Kerstin Luedtke

Efficacy of interventions used by physiotherapists for patients with headache and migraine-systematic review and meta-analysis.

Aim We aimed to conduct a systematic review evaluating the effectiveness of interventions used by physiotherapists on the intensity, frequency and duration of migraine, tension-type (TTH) and cervicogenic headache (CGH). Methods We performed a systematic search of electronic databases and a hand search for controlled trials. A risk of bias analysis was conducted using the Cochrane risk of bias tool (RoB). Meta-analyses present the combined mean effects; sensitivity analyses evaluate the influence of methodological quality. Results Of 77 eligible trials, 26 were included in the RoB assessment. Twenty trials were included in meta-analyses. Nineteen out of 26 trials had a high RoB in >1 domain. Meta-analyses of all trials indicated a reduction of TTH (pu2009<u20090.0001; mean reduction −1.11 on a 0–10 visual analog scale (VAS); 95% CI −1.64 to −0.57) and CGH (pu2009=u20090.0002; mean reduction −2.52 on a 0–10 VAS; 95% CI −3.86 to −1.19) pain intensity, CGH frequency (pu2009<u20090.00001; mean reduction −1.34 days per month; 95% CI −1.40 to −1.28), and migraine (pu2009=u20090.0001; mean reduction −22.39 hours without relief; 95% CI −33.90 to −10.88) and CGH (pu2009<u20090.00001; mean reduction −1.68 hours per day; 95% CI −2.09 to −1.26) duration. Excluding high RoB trials increased the effect sizes and reached additional statistical significance for migraine pain intensity (pu2009<u20090.00001; mean reduction −1.94 on a 0–10 VAS; 95% CI −2.61 to −1.27) and frequency (pu2009<u20090.00001; mean reduction −9.07 days per month; 95% CI −9.52 to −8.62). Discussion Results suggest a statistically significant reduction in the intensity, frequency and duration of migraine, TTH and CGH. Pain reduction and reduction in CGH frequency do not reach clinically relevant effect sizes. Small sample sizes, inadequate use of headache classification, and other methodological shortcomings reduce the confidence in these results. Methodologically sound, randomized controlled trials with adequate sample sizes are required to provide information on whether and which physiotherapy approach is effective. According to Grading of Recommendations Assessment, Development and Evaluation (GRADE), the current level of evidence is low.

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.

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

BackgroundMigraine 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.MethodsOne 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.FindingsUsing 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.ConclusionsThe 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 registrationGerman Clinical Trial Register DRKS-ID: DRKS00009622.

Increased mechanosensivity of the greater occipital nerve in subjects with side-dominant head and neck pain – a diagnostic case-control study

ABSTRACT Objectives: To investigate differences in pressure pain thresholds (PPTs) and longitudinal mechanosensitivity of the greater occipital nerve (GON) between patients with side-dominant head and neck pain (SDHNP) and healthy controls. Evaluation of neural sensitivity is not a standard procedure in the physical examination of headache patients but may influence treatment decisions. Methods: Two blinded investigators evaluated PPTs on two different locations bilaterally over the GON as well as the occipitalis longsitting-slump (OLSS) in subjects with SDHNP (n = 38)) and healthy controls (n = 38). Results: Pressure pain sensitivity of the GON was lower at the occiput in patients compared to controls (p = 0.001). Differences in pressure sensitivity of the GON at the nucheal line, or between the dominant headache side and the non-dominant side were not found (p > 0.05). The OLSS showed significant higher pain intensity in SDHNP (p < 0.001). In comparison to the non-dominant side, the dominant side was significantly more sensitive (p = 0.004). Discussion: Palpation of the GON at the occiput and the OLSS may be potentially relevant tests in SDHNP. One explanation for an increased bilateral sensitivity may be sensitization mechanisms. Future research should investigate the efficacy of neurodynamic techniques directed at the GON. Level of Evidence: 3b.

Comment on Castien et al. (2018) pressure pain thresholds over the cranio-cervical region in headache - a systematic review and meta-analysis

The recently published systematic review by Castien et al. [1] is summarising data in a field of highly ambiguous reporting. Pain thresholds in headache patients have been investigated by a large number of researchers with inconsistent results and it is certainly important to summarise and evaluate all data in a systematic review and meta-analysis. However, the present review can only partially shed light on the issue, due to a number of rather grave methodological shortcomings. The underlying concept is, that especially the two primary headache types, TTH and migraine, show a component of (peripheral or central) sensitization. There are two major difficulties for researchers trying to clarify the presence or absence of sensitization:

Altered muscle activity during rest and during mental or physical activity is not a trait symptom of migraine - a neck muscle EMG study

BackgroundMigraineurs have a high prevalence of neck pain prior to or during headache attacks. Whether neck pain is a symptom of migraine or an indicator for a constant neck muscle dysfunction potentially triggering migraine attacks is a topic of scientific debate. The presence of myofascial trigger points in neck muscles including the trapezius muscle, points towards muscle alterations associated with migraine. We measured electromyography (EMG) of the neck muscles in a large cohort to identify whether neck pain and neckmuscle tension reported by migraine patients can be attributed to increased neck muscle activation during rest, mental stress or physical activity.MethodsSurface EMG responses of the trapezius muscle were recorded during a paradigm including rest periods, mental stress and physical activity of 102 participants (31 chronic migraine, 43 episodic migraine, 28 healthy participants).ResultsAll groups showed increased trapezius activity during mental stress and physical activity compared to rest. There was no statistically significant difference between migraine patients and healthy controls for any of the 3 conditions except for the initial mental stress situation (F (2,56.022)u2009=u20098.302, pxa0=u20090.001), where controls increased tension by only 4.75%, episodic migraineurs by 17.39% and chronic migraineurs by 28.61%. Both migraine groups returned to resting EMG levels within the same timeframe as healthy controls.ConclusionsNeck pain associated with migraine can therefore not be attributed to increased trapezius activity during rest, mental stress and physical activity or prolonged muscle activity and should not be seen as a constantly underlying trigger but rather as an accompanying symptom of migraine.

Upper cervical two-point discrimination thresholds in migraine patients and headache-free controls

BackgroundChronic pain including migraine is associated with structural and functional changes in the somatosensory cortex. Previous reports proposed two-point discrimination (TPD) as a measurement for cortical alterations. Limited evidence exists for tactile acuity in the neck and no data is available for migraine.MethodsTo introduce a standardized protocol for the measurement of TPD in the upper cervical spine, 51 healthy participants were investigated with a newly developed paradigm which was evaluated for intra-rater reliability. The same protocol was applied by two further examiners to 28 migraine patients and 21 age-, and gender-matched healthy controls to investigate inter-rater reliability and between group differences.ResultsResults indicated excellent intra-rater (right ICC(2,4)u2009=u20090.82, left ICC(2,4)u2009=u20090.83) and good inter-rater reliability (right ICC(2,4)u2009=u20090.70, left ICC(2,4)u2009=u20090.75). Migraine patients had larger TPD thresholds (26.86u2009±u20097.21) than healthy controls (23.30u2009±u20096.17) but these became only statistically significant for the right side of the neck (pu2009=u20090.02). There was a significant, moderate association with age for the right side (ru2009=u20090.42 pu2009=u20090.002, nu2009=u200951), and less strong association for the left side (ru2009=u20090.34, pu2009=u20090.14) in healthy individuals. TPD did not correlate with headache days per month or the dominant headache side in migraine patients.ConclusionsSurprisingly, migraine patients showed increased TPD thresholds in the upper cervical spine interictally. Although a body of evidence supports that hypersensitivity is part of the migraine attack, the current report indicates that interictally, migraine patients showed worse tactile acuity similar to other chronic pain populations. This has been hypothesized to indicate structural and functional re-organisation of the somatosensory cortex.

Does the rectus capitis posterior minor muscle contribute to the pathogenesis of chronic headache

The contribution of cervical musculoskeletal structures to the pathogenesis of headache is a topic of ongoing clinical and scientific debate. Whereas trigeminovascular mechanisms and especially brainstem alterations (1), as well as genetic factors, seem to play a dominant role for the development of migraine (2), the mechanisms of tension-type headache (TTH) are less clear. Furthermore, the transition from episodic to chronic headache states remains an area of speculation rather than knowledge. The use of analgetic medication with its associated neurotransmitter actions (3), especially the use of NSAIDS and triptans (4) but also comorbidities (5), and the presence of trigger points (6) as well as many other external or internal factors have been proposed as contributing factors to chronicity. In the present study ‘Correlation between chronic headaches and the rectus capitis posterior minor muscle: A comparative analysis of cross-sectional trail’, Yuan et al. (7) investigated themagnetic resonance imaging (MRI) images of the rectus capitis posterior minor muscle (RCPmi) of 115 chronic headache patients (diagnosis not further specified) and of 120 ageand gender-matched headache-free participants, for changes in cross-sectional size (7). The results indicated that male participants in both groups showed larger RCPmi and, more to the point, that the RCPmi in the headache group was significantly larger than in the non-headache group. The authors concluded that this RCPmi hypertrophy could contribute to the pathogenesis of chronic headache by influencing the so-called ‘myodural bridge’, i.e. a connection between the RCPmi and the spinal dura (8). Recently, similar connections have been identified between the RCPma or the obliquus capitis inferior muscle and the spinal dura (9). The suggested role of these connections is to prevent an infolding of the dura during cervical extension and to protect the spinal dura from excessive loading or tension. Does that mean that the book is closed and that enlarged neck muscles are the cause of headache? Certainly not. The authors themselves do not provide an explanation why the RCPmi of chronic headache patients should be enlarged. A simple suggestion from a physiotherapy point of view would be habitual posture changes. An EMG study has shown that the RCPmi is activated during ventral translation of the head (10). Ongoing activity during positions that involve ventral translation of the head (e.g. during computer work) could therefore result in hypertrophy of the RCPmi. Previous publications indicated a correlation between ventral translation of the head and chronic headaches supporting this hypothesis (11,12). However, physiotherapy aiming at posture corrections is not effective for the reduction of chronic headaches and this theory seems somewhat simplistic. A more likely explanation is that central effects of the headache syndrome itself are responsible for a hyperactivity of the neck muscles: increased muscle size might not be limited to RCPmi but may constitute a general phenomenon in specific headache types. Headache patients have generally shown higher EMG activity in the neck muscles (13), especially during mental activity (14), but also during specific exercises (15). This has been specifically demonstrated for the scaleni muscles and the sternocleidomastoid muscles in boys and girls with migraine (compared with TTH) (16). Heightened muscle activity will lead to muscle hypertrophy. If the hypothesis is true that a connection between the RCPmi and the spinal dura via the myodural bridge can influence headaches by either increasing the tension on the cranial dura or interfering with the cerebro-spinal fluid circulation through the

EHMTI-0091. Physiotherapy interventions for headaches: a systematic review and meta-analysis

Methods Search strategy with pre-defined key terms conducted in MEDLINE, CENTRAL, PeDRO, reference lists of retrieved articles, and journal contents. Controlled trials, employing physiotherapy interventions for the reduction of headaches published in any language between 11/2002 and 04/2014 were included. Studies using chiropractic, osteopathic or acupuncture techniques were excluded. Quality was evaluated using the Cochrane risk of bias tool.