Clinical Reasoning Behind Non-Pharmacological Interventions for the Management of Headaches: A Narrative Literature Review

Abstract

Headache is the clinical syndrome most commonly observed by neurologists in daily practice. Pharmacological and non-pharmacological treatments are commonly used for the management of headaches; however, the clinical reasoning behind these interventions is not properly applied. We conducted a narrative literature review using as data sources for academic PubMed, MEDLINE, EMBASE, AMED, CINAHL, EBSCO, PEDro, Cochrane Database of Systematic Reviews, Cochrane Collaboration Trials Register, and SCOPUS. This narrative literature review mainly considered systematic reviews, meta-analyses, randomised clinical trials, and expert opinions published after the year 2000 discussing clinical reasoning for application of non-pharmacological interventions in individuals with tension-type, migraine, and cervicogenic headaches. After the data extraction, we organized the literature thematically as follows: (1) mapping of theoretical aspects of non-pharmacological interventions; (2) summarizing most updated literature about effectiveness of non-pharmacological interventions grouped by targeted tissue and headache; (3) identifying research gaps in the existing literature and proposing hypotheses for better understanding of current clinical reasoning. We found that there are many non-pharmacological treatment strategies used for headaches, including beyond the tissue-based impairment treatments (bottom-up) and strategies targeting the central nervous system (top down). Bottom-up strategies include joint-biased, soft-tissue biased, or needling interventions, whereas top-down strategies include exercise and cognitive interventions. Evidence shows that the effectiveness of these interventions depends on the application of proper clinical reasoning, since not all strategies are effective for all headaches. For instance, evidence of non-pharmacological interventions is more controversial for migraines than for tension-type or cervicogenic headaches, since migraine pathogenesis involves activation of sub-cortical structures and the trigemino- vascular system, whereas pathogenesis of tension-type or cervicogenic headaches is most associated to musculoskeletal impairments of the cervical spine. We conclude that current literature suggests that not all non-pharmacological interventions are effective for all headaches, and that multimodal, not isolated, approaches seem to be more effective for patients with headaches. Most published studies have reported small clinical effects in the short term. This narrative literature review provides some hypotheses for discrepancies in the available literature and future research. Clinical reasoning should be applied to better understand the effects of non-pharmacological interventions.

Postural physiotherapy for cervicogenic headache after occipital nerve block: a retrospective study

“…Anesthetic blockade, combined or not with a corticosteroid or botulinum toxin injection are also used (Wang & Wang, 2014;Karadas et al, 2012). Moreover, non-pharmacological resources may be useful auxiliary tools in the treatment of cervicogenic headaches (Côté et al, 2019;Peñas et al, 2020), in particular, physiotherapy, acupuncture, and shiatsu (Sakata & Issy, 2010;Dach et al, 2015).…”

Effectiveness of Mulligan manual therapy over exercise on headache frequency, intensity and disability for patients with migraine, tension-type headache and cervicogenic headache – a protocol of a pragmatic randomized controlled trial

“…The non-pharmacological management of common headache types can include physiotherapy [11]. This may consist of exercise and spinal manual therapy, the latter of which is often provided due to the presence of neck pain in these patients [12]. Neck pain is characteristic of CGH [5] but is also very common in people who suffer from migraine and TTH [13].…”

“…Sensitization of the trigeminocervical nucleus appears to be a common feature in migraine, TTH and CGH [31]. Although such sensitization may have arisen through different means in each of the headache forms, desensitization of this nucleus by manual therapy and exercise may theoretically be a viable treatment option [12].…”

Baş Ağrili Bi̇reylerde Servi̇kal Kas İskelet Si̇stemi̇ Bozukluklari

“…Baş ağrısı, farklı yaş gruplarında görülebilen, sık karşılaşılan, birçok etkene bağlı, bireysel ve sosyo-ekonomik etkileri oldukça fazla olan genel bir sağlık problemidir (1,2). Baş ağrısının, bireylerde önemli ölçüde ağrıya ve buna bağlı engelliliğe neden olduğu ve sağlık hizmetleri sistemlerinde önemli maliyetler oluşturduğu bildirilmektedir (3). Ömür boyu en az bir kez baş ağrısı yaşayan bireylerin oranının erkeklerde %93, kadınlarda %99 olmak üzere genel populasyonda %90'ın üzerinde olduğu belirtilmektedir (4).…”