Chiropractors see adult patients with headaches everyday, which means understanding the evidence and best practices for their assessment and management is crucial to facilitate best practices and optimize patient safety and outcomes. This week, a summary of a recent guideline development paper (via Clinical Compass) regarding the chiropractic management of adults with tension-type and cervicogenic headaches.

Tension-type headache (TTH) is a common primary headache disorder that affects approximately 26% of adults worldwide. The typical symptoms of TTH include a pressing or tightening sensation of the muscles around the head and neck, often described as a “tight band” around the head with referred head pain. Nausea, vomiting, or sensitivity to light and sound are not typically present.

Cervicogenic headache (CGH) is much less common than TTH, with a reported prevalence of 0.2% in 30- to 44-year-olds and 4.1% in 18- to 65 years-olds. CGH is a secondary headache disorder that arises from a cervical spine disorder that involves the facet joints, intervertebral discs, and/or soft tissues.

Neck pain and dysfunction are common in both TTH (88% of patients) and CGH (92%), although neck symptoms in TTH are not considered a cause of headache.

Patients with headache commonly seek chiropractic care, representing about 6% of all chiropractic patients. Chiropractors typically use spinal manipulative therapy (i.e. high-velocity, low-amplitude thrust) for headaches, although they may use a broad range of other nonpharmacological treatments.

Recent clinical practice guidelines for the chiropractic management of headaches were published in 2011 and 2019, both reporting that spinal manipulative therapy was beneficial for CGH, but the evidence was limited for TTH. However, not all modalities commonly used by chiropractors (ex. dry needling) were covered in these guidelines. Therefore, an updated guideline is needed that includes any new evidence and a broader range of therapies used by chiropractors for headache.

Since the effective management of CGH and TTH relies on an accurate diagnosis, an updated review and guideline addressing diagnostic and evaluation components is also needed that would help clinicians in making decisions vis-à-vis planning care and referral.

Nonpharmacological care was defined for this clinical practice guideline as interventions other than medications, injections, or surgeries, such as manual therapies, exercise, education, mind–body interventions, acupuncture, dry needling, and physical therapy modalities. No recent, comprehensive clinical practice guidelines have addressed the use of these therapies by chiropractors.

Excerpt from the Clinical Application & Conclusions section of the review:

“This guideline offers up-to-date evidence-based consensus statements for the nonpharmaceutical management of CGH and TTH in adults that provide guidance to chiropractors about which nonpharmacological interventions are appropriate.

A history, examination and diagnosis are encouraged, as well as spinal manipulative therapy for patients with CGH, and spinal manipulative therapy plus multimodal care for patients with TTH.

There was a lack of high certainty evidence for several nonpharmacological therapies (ex. acupuncture, education, meditation/mindfulness, and modalities used in isolation); therefore, strong statements for these interventions were not possible.”

This week’s Research Review: