Effectiveness of a manual therapy protocol based on articulatory techniques in migraine patients. A randomized controlled trial

Can upper cervical manual therapy affect the blink reflex in subjects with migraine and neck pain?

BACKGROUND

Neck pain is a common complaint among migraineurs possibly due to the anatomic connections between cervical and trigeminal afferents in the trigeminocervical complex (TCC). Manual therapy (MT) is used in the management of headache disorders, with demonstrable neurophysiological effects. The blink reflex (BR) is one method of analyzing neurophysiological effects in headache patients. The purpose of this study was to investigate the effect of upper cervical spine MT on BR in subjects with migraine and neck pain.

METHODS & MATERIALS

Twenty subjects were assigned to a medication plus MT (MedMT) group (n = 10) and medication plus sham MT (sham MT) group (n = 10). After random assignment, all patients underwent testing for the BR (R1, R2, R2c responses). Then, subjects in group MedMT and group sham MT received either 4 sessions of MT or sham MT to the upper cervical spine. After completion of the intervention, BR testing was repeated.

RESULTS

There were no significant differences in both side R1 latency between group MT and group sham MT (P > 0.050). For both sides, R2 latencies were significantly prolonged in MedMT group compared with sham MT group (P < 0.050). Subjects in MedMT group showed significant prolongation in right and left R2c latency compared with sham MT group (P < 0.050).

DISCUSSION

The present study demonstrated that upper cervical MT affected trigeminal nociceptive neurotransmission in subjects with migraine and neck pain as reflected by changes in the BR. The increase in BR late response latencies of BR indicates an inhibitory effect of upper cervical spine MT on the TCC in these subjects. Trial Registration: The trial design was registered at the Iranian Registry of Clinical Trials (IRCT ID: IRCT20160621028567N2, url: https://www.irct.ir/) before the first patient was enrolled.

Potential mechanisms for osteopathic manipulative treatment to alleviate migraine-like pain in female rats

Introduction

Migraines are the leading cause of disability in the United States, and the use of non-pharmaceutical treatments like osteopathic manipulative treatment (OMT) has shown promise. Despite its potential, the lack of mechanistic understanding has hindered widespread adoption. This study aims to investigate the efficacy of OMT in treating acute migraines and unravel its underlying mechanisms of action.

Methods

Female rats were subjected to a "two-hit" approach to induce migraine-like pain. This involved bilateral injections of Complete Freund's Adjuvant (CFA) into the trapezius muscle (1st hit) followed by exposure to Umbellulone, a human migraine trigger, on Day 6 post-CFA (2nd hit). Soft tissue and articulatory techniques were applied to the cervical region for acute abortive or repeated prophylactic treatment. Cutaneous allodynia and trigeminal system activation were assessed through behavioral tests and immunohistochemical staining.

Results

Following Umbellulone inhalation, CFA-primed rats exhibited periorbital and hind paw allodynia. Immediate application of OMT after Umbellulone inhalation as an abortive treatment partially alleviated cutaneous allodynia. With OMT applied thrice as a prophylactic measure, complete suppression of tactile hypersensitivity was observed. Prophylactic OMT also prevented the increase of c-fos signals in the trigeminal nucleus caudalis and the elevation of calcitonin gene-related peptide expression in trigeminal ganglia induced by CFA and Umbellulone exposure at 2 h post-inhalation.

Discussion

These findings provide mechanistic insights into OMT's migraine-relief potential and underscore its viability as a non-pharmacological avenue for managing migraines.

Differences in musculoskeletal dysfunctions and in postural alterations between chronic migraine and chronic tension type headache: A cross-sectional study

OBJECTIVE

The aim of present study is to assess postural alterations and musculoskeletal dysfunctions over all spine in patients with chronic migraine and chronic tension type headache, moreover to highlight the differences between these two forms of primary headache.

METHODS

A Cross sectional study was adopted to evaluate the musculoskeletal profile in patients with chronic migraine and with chronic tension type headache. The Bio photogrammetric evaluation was performed using the postural assessment software PAS/SAPO, while unilateral passive accessory intervertebral motion (PAIMs) were applied for manual examinations of spine segments from C0 to L5 vertebra. The One-way Analysis of Variance (ANOVA) test was used to compare the three groups with the software GraphPad InStat 3.06.

RESULTS

A total of 60 patients were recruited, 20 for chronic tension type group, 20 for chronic migraine group and 20 healthy controls. The most interesting findings was that patients with chronic primary headaches presented postural alterations in all parameters (cranio-vertebral angle and lumbar-pelvic angle) and musculoskeletal dysfunctions in all spine with respect to healthy controls. Finally, the most clinically relevant finding was that no differences were found between chronic migraine and chronic tension type headache concerning the postural alterations nor the musculoskeletal dysfunctions.

CONCLUSION

The sensitization acts as a substrate or consequence of these musculoskeletal dysfunctions in chronic primary headache. Therefore, non-pharmacological treatments targeted in the musculoskeletal system may be a good option in the management of chronic primary headache, especially when these therapies integrate various techniques that involve all spine.

A Multimodal Conservative Approach to Treating Migraine: A Physical Therapist's Perspective

PURPOSE OF REVIEW

Migraine is common and interventions to treat or manage it vary. Physical therapists possess a varied skill set that can assess and treat limitations related to migraine and its symptoms. Conservative and non-pharmacological examination and treatment techniques for migraine and headache management are reviewed in terms of efficacy and relevance in order to describe the physical therapist's abilities and clinical reasoning process when confronting a patient with migraine symptoms.

RECENT FINDINGS

A thorough examination is necessary to detect red flags and will reveal a person with migraine's biopsychosocial limitations to manage their symptoms. Strength, endurance, cervical mobility, and visual deficits are common in those reporting headaches and examination techniques, along with patient-reported outcome measures, can elicit objective data for re-assessment during an episode of care. Exercise interventions, manual therapy, biofeedback techniques, and vestibular therapy have become viable and efficacious non-pharmacological interventions in recent years to assist the patient with managing and mitigating their migraine symptoms, along with mindfulness-based exercises. A case study, with individualized treatment approaches based on examination findings, current evidence, and accrued expertise, demonstrates the clinical applicability of a physical therapist's multimodal approach to treating migraine. Psychologically- informed physical therapy with mindfulness-based approaches and biofeedback can help a patient gain more control over their symptoms and their body's response to head pain, while exercise and vestibular therapy can assist the system with recovery and adaptation from deficits related to migraine symptoms. A thorough examination, with an individually- tailored rehabilitation plan incorporating movement and mindfulness-based therapies, is recommended.

Cervical Impairments in Subjects with Chronic Migraine: An Observational Study

OBJECTIVE

The aim of this investigation was to compare the thickness of the deep local muscles in the neck region, as well as local and widespread sensitivity and functionality, between individuals with migraine and healthy control subjects.

METHODS

An observational study was carried out in accordance with the STROBE statements. The flexor longus colli and multifidus, two neck-stabilizing muscles, were measured using B-mode ultrasound imaging. The upper trapezius, masseter, temporalis, anterior tibialis, and median nerve all underwent bilateral pressure-pain threshold (PPT) assessments. The statistical program SPSS 29.0 was used to implement the Mann-Whitney U test and Chi-squared test. Spearman Rho was utilized to establish the correlations between the variables.

RESULTS

Sixty participants were enrolled in the study. The subjects, who were matched in terms of age, gender, and body mass index (BMI), were equally divided into migraine and control groups. No significant differences between the groups were found in the multifidus CSA regarding both sides at rest (right: p = 0.625; left: p = 0.203). However, in contraction, the multifidus CSA showed a significant decrease on the left side in the patients with migraine compared to the controls (p = 0.032), but no significant differences were found in the right multifidus CSA in contraction between the two groups (p = 0.270). In comparison to the healthy volunteers, the migraine sufferers showed a substantial reduction in CSA in the longus colli muscle on both the left side (p = 0.001) and the right side at rest (p = 0.003), as well as in the CSA of the left longus colli in contraction (p < 0.001). Furthermore, the migraine patients showed significantly lower PPT compared to the healthy subjects in local and widespread areas bilaterally. All the parameters revealed higher sensitization in the migraine group in the following areas: the right and left temporal regions (p < 0.001), the right and left upper trapezius (p < 0.001 and p < 0.01, respectively), the right and left masseter muscles (p < 0.01), the right and left median nerves (p < 0.001 and p < 0.01, respectively), and the right and left anterior tibialis muscles (p < 0.001). In terms of the craniocervical flexion test (CCFT), the migraine patients demonstrated significantly lower values than the healthy subjects (p < 0.001). A moderate positive correlation was noted between the PPT in the right temporalis muscle and that in the left longus colli and the right multifidus in contraction. The PPT in the right temporalis muscle also exhibited a positive correlation with the CCFT, although this correlation was low. Between the PPT values, the upper trapezius on both sides showed a moderate positive correlation with the median nerve bilaterally.

CONCLUSIONS

This research suggests that individuals with migraine may experience local and widespread pain sensitization. A decrease in functionality due to the low muscle endurance of the deep cervical muscles is also accompanied by low values of muscle thickness in contraction. These findings may help to select more accurate treatment approaches for patients with migraine.

Sex-related differences in migraine clinical features by frequency of occurrence: a cross-sectional study

OBJECTIVES

The sex-related differences of migraine hold clinical relevance to achieve a better diagnosis and treatment. The purpose of this cross-sectional study was to evaluate sex-related differences in migraine features, the impact, and health care resources for people who suffer from episodic migraine (EM) and chronic migraine (CM).

METHODS

184 patients (72 % women; 61.4 % with EM; mean (SD) age of 38.7 (10.4) years) were assessed through the Migraine Disability Assessment, the Short Form 36 Health Survey, the Beck Depression Inventory II and the State-Trait Anxiety Inventory. Additionally, medication intake and medical assistance were recorded. Multivariate analyses were performed, stratifying by frequency of occurrence (EM and CM) and sex (men and women).

RESULTS

The results showed that women presented a greater number of symptoms (p=0.03), pain intensity (p<0.01), pain duration (p=0.03), disability (p=0.01), amount of symptomatic medication (p=0.04) and medical visits (p=0.001), as well as a worse physical role (p=0.004) than men with EM. However, no significant differences between them were found for CM (p>0.05). Moreover, it was identified that there was a significant increase in medication intake among people with CM compared to EM (p<0.001). It is worth noting that there were no significant differences by diagnosis and sex in emotional status (p>0.05).

CONCLUSIONS

Migraine features, impact and health care resources were greater in women than men with EM; yet no significant differences between them were found for CM. The findings of the present study may contribute to a better diagnosis and treatment response in people with migraines.

Effectiveness of a Manual Therapy Protocol in Women with Pelvic Pain Due to Endometriosis: A Randomized Clinical Trial

A randomized controlled trial was carried out to assess the effectiveness of a manual therapy protocol in terms of the clinical characteristics, quality of life, and emotional condition of the women with endometriosis-related pelvic pain. Forty-one women (mean age of 36.10 (6.97) years) with pelvic pain due to endometriosis were randomly divided into (i) a manual therapy group (MTG) (n = 21) and (ii) a placebo group (PG) (n = 20). Both groups received an 8-week intervention. Pain, lumbar mobility, endometriosis health profile, quality of life, depression and anxiety levels, and the patient's perception of change were assessed before (T0) and after (T1) the intervention, as well as at a one-month follow-up (T2) and a six-month follow-up (T3). The MTG significantly improved pain intensity, powerlessness, lumbar mobility, and physical quality of life at T1 (p < 0.05). The results were maintained for pain intensity at T2 and T3. In addition, both the MTG and PG improved emotional wellbeing at T1 (p < 0.05). Neither group improved in terms of social support, self-image, and depression and anxiety levels after the intervention (p > 0.05). In conclusion, manual therapy may be an excellent complement to the gynecological treatment of endometriosis-related pelvic pain by alleviating pain and improving women's endometriosis health profile and physical quality of life.

Effects on neuromodulation, acupuncture, and aerobic exercises on migraine and tension-type headache outcomes: A systematic review and meta-analysis

BACKGROUND

Headache disorders are common diseases that cause a social burden. This systematic review and meta-analysis aimed to evaluate the effects of various non-pharmacological treatments to address or prevent acute headaches, including neuromodulation, acupuncture, and aerobic exercises in patients with episodic migraine and tension-type headache (TTH).

METHODS

We performed a systematic search of the electronic databases PubMed, Cochrane Library, Embase, China National Knowledge Infrastructure, WANFANG MEDICINE ONLINE, and Chinese Medical Journal database using Stata/SE 14.0 to obtain weighted mean differences (WMDs). The outcomes included monthly headache days, headache intensity, headache duration, days per month of acute medication use, and the Medical Outcomes Study 36-Item Short-Form Health Survey.

RESULTS

Of 872 identified articles, 27 were included in the meta-analysis. Neuromodulation was associated with reduced headache days (WMD: -1.274, 95% CI [-1.914, -0.634], P < .001), duration (WMD: -2.2, 95% CI [-3.32, -0.107], P < .001) and medication consumption (WMD: -1.808, 95% CI [-2.546, -1.071], P < .001) in cases of migraine. Acupuncture was associated with the alleviation of headache days (WMD: -0.677, 95% CI [-0.932, -0.422], P < .001) and intensity (WMD: -0.893, 95% CI [-1.573, -0.212], P = .01) in cases of migraine and acute medication use (WMD: -3.29, 95% CI [-4.86, -1.72], P < .001) in cases of TTH. Aerobic exercise was associated with reduced headache duration (WMD: -5.1, 95% CI [-8.97, -1.22], P = .01) in cases of TTH. The risk of bias for included articles was moderate.

CONCLUSIONS

There is low- and moderate-quality evidence that neuromodulation, acupuncture, and aerobic exercises are associated with attenuated headache symptoms in patients with episodic migraine or TTH. However, high-quality studies are needed to draw more detailed conclusions.

Potential Add-On Effects of Manual Therapy Techniques in Migraine Patients: A Randomised Controlled Trial

Objective: To ascertain whether the combination of soft tissue and articulatory manual techniques is more effective than either one of these techniques alone for reducing migraine impact; Methods: Seventy-five participants with migraine were randomly divided into three groups (n = 25 per group): (i) soft tissue (STG), (ii) articulatory (AG), and (iii) combined treatment (STAG). Pain, frequency of occurrence, duration, disability and impact, depression and anxiety levels, and perception of change were analysed at baseline, post intervention (T2) and at four-week follow-up (T3); Results: STAG showed a significantly greater reduction in pain versus STG and AG at T2 (p < 0.001; p = 0.014) and at T3 (p < 0.001; p = 0.01). Furthermore, STAG achieved a significantly greater reduction in pain duration versus STG at T2 (p = 0.020) and T3 (p = 0.026) and a greater impression of change versus STG (p = 0.004) and AG (p = 0.037) at T3. Similar effects were observed in all groups for frequency of occurrence, migraine disability, impact, and depression and anxiety levels; Conclusions: A combined manual therapy protocol including soft tissue and articulatory techniques yields larger improvements on pain and perception of change than either technique alone, yet the three therapeutic approaches show similar benefits for reducing pain, disability and impact caused by the migraine, depression or anxiety levels.

Effect of a Craniosacral Therapy Protocol in People with Migraine: A Randomized Controlled Trial

Background: Migraine is a common neurological disorder, and it is the second leading cause of disability worldwide. Manual techniques based on physical therapy have been proposed to improve migraine aspects; however, further research is needed on their effectiveness. The aim of this study was to evaluate the effectiveness of a craniosacral therapy protocol on different features in migraine patients. Methods: Fifty individuals with migraine were randomly divided into two groups (n = 25 per group): (i) craniosacral therapy group (CTG), following a craniosacral therapy protocol, and (ii) sham control group (SCG), with a sham treatment. The analyzed variables were pain, migraine severity and frequency of episodes, functional, emotional, and overall disability, medication intake, and self-reported perceived changes, at baseline, after a 4 week intervention, and at 8 week follow-up. Results: After the intervention, the CTG significantly reduced pain (p = 0.01), frequency of episodes (p = 0.001), functional (p = 0.001) and overall disability (p = 0.02), and medication intake (p = 0.01), as well as led to a significantly higher self-reported perception of change (p = 0.01), when compared to SCG. In addition, the results were maintained at follow-up evaluation in all variables. Conclusions: A protocol based on craniosacral therapy is effective in improving pain, frequency of episodes, functional and overall disability, and medication intake in migraineurs. This protocol may be considered as a therapeutic approach in migraine patients.

[Effectiveness of physiotherapeutic treatment interventions on pain intensity, duration, frequency, and quality of life of patients with migraine : A systematic review]

BACKGROUND

According to the current guidelines preventive treatment of migraine should consist of a combination of pharmacological and nonpharmacological forms of treatment. Physiotherapeutic modalities could be an option for nonpharmacological migraine management.

OBJECTIVE

The aim was to assess the efficacy of physiotherapeutic interventions on pain intensity, duration and frequency as well as the quality of life of patients with migraine.

METHODS

A systematic literature search was carried out in four databases: the Physiotherapy Evidence Database (PEDro), Web of Science, Medline via PubMed and the Cochrane Library. Randomized controlled trials (RCTs) that were published up to the end of July 2021 and examined the effectiveness of physiotherapeutic treatment in migraine patients were eligible for inclusion. Studies that did not examine an adult population, interventions not carried out by a physiotherapist or not reporting an appropriate outcome were excluded. The assessment of the risk of bias was carried out with the revised version of the Cochrane risk of bias tool 2.0. A descriptive and quantitative synthesis using mean difference with a random effects model and 95% confidence intervals were used.

RESULTS

The present review included 13 RCTs reporting on a total of 595 patients. The risk of bias was high for four studies, low for two studies and the remaining seven studies had some concerns. The interventions examined were multimodal physiotherapy programs, various mobilization techniques, trigger point therapy, manual lymphatic drainage, massage and various stretching techniques. All interventions examined had a significantly positive effect on the selected parameters compared to the baseline values. Especially combinations of various physiotherapeutic modalities showed clinically relevant results.

CONCLUSION

The evidence suggests that multimodal physiotherapy treatment is a good supplement to medication and should therefore be considered as a nonpharmacological treatment for patients with migraine; however, further RCTs with a low risk of bias are necessary in order to confirm the effectiveness with high quality evidence.