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Physiotherapy reduced recurrent headaches linked to neck pain and dysfunction in older adults

Question In older adults with recurrent headaches associated with neck pain and cervical musculoskeletal dysfunction, what is the effectiveness of physiotherapy (PT) compared with usual care? Methods Design Randomized controlled trial. ClinicalTrials.gov NCT01736774. Allocation Concealed.* Blinding Blinded* (outcome assessors). Follow-up period 9 months. Setting Headache clinic, Maharaj University Hospital, Thailand. Patients 65 older adults, 50 to 75 years of age (mean age 61 y, 86% women), who had recurrent headache (1/wk for 1 y) diagnosed as migraine, tension-type, cervicogenic, or mixed headache with associated neck pain and cervical musculoskeletal dysfunction (restricted active extension and rotation range of cervical motion and palpable upper cervical joint dysfunction); neck pain rated as 3 on a visual analogue scale (range 0 to 10; 10 = worst pain); and Neck Disability Index score 10 (scale range 0 to 100, higher score = greater disability). Exclusion criteria included temporal arteritis, trigeminal neuralgia, cluster headache, or chronic paroxysmal hemicrania continua; temporomandibular, neurologic, or cognitive disorders; previous serious head and neck trauma; contraindication to cervical mobilization; or PT for headache in the past year. Intervention 10-week PT program (14 individual 45-min sessions, 2/wk for 4 wk, then 1/wk for 6 wk) comprising cervical mobilization and a therapeutic exercise program (n =33) or usual care (n =32). Outcomes Primary outcome was headache frequency at 11 weeks, 6 months, and 9 months. Secondary outcomes included headache intensity and quality of life (Short Form-36, Thai version). Patient follow-up 100%. Main results The main results are in the Table. Conclusion In older adults with recurrent headaches associated with neck pain and cervical musculoskeletal dysfunction, a physiotherapy program reduced headache frequency and intensity. Physiotherapy (PT) vs usual care (UC) in older adults with recurrent headaches associated with neck pain Outcomes Follow-up Mean change from baseline Mean difference between groups (95% CI) PT UC Headache frequency (d/wk) 11 wk 2.6 0.9 1.6 (2.5 to 0.6) 6 mo 2.8 1.0 1.7 (2.6 to 0.8) 9 mo 3.5 1.0 2.4 (3.2 to 1.5) Headache intensity 11 wk 3.1 0.1 3.3 (4.1 to 2.4) 6 mo 2.9 0.7 2.3 (3.4 to 1.3) 9 mo 3.2 1.1 2.4 (3.6 to 1.1) Physical QoL 11 wk 24.0 2.1 25.3 (19.2 to 31.4) 9 mo 23.3 0.9 21.6 (16.0 to 27.2) Mental QoL 11 wk 18.1 6.7 23.4 (17.6 to 29.2) 9 mo 13.8 5.6 17.9 (11.6 to 24.2) QoL = quality of life; other abbreviations defined in Glossary. Mean difference between groups adjusted for baseline values. Numerical rating scale, range 0 to 10, lower score = reduced intensity; mean score over a 7-d period. For changes from baseline within groups, negative values = benefit. For difference between groups, negative values = physiotherapy benefit. Short-Form 36, Thai version, higher scores = better QoL. For changes from baseline within groups, positive values = benefit. For difference between groups, positive values = physiotherapy benefit. Commentary The randomized controlled trial by Uthaikhup and colleagues substantiates the benefits of PT compared with usual care (medications) in reducing headache frequency, intensity, and duration and improving cervicalgia and overall quality of life. The sample size was small (65 patients, 50 to 75 y of age), but the benefit of PT was statistically significant. The trial reported a nonsignificant reduction in analgesic medication use in the PT group, which is intuitively encouraging. These results are concordant with other studies showing the positive effect of such various forms of exercise as community-based programs (1), yoga (2), and aerobic exercise (3) on pain and disability. As expected, there were no adverse effects of PT. This trial supports the use of nonpharmacologic therapies for chronic pain syndromes, consonant with current attempts to decrease overuse of opioids in the USA. Applicability on a larger scale is limited by the availability of PT, insurance restrictions, time-consuming appointments, and highly variable certification and recertification requirements by different payers. Reducing barriers to nonpharmacologic therapy for pain has potential individual- and population-level benefits.