Neck-shoulder region training for chronic headache in women: a randomized controlled trial

Key Points

1. Prescribing 6 months of progressive neck specific exercises had minimal effect on chronic headache.
2. Not all patients with chronic headache have neck muscle dysfunction and patients should be carefully selected.
3. The study design could have been improved by specifically selecting patients with poor neck physical function which might have had a better effect on neck function and headache.

BACKGROUND & OBJECTIVE

Headaches cause considerable disability with 52% of the world population suffering from various types of headaches. Headaches due to neck pain and sore muscles in the neck–shoulder region are commonly diagnosed as tension-type or cervicogenic headaches. To manage chronic cervicogenic headache, tension-type headache and migraine, a variety of physiotherapeutic and exercise rehabilitation treatments have been recommended.

The aim of this study was to investigate whether a specific progressive therapeutic exercise program for the neck–shoulder region is effective in reducing the intensity, frequency, and duration of headache in comparison to the control group receiving a placebo dose of transcutaneous electrical nerve stimulation (TENS).

Headaches due to neck pain and sore muscles in the neck–shoulder region are commonly diagnosed as tension-type or cervicogenic headaches.

Aerobic exercise can improve headache intensity, frequency and duration of headache and quality of life.

METHODS

To be included in the study female participants were to report at least 8 days per month of headache of at least 4/10 on a visual analogue scale and score 56 or more on the headache impact test. The primary outcome was headache intensity but secondary outcomes of changes in headache frequency and duration and the neck disability index were also measured.

Patients were excluded if they had significant depression, severe neck degeneration or neck trauma including a whiplash injury, those who already exercised three times per week and those having neck treatment.

The exercise program consisted of low load cervical and axio-scapular motor control, progressing to isometrics and then resistance band exercises (see video below).

NECK-SHOULDER REGION TRAINING FOR CHRONIC HEADACHE IN WOMEN

Exercises were to be performed for 15-30 minutes, 6 times per week for the first 3 months and then 4 times per week. Stretches were performed 3 times per week with follow-up at 3 months and 6 months.

RESULTS

116 women with primary headache, 53% migraine, 47% tension type headache or cervicogenic headache were included in the study. There were no between group differences for headache intensity and duration. There was minimal change (-.05/10) for headache intensity and some change (mean 5-11 hours/week) for duration (see figure 1).

Patients performing the specific exercise program had significantly decreased headache frequency from 4.5 to 2.4 days/week. Greater improvement in the neck disability index (4%), rotation range (8 degrees) and neck flexor endurance time (22 seconds) was also found in the exercise group. However, these changes are unlikely to be clinically meaningful due to the small changes (1,2) and/or mean baseline values being within normal limits (3,4).

LIMITATIONS

Therapists were not blinded during the reassessments which could have influenced the results. All patients with chronic headache were considered as a homogenous group. Baseline values of neck function would suggest that the majority of people in the study did not have cervical musculoskeletal impairments. For example, more than 70% were able to hold the neck extensor endurance test for the maximal 180 seconds and neck flexor endurance hold times were on average 50 seconds, which is beyond normal limits (3,4).

A recent study found that 60% of patients with migraine with neck pain did not have cervical musculoskeletal dysfunction (5). Thus, it is likely that some people in the current study did have impairments in muscle function, but many did not.

CLINICAL IMPLICATIONS

The authors concluded that the specific neck-shoulder progressive exercise program was well tolerated and almost halved headache frequency (4-2 days /week), although a 30 percent reduction was also seen in the placebo group. They suggest the exercise program could be recommended as a treatment option for women with chronic headache. However, it should be acknowledged that overall, the effects were modest. There were no differences seen in headache intensity or duration and changes in neck disability or function overall were not clinically meaningful.

Given there is evidence that aerobic exercise can improve headache intensity, frequency and duration of headache and quality of life (6,7) it would appear that this would be a better recommendation for patients with chronic headache at this stage. Clinically it would seem to be important to specifically choose patients who have cervical musculoskeletal impairments to determine if neck strengthening is of any benefit to patients with chronic headache. This way we can identify the people most likely to benefit and better determine the effect of this type of program in those individuals.

+STUDY REFERENCE

Rinne M, Garam S, Kukkonen-Harjula K, Tokola K, Hakkinen A, Ylinen J, Nikander R (2023) Neck-Shoulder Region Training for Chronic Headache in Women: A Randomized Controlled Trial. Clin Rehabil, Published online ahead of print.

SUPPORTING REFERENCE

1. Pool JJ, Ostelo RW, Hoving JL, Bouter LM, de Vet HC. Minimal clinically important change of the Neck Disability Index and the Numerical Rating Scale for patients with neck pain. Spine. 2007;32:3047-51.
2. Audette I, Dumas JP, Cote JN, De Serres SJ. Validity and between-day reliability of the cervical range of motion (CROM) device. J Orthop Sports Phys Ther. 2010;40:318-23.
3. Edmondston S, Bjoernsdottir G, Palsson T, Solgard H, Ussing K, Allison G. Endurance and fatigue characteristics of the neck flexor and extensor muscles during isometric tests in patients with postural neck pain. Man Ther. 2011;16:332-8.
4. Harris KD, Heer DM, Roy TC, Santos DM, Whitman JM, Wainner RS. Reliability of a measurement of neck flexor muscle endurance. Phys Ther. 2005;85:1349-55.
5. Liang Z, Thomas L, Jull G, Minto J, Zareie H, Treleaven J. Neck pain associated with migraine does not necessarily reflect cervical musculoskeletal dysfunction. Headache: The Journal of Head and Face Pain. 2021;61:882-94.
6. Lemmens J, De Pauw J, Van Soom T, Michiels S, Versijpt J, van Breda E, et al. The effect of aerobic exercise on the number of migraine days, duration and pain intensity in migraine: a systematic literature review and meta-analysis. J Headache Pain. 2019;20:16.
7. La Touche R, Fernández Pérez JJ, Proy Acosta A, González Campodónico L, Martínez García S, Adraos Juárez D, et al. Is aerobic exercise helpful in patients with migraine? A systematic review and meta-analysis. Scand J Med Sci Sports. 2020;30:965-82.