controls: range of cervical motion, flexion-rotation, pressure pain thresholds, and forward head posture in a standing position.

LIMITATIONS

Manual joint testing and evaluation of trigger points were the 2 most frequently investigated tests not included in the meta-analyses because of heterogeneity of reporting and procedures.

CONCLUSIONS

Three tests confirmed the presence of musculoskeletal impairments in participants with migraine when combined in meta-analyses. Pressure pain thresholds added information on sensory processing. Additional tests might be useful but require standardized protocols and reporting.

A Neuroscience Perspective of Physical Treatment of Headache and Neck Pain

The most prevalent primary headaches tension-type headache and migraine are frequently associated with neck pain. A wide variety of treatment options is available for people with headache and neck pain. Some of these interventions are recommended in guidelines on headache: self-management strategies, pharmacological and non-pharmacological interventions. Physical treatment is a frequently applied treatment for headache. Although this treatment for headache is predominantly targeted on the cervical spine, the neurophysiological background of this intervention remains unclear. Recent knowledge from neuroscience will enhance clinical reasoning in physical treatment of headache. Therefore, we summarize the neuro- anatomical and—physiological findings on headache and neck pain from experimental research in both animals and humans. Several neurophysiological models (referred pain, central sensitization) are proposed to understand the co-occurrence of headache and neck pain. This information can be of added value in understanding the use of physical treatment as a treatment option for patients with headache and neck pain.

Is There Support for the Paradigm 'Spinal Posture as a Trigger for Episodic Headache'? A Comprehensive Review

PURPOSE OF REVIEW

The International Classification of Headache Disorders provides an extensive framework to classify headaches. Physiotherapy is indicated if neuromusculoskeletal dysfunctions are involved in the pathophysiology. Maladaptive postures seem a dominant trigger in tension-type and cervicogenic headache. Yet, outcomes following physiotherapy vary. The absence of protocol studies to identify determinants concerning the role of spinal posture in headache might explain such variability. Hence, multi-dimensional profiling of patients with headache based on interactions between spinal posture, psychosocial and lifestyle factors might be essential. Therefore, the aim of this paper was to perform a comprehensive review to find support for the paradigm of spinal posture triggering episodic headache based on a multi-dimensional view on tension-type and cervicogenic headache including modern pain neuroscience.

RECENT FINDINGS

A review was conducted to support spinal posture-induced episodic headache. Pubmed, Web of Science, Pedro and the Cochrane database were explored based on the following 'Mesh' or 'Topics': 'Headache', 'Posture', 'Spine', 'Psychosocial', 'Lifestyle'. The contemporary review of neuroanatomical, biomechanical and non-nociceptive pathways, with integration of modern pain neuroscience in tension-type and cervicogenic headache, supports spinal posture as a trigger for episodic headache. Maladaptive postures can activate C1-C3 nociceptors. Convergence with trigeminal afferents at the trigeminocervical nucleus could explain spinal headache. Interactions with psychosocial and lifestyle factors might contribute to peripheral and central sensitisation. Neuroanatomical, biomechanical and non-nociceptive pathways seem to justify profiling patients based on a postural trigger. Further research is needed to determine the contribution of postural dysfunctions in headache and the effect of specific interventions.

Asymmetric Thickness of Oblique Capitis Inferior and Cervical Kinesthesia in Patients With Unilateral Cervicogenic Headache

OBJECTIVE

The purpose of this study was to compare the thickness of the oblique cervical inferior (OCI) and the error of the head reposition test between the painful and nonpainful sides of patients with cervicogenic headache (CeH) and between the patients and the asymptomatic group.

METHODS

Thirteen patients (24.5 ± 4.8 years) and 14 asymptomatic participants (23.9 ± 2.7 years) were included. The head reposition test was recorded by a 3-dimensional motion analysis system. The thickness of the OCI was recorded by ultrasonography. The measured outcomes were compared between the painful and nonpainful sides and with the asymptomatic participants.

RESULTS

The thickness of the OCI in the rest condition on the painful side (9.92 ± 2.31 mm) was smaller than that of the nonpainful side (10.56 ± 2.24 mm). The constant error of the head-to-target test toward the nonpainful side was smaller in the patients with CeH (-1.6 ± 4.3°) than in the asymptomatic group (3.3 ± 3.7°, P = 0.005).

CONCLUSION

Asymmetric OCI and cervical proprioception were demonstrated in patients with CeH.

Cervical musculoskeletal dysfunction in headache: How should it be defined?

Neck pain commonly accompanies migraine and tension-type headache, but the literature is divided on whether this neck pain is a headache symptom or is associated with cervical musculoskeletal dysfunction. Clarification is essential for hypotheses on the pathogenesis of these headaches and their variants and for decisions on suitability of local neck treatments, both from research and clinical practice perspectives. Reasons for disparate findings could relate to participant selection in headache studies and/or the bases on which decisions on the presence of cervical musculoskeletal dysfunction are reached. Propositions towards gaining a clearer picture of migraine and tension-type headache related neck pain include first, stricter inclusion criteria and reporting of headache characteristics of study participants. Second, reliance on pain sensitivity or the presence of neck tenderness/trigger points as measures be discarded, as they are not uniquely tied to a musculoskeletal disorder. Instead, place reliance on tests of musculoskeletal (dys)function. Third, the values and interpretation of single measures or tests of impairment/dysfunctions can be non-informative and do not reflect the presentation of cervical musculoskeletal disorders. Rather, a typical presentation includes at a fundamental level, interrelated changes in cervical movement, segmental joint and muscle function. We advocate that these measures be adopted as the core set of related measures to define cervical musculoskeletal dysfunction in headache. This does not deter inclusion of other measures of interest or qualification.

The C0-C2 axial rotation test: normal values, intra- and inter-rater reliability and correlation with the flexion rotation test in normal subjects

OBJECTIVES

Impairment in upper cervical spine mobility is associated with cervicogenic headache severity and disability. Measures of such mobility include the flexion-rotation test (FRT), which requires full cervical flexion and may be influenced by lower cervical spine dysfunction. The C0-C2 axial rotation test also evaluates upper cervical mobility but normal values and reliability have not been reported. Our objective is to determine normal values, and intra-rater and inter-rater reliability of the C0-C2 axial rotation test.

METHODS

Two therapists independently evaluated the FRT and C0-C2 axial rotation test with an iPhone compass application on 32 asymptomatic subjects with mean age 40.53 (SD 11.64) years on two occasions. Measurement procedures were standardized; and order of testing randomized.

RESULTS

For the FRT and C0-C2 axial rotation test reliability was high (ICC > 0.88). For rater one, Mean range to the left during the FRT and C0-C2 axial rotation test was 45.0° (6.04) and 14.43° (2.94), respectively, while range to the right was 44.6° (6.57) and 15.44° (2.68). For the FRT and C0-C2 axial rotation test the standard error of measurement was at most 2°, while the minimum detectable change was at most 4°. A strong positive correlation exists between the FRT and C0-C2 axial rotation test (r = 0.84, P < 0.01).

DISCUSSION

The range recorded during the C0-C2 axial rotation test and FRT have high levels of reliability when evaluated using an iPhone. The strong correlation between the FRT and C0-C2 axial rotation test indicate that both may be measuring similar constructs, but each test needs to be referenced to normal values.

Pericranial Tenderness in Females With Episodic Cervical Headache vs Asymptomatic Controls: A Cross-sectional Study

OBJECTIVES

The purpose of this study was to compare pericranial tenderness of females with episodic cervical headache vs matched asymptomatic controls.

METHODS

Through a single-blind, cross-sectional study, pericranial tenderness was compared between 20 females with episodic cervical headaches (29.4 ± 13.2 years) and 20 age-matched female asymptomatic controls (30.1 ± 13.7 years). Pericranial tenderness was bilaterally measured in a headache-free period with the "total tenderness score" (TTS) in the suboccipital, temporal, frontal, masseter, upper trapezius (UT), levator scapula, and sternocleidomastoid (SCM) muscle insertions. Passive cervical mobility, headache intensity, frequency, and duration were secondary outcomes. Analysis was done with a 95% confidence level (SPSS version 22). The Mann-Whitney U-test was used to compare pericranial, cephalic, cervical, and muscle-specific tenderness between groups. Correlations between passive cervical mobility and headache characteristics and the TTS were estimated with Spearman's ρ.

RESULTS

The headache group (1.25 ± 0.89) showed a 2 times higher (P < .05) pericranial TTS compared to the control group (0.62 ± 0.70). Higher (P < .05) scores were observed for the left suboccipital, temporal, masseter, UT, levator scapula, and SCM muscles and the right suboccipital, frontal, UT, and levator scapula muscles. Grouping the tenderness scores into cervical (suboccipital, UT, levator scapula, SCM) and cephalic (frontal, temporal, masseter) regions revealed greater scores (P < .05) in the headache group. In the latter, the TTS was significantly positively correlated with passive cervical extension (ρ = 0.78).

CONCLUSION

Consistent higher tenderness scores were observed and suggest involvement of sensitization in patients with episodic cervical headaches. A positive correlation was seen between passive cervical extension and sensitivity.

Development and psychometric validation of the headache screening questionnaire - Dutch Version

BACKGROUND

Headache is a common disorder which may lead to substantial socio-economic loss. Treatment options include self-management strategies, medication and physiotherapy. Physiotherapists need to be able to screen for the presence of migraine and tension-type headache (TTH), so they can adjust their treatment strategies to the type of headache. A quick screening questionnaire to recognize migraine and TTH in the physiotherapy practice is needed.

OBJECTIVE

The aim of this study was to create a headache screening questionnaire based on the ICHD-3 beta criteria for migraine and TTH, and to establish its content and criterion validity.

DESIGN

A cross-sectional design was used during the validation phase of the study.

METHODS

A screening questionnaire was developed for migraine and TTH. Content validity was checked by the research group and a headache research expert. For validation of this questionnaire, patients from the headache clinic of the Canisius Wilhelmina Hospital in Nijmegen were recruited. The outcome of the questionnaire was compared to the ICHD-3 beta diagnosis of the headache specialist. For criterion validity, sensitivity, specificity, likelihood ratios, and positive- and negative predictive values were calculated.

RESULTS

A 10-item questionnaire has been developed: the Headache Screening Questionnaire. For validation of the Dutch version (HSQ-DV), 105 patients were included in the study. The sensitivity and specificity were 0.89 and 0.54 respectively for probable migraine, and for probable TTH 0.92 and 0.48 respectively.

CONCLUSION

The HSQ-DV is a sensitive screening tool to detect patients with probable migraine and probable TTH.

Stratifying migraine patients based on dynamic pain provocation over the upper cervical spine

Background

Migraine patients usually report a high prevalence of neck pain preceding or during the migraine attack. A recent investigation of musculoskeletal dysfunctions in migraine patients concluded that neck pain is not simply a symptom of the migraine attack but corresponds to identifiable muscle and joint alterations. Particularly pain provocation using palpation of the joints in the upper cervical spine was significantly more prevalent in patients with migraine than in headache-free participants.

Methods

One hundred seventy-nine migraineurs (diagnosed according to IHS classification criteria version III beta) and 73 age- and gender-matched healthy controls were examined by a physiotherapist blinded towards the diagnosis, using a palpation technique over the upper cervical spine. The palpation combined oscillating movements and sustained pressure.

Findings

Using simple palpation of the upper cervical spine, migraine patients can be stratified into three groups: painfree (11%), local pain only (42%), and pain referred to the head during sustained pressure (47%). Combining both test components (palpation and sustained pressure) has a high sensitivity and specificity for migraine.

Conclusions

The response to palpation of the upper cervical spine may indicate migraine subtypes. The presence of musculoskeletal dysfunctions of the upper cervical spine should be identified and treated to avoid ongoing nociceptive input into the trigeminocervical complex.

Trial registration

German Clinical Trial Register DRKS-ID: DRKS00009622.

Musculoskeletal dysfunction in migraine patients

Objective The aim of this project was to evaluate the prevalence and pattern of musculoskeletal dysfunctions in migraine patients using a rigorous methodological approach and validating an international consensus cluster of headache assessment tests. Methods A physiotherapist, blinded towards the diagnosis, examined 138 migraine patients (frequent episodic and chronic), recruited at a specialised headache clinic, and 73 age and gender matched healthy controls following a standardised protocol. Eleven tests, previously identified in an international consensus procedure, were used to evaluate cervical and thoracic musculoskeletal dysfunctions. Results Primary analyses indicated statistically significant differences across groups for the total number of trigger points, flexion-rotation test, thoracic screening, manual joint testing of the upper cervical spine, cranio-cervical flexion test, and reproduction and resolution. Ninety three percent of the assessed patients had at least three musculoskeletal dysfunctions. Post-hoc tests showed significant differences between episodic or chronic migraine patients and healthy controls, but not between migraine groups. Conclusions A standardised set of six physical examination tests showed a high prevalence of musculoskeletal dysfunctions in migraine patients. These dysfunctions support a reciprocal interaction between the trigeminal and the cervical systems as a trait symptom in migraine.