Tension headache — is the spine to blame?

Aim of the study: An updated systematic review of cervical musculoskeletal dysfunction in migraine and tension-type headache is needed. Influencing factors (pain hypersensitivity with cervical musculoskeletal testing, active trigger points and tenderness) have not been investigated.

Results: Seventy-seven studies were included, comprising 2551 participants. New findings in migraine were increased forward head posture in standing (MD = -2.51°[-4.94°, -0.09°]), reduced flexion/rotation range (MD = -9.47°[-15.78°, -3.16°]), reduced flexor strength (Std. MD = -0.34[-0.57, -0.10]) and endurance (MD = -14.37[-28.15, -0.58]), and reduced extensor strength (Std. MD = -0.34[-0.60, -0.08]) in migraine. Tension-type headache had reduced extensor strength (Std. MD = -0.45[-0.85, -0.04]). Certainty was very low for all findings due to heterogeneity and small effect size. Active trigger points and tenderness were common, particularly, in chronic headache. A negative relationship between cervical musculoskeletal performance and active trigger points and tenderness was found in 2 from 77 studies (r < - 0.47). Several cervical musculoskeletal impairments are present in migraine and tension-type headache with very low certainty.

Aim of the study: This meta-analysis evaluates pressure pain sensitivity values in symptomatic and distant pain-free areas comparing individuals with tension-type headache to controls.

Results: Twenty studies were included. Patients with tension-type headache exhibited lower pressure pain thresholds than headache-free controls: Trigeminal (MD -49.11 kPa, 95% CI -66.05 to -32.17), cervical spine (MD -88.17 kPa, 95% CI -108.43 to -67.92) and distant pain-free areas (MD -98.43 kPa, 95% CI -136.78 to -60.09). Differences were significant for chronic, episodic, and mixed episodic and chronic tension-type headache within the trigeminal and neck (symptomatic areas), but only significant for chronic tension-type headache (MD -102.86, 95% CI -139.47 to -66.25 kPa) for distant pain-free areas. In general, women had lower pressure pain thresholds than men. The methodological quality ranged from fair (45%) to good (40%). The results showed a high heterogeneity and publication bias.

Aim of the study: 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.

Aim of the study: Non-pharmacological treatments help control tension-type headache; however, evidence about their effectiveness is still limited. This study evaluates the effectiveness of physical therapy based on cervical spine kinesiotherapy and posture correction exercises compared to a programme of relaxation techniques only (Schultz's Autogenic Training, AT).

Results: Both interventions achieved a decrease in all the parameters of pain; however, decreases in frequency and intensity were more significant in the combined treatment group (P<0.01) (d=0.4). Such active, non-invasive therapies as AT and cervical spine kinesiotherapy, and especially the combination of both, effectively reduce tension-type headache by preventing and managing the potential psychophysical causes of this disorder. Future research should aim to assess the long-term effects of these interventions.

Aim of the study: The effectiveness of Mulligan manual therapy has been investigated in cervicogenic headache but not in tension-type headache (TTH). To compare the effectiveness of exercise + Mulligan manual therapy over exercise or exercise + sham in episodic TTH.

Results: Headache frequency reduced significantly in group exercise + Mulligan manual therapy compared to group exercise post-intervention (MD -1.0 day, 95% CI -2.0 to -0.0) (p = .002), and at 3-month follow-up (MD -1 days, 95% CI -2.0 to 0.0) (p = .002), but only at post-intervention compared to group exercise + sham (MD 1.0 day, 95% CI 0.0 to 2.0) (p = .008). The clinical relevance is unclear as between-group differences did not reach a clinical threshold. No difference was observed at 6 months (p > .17). A similar trend was observed for other outcomes. There was no difference between groups exercise and exercise + sham for any outcome (p > .17). In episodic TTH, exercise + Mulligan manual therapy provided short-term clinically uncertain improvements in headache parameters. These results differ to studies of cervicogenic headache. Unsuitability of Mulligan manual therapy for underlying pathophysiological mechanisms in episodic TTH may explain these results.

Aim of the study: Roentgenographic studies were carried out on 372 patients with tension-type headache and 225 normal control subjects to determine relationships between straightened cervical spines, low-set shoulders, and cervical spine instability. A great majority of the patients with tension-type headache were found also to have straightened cervical spine.

Results: The low-set shoulder was frequently seen in patients with tension-type headache, and it may result in traction of the brachial plexus, which gives rise to pain in the neck and shoulders. Cervical spine instability, on the other hand, was rather infrequent in patients with tension-type headache. Its relationship to tension-type headache is unclear and warrants further study. Our results suggest that both a straightened cervical spine and low-set shoulders may play an important role in the pathogenesis of tension-type headache and its accessory symptoms.