Posts in headaches
Manual Physical Therapy Interventions Improve Quality Of Life In Patients With Headache

Headaches are a common source of pain and disability with total costs estimated over 30 billion dollars per year. Patients’ signs and symptoms help classify headaches into categories including migraine, tension type, cluster, and cervicogenic but some are found to be multifactorial in nature. Some of the most effective interventions for headache are provided by Physical Therapists including manual therapy and exercise. These combined treatments have been shown to be more cost and clinically effective than primary care management, exercise alone, and modalities in the short and long term. Specifically, a manual therapy and exercise approach has been shown to be 1/3 the cost of standard physical therapy and primary care management. A recent review of the evidence highlights the impact of these interventions on a patient’s quality of life.

Authors reviewed the available evidence on the impact of manual therapy on various headache types (Falsiroli Maistrello et al. Curr Pain Headache Rep. 2019). They included 7 randomized controlled trials in their systematic review and meta analysis. Consistent with previous research they found a significant impact of manual therapy, including spinal manipulation by Physical Therapists, immediately after treatment and at short and long term follow up. Authors concluded “manual therapy should be considered as an effective approach in improving quality of life” in patients with headache including tension and migraine.

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What Are The Most Effective Treatments For Tension Headaches?

Tension-type headaches are headaches related to muscle trigger points or muscle tenderness in the head and neck and are the most common type of headache in adults. In our Boulder physical therapy practice, we utilize hands-on techniques addressing muscles and joints of the upper cervical region for headaches. A recent systematic review and meta-analysis (Jiang et al, Medicine 2019) concluded that the combination of upper cervical spinal manipulation and soft-tissue treatment techniques were more effective for short-term pain reduction than soft tissue work alone.

It is important to note that postural impairments and upper cervical muscle atrophy have also been correlated with headache and the effect of exercise to change these contributing factors was not addressed in this study.

Please contact the headache experts at Mend to determine what combination of spinal manipulation, soft tissue mobilization and exercise is right to address your specific headache complaint.

Significant Cervical Weakness Found Among Patients With Migraine

According to the Global Health Burden studies, Migraine is the 3rd most prevalent disorder (14.7% of global population: 1 in 7 people)  and 3rd most cause of disability in those under 50 years old. It is more prevalent than diabetes, epilepsy and asthma combined. Migraines occur with 17% of women and 6% of men.  Symptoms of migraine include: Headache on bilateral or unilateral sides around temporal region, with or without visual disturbances.

A recent study (JOSPT 2019) investigated the role of the musculature in the cervical spine in those with migraines. A lack in neck endurance strength of the neck musculature has been shown to be correlated with chronic migraines. The authors found a significant difference in neck extensor and flexor strength with those with and without migraines. The findings of the study suggest addressing the strength of the musculature of the neck to assist in management of headaches

Physical Therapy Headache Solutions

Headaches remain a significant source of pain and disability for patients in our country costing over $30 billion dollars each year. Symptoms can be driven by different types of headache including tension, migraine, and cervicogenic (driven from the neck). Cervicogenic headaches can be found in 4% of the general population, 20% of all patients with headaches, and up to 50% of patients with headaches after a whiplash mechanism of injury.

The upper neck vertebrae are most commonly associated with these symptoms with the 2nd and 3rd vertebral joint driving 70% of headaches. The clinical diagnosis can be made based on the following criteria

  1. Pain that originates in the neck and radiates to the frontal and temporal regions

  2. Unilateral symptoms (may be bilateral but never together)

  3. Radiates to ipsilateral shoulder and arm

  4. Provocation of symptoms with neck movement

  5. History of neck pain

Physical Therapy remains a first line treatment for cervicogenic headaches. Researchers advocate for a mulitimodal approach including spinal manipulation, neck and upper back strengthening (see videos). These interventions have received the highest grade (A) of evidence for treatment of this condition. Specifically, evidence supports the use of manual therapy and exercise over primary care management, manual therapy or exercise alone in patients with neck pain and headache. These benefits are sustained at 1 and 2 year follow up time periods. Finally, the number needed to treat (NNT) is 2 for patients with neck pain treated with manual physical therapy and exercise to achieve one additional successful outcome than would have occurred if patients received an alternative treatment.

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Concussion Rates at Altitude

Winter sports are in full spring in Colorado with many people taking their athletic pursuits outside.  Skiing and snowboarding continue to grow in popularity throughout our state among both children and adults.  Thankfully, ski helmets have become the norm at our state's ski areas.  These helmets are an essential piece of equipment to reduce the forces placed on the brain and skull during a fall.  Concussion is one of the most commonly diagnosed injuries to the head among athletes.  New research is examining the impact of altitude on concussion incidence and symptoms.   

Authors have previously reported fewer concussions are diagnosed in high school and professional athletes competing at higher altitudes (Myer et al. 2014, Smith et al. 2013).  This has led clinicians and researchers to believe high altitudes may have a protective effect on brain injuries like concussion.  These first two articles were only preliminary reports and the definition of injury and high altitudes was not clear.  A recent article in the Journal of Orthopedic and Sports Physical Therapy examined concussion rates at 21 NCAA division I football programs across the country (Lynall et al. 2016).  The article stated 169 concussions were reported by these programs medical staffs over 63 seasons (1-5 seasons for each team).  Surprisingly, these authors found higher altitudes may be associated with higher rates of concussions.  

Differences between this study and previously studies may be due to differences in research methodology including injury tracking and athlete selection.  For example, the college athletes in this study may not have enough time prior to competition for beneficial physiological adaptations to occur compared to their pro counterparts.  Usually adaptations are observed 48-72 hours after traveling to altitude.  Further research is needed to determine the impact of these physiological changes on brain health in athletes, but this research adds to existing research questioning the protective benefits of altitude competition on concussion rates. 

Jaw Pain and Physical Therapy Treatments

Temporomandibular Disorders (TMJ/TMD)


TMJ/TMD are a major cause of non dental jaw and facial pain.  Approximately 18 million word days are lost annually per 100 million full time working adults due to symptoms of TMD (2).  

Women have a 3:1 greater ratio of incidence compared to men between age 30 and 50 (1).

Disk Displacement and Arthritic symptoms peak at age 30 and 50, respectively (1).

Symptoms can be broken down into 3 areas:

Muscle or myofascial pain (45%), Osteoarthritis (41%), and Osteoarthrosis

Physical Therapy Treatments

Review articles support a mulimodal approach for the management of TMD including: joint mobilization/manipulation, soft tissue mobilization, active exercise, proprioception training, and relaxation training (6,7,11).

boulder physical therapy treatments jaw pain face pain

Evidence for Physical Therapy Interventions 

Shiffman et al. found rehabilitation was as effective as arthroscopic surgery or arthroplasty (4).

Manual therapy has been shown to be more cost effective and less prone to side effects than dental treatments (5).

Dry needling of the facial muscles has shown positive results in recent trials (12).

Neuromuscular re education and behavioral changes are more effective than splinting (6).

Nicolakis et al. demonstrated >85% of patients with TMD treated with PT report excellent functional improvement, reduce pain, and improved ROM.  76% of patients required no further care up to 3 years after treatment (8,9).

Furto et al. demonstrated improved short term outcomes following Physical Therapy treatments involving manual therapy and exercise (10).

Manual therapy interventions to the cervical and thoracic spines, as well as, dry needling has demonstrated further improvements in pain and disability (12). 

When to Refer to Physical Therapy

Patients with TMD often display signs and symptoms including: TMJ pain and myofascial pain in the face, jaw or neck, TMJ sounds, restrictions, deviations, or deflections of the jaw during jaw opening and closing.

The American Association for Dental Research reports

"Unless there are specific and justifiable indications to the contrary, treatment of patients with TMD initially should be based on the use of conservative, reversible, and evidence based therapeutic modalities."


1. Manfredini, D. et al. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011 Oct;112(4):453-62.

2. Okeson, J. et al. Temporomandibular disorders in medical practice. J Fam Pract. 1996. 43(4):347-56.

3. Truelove, E. The efficacy of traditional, low cost and non splint therapies for temporomandibular disorder. A randomized controlled trial. J Am Dent Assoc. 2006.

4. Schiffman et al. Randomized Effectiveness Study of Four Therapeutic Strategies for TMJ Closed Lock J Dent Res 1986(1):58-63, 2007

5. Kalamir A, Pollard H, Vitiello
myofascial therapy for chronic myogenous temporoman- dibular disorders: a randomized, controlled pilot study. J Man Manip Ther. 2010;18(3):139-146.

6. Medlicott, M. et al. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporo- mandibular disorders. Phys Ther. 2006;86:955-973.

7. Kalamir, A. et al. Manual therapy for temporomandibular disorders. A review of the literature. J Bodywork Movement Therapies. 2007.

8. Nicolakis, P et al. An investigation of the effectiveness of exercise and manual therapy in treating symptoms of TMJ osteoarthritis. Cranio. 2001. 19(1):26-32. 

9. Long term outcome after treatment of temporomandibular joint osteoarthritis with exercise and manual therapy. Cranio. 2002. 20(1):23-27.

10. Furto, E. et al. Manual physical therapy interventions and exdrcise for patients with temporomandibular disorders. Cranio. 2006. 24(4):283-91.

11. Shaffer, S. Temporomandibular disorders. Part 2: conservative management. JMMT. 2014.

12. Gonzalez-Iglesias, J. et al. Mobilization with movement, thoracic spine manipulation, cervical spine manipulation, and dry needling for the management of temporomandibu- lar disorder: A prospective case series. Phys Ther Theory and Prac. 2013.