Posts tagged headaches
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.

Click Here to schedule your next appointment with the experts at MEND

Neck Pain and Physical Therapy Treatments
neck pain, physical therapy, treatment

Neck Pain Background Information

Neck pain affects 10-15% of the population at any one time, with a lifetime incidence of 22-70% (1). Only 6% of patients with neck pain report resolution of symptoms at one year (2).

A recent systematic review demonstrated the prognosis from idiopathic neck pain is poor (3) and 50-75% of patients with neck pain will report symptoms at 1 and 5 year follow up (4).

Evidence suggests the utilization of manual therapy and exercise is a more cost effective intervention compared to primary care management alone or standard physical therapy (see graph). (5)

Our effectiveness in treating patients increases as we match interventions to a patient’s signs and symptoms. Evidence suggests outcomes are improved by correctly matching each Physical Therapy intervention to a specific patient category see below.(6)

Patients with mechanical neck pain, cervical radiculopathy, and cervicogenic headaches can benefit from Physical Therapy interventions including manual therapy and exercise to reduce pain and improve disability. 

neck pain costs, manual therapy, boulder physical therapy

Physical Therapy Interventions for Neck Pain

Exercise and Conditioning

Physical Therapy strengthening, neck pain

Patients within this category may display lower pain and disability levels and report a longer duration of symptoms.

Exercises will aim to improve muscle function within the deep cervical flexors and scapular muscles.

A recent systematic review provided Level 1 evidence on the benefits of exercise for patients with mechanical neck pain.(7)

Strong evidence supports the utilization of proprioception and strengthening exercises for patients with recurrent or chronic neck pain.(8)


A recent Cochrane review documented the improved effectiveness of manual therapy and exercise over manual therapy alone in patients with neck pain with or without headaches.(10)

Authors report the benefit of cervical manipulation on reducing head- ache intensity and frequency in patients with headache.(9)

The utilization of manual therapy and cervical strengthening has been show to reduce pain, disability, and headaches over both the short and long term (see graph) (11). 

headache, neck pain, boulder physical therapy treatments

Neck and Arm Pain/Cervical Radiculopathy


Patients within this category include those who have signs and symptoms of nerve root impingement or radicular symptoms.

Studies demonstrate 26% of patients with cervical radiculopathy who undergo surgery continue to experience high levels of pain at a 1-year follow-up.(12) Studies also suggest that patient outcomes may be superior with conservative management versus surgical interventions.(13, 14)

Physical therapy interventions consisting of manual therapy (17), cervical traction (15, 16), and cervical centralization exercises have been shown to decrease pain and improve function in this population.

Recently authors reported 91% of patients with cervical radiculopathy who underwent treatment of manual physical therapy, cervical traction and strengthening exercises showed significant functional improvement. (17). 

neck and arm pain, boulder physical therapy treatments, centralization

Pain Control

This subgroup comprises patients with acute or traumatic onset of neck pain, including whiplash injury, and those presenting with high levels of pain and disability.

Physical therapy interventions for this category aim to decrease pain and allow transition into other subgroups for treatment to reduce disability.

Evidence suggests utilization of thoracic spine manipulation18, cervical spine mobilizations19, neck active ROM exercises20, gentle soft tissue massage(21), and physical modalities such as TENS (22).

Interventions matched to patient’s signs and symptoms within the category demonstrate greater changes in pain and disability than unmatched interventions (6). 


neck pain, mobility, boulder physical therapy treatments

Patients within this group include those with symptoms proximal to the elbow, an acute onset (<30 days), and are younger than 60 years old.(6)

Evidence supports the utilization of both cervical and thoracic mobilization/manipulation, with exercise, to restore mobility, decrease pain, and improve function. (1, 22, 23)

Utilization of manual therapy can reduce long term management costs by as much as 2/3 in comparison with exercises or medical management alone. (24) 


Childs, J. Cleland, J. et al. Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther 2008;38(9):A1-A34.

Picavet HS, Schouten JS. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC(3)-study. Pain. 2003;102:167-178.

Hush JM, Lin CC, Michaleff ZA, Verhagen A, Refshauge KM. Prognosis of acute idiopathic neck pain is poor: a systematic review and meta-analysis. Arch Phys Med Rehabil 2011;92:824-9

Carroll L. Hogg-Johnson, S. et al. Course and Prognostic Factors for Neck Pain in the General Population. Spine. 2008;33(4):S75–S82.

Korthals-de Bos IB, Hoving JL, van Tulder MW, et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomized controlled trial. BMJ. 2003.

Fritz JM, Brennan GP. Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Phys Ther. 2007;87:513–524.

Kay, T. Gross, A. et al. Exercises for mechanical neck disorders. Cochrane Database of Systematic Reviews. 2005. CD004250.

Sarig-Bahat, H. Evidence for exercise therapy in mechanical neck disorders. Manual Therapy. 2003;8:10-20.

Nilsson, N. Christensen, J. et al. The effect of cervical manipulation on cervicogenic headache. J Manip Phys Ther. 1997;20:326-330.

10. Gross, A. Hoving, J. et al. A Cochrane Review of Manipulation and Mobilization for Mechanical Neck Pain. Spine 2004;29:1541–1548

11. Jull, G. Trott, P. et al. A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache. Spine. 2002;27(17):1835–1843

12. Heckmann JG, Lang CJ, Zobelein I, Laumer R, Druschky A, Neundorfer B. Herniated cervical intervertebral discs with radiculopa- thy: an outcome study of conservatively or surgically treated patients. J Spinal Disord. 1999;12:396-401.

13. Honet JC, Puri K. Cervical radiculitis: treatment and results in 82 patients. Arch Phys Med Rehabil. 1976;57:12-16.

14. Sampath P, Bendebba M, Davis JD, Ducker T. Outcome in patients with cervical radiculopathy. Prospective, multicenter study with independent clinical review. Spine. 1999;24:591-597.

15. Graham N, Gross AR, Goldsmith C. Mechanical traction for mechanical neck disorders: a systematic review. J Rehabil Med. 2006;38:145-152.

16. Moeti P, Marchetti G. Clinical outcome from mechanical intermittent cervical traction for the treatment of cervical radiculopathy: a case series. J Orthop Sports Phys Ther. 2001;31:207-213.

17. Cleland, J; Whitman, J; Fritz, J; Palmer, J. Manual Physical Therapy, Cervical Traction and Strengthening Exercises in Patients with Cervical Radiculopathy: A Case Series. J Orthop Sports Phys Ther. 2005:35(12):802-809.

18. Gonzalez-Iglesias, J., Fernandez-de-las-Penas, C., Cleland, J., & Gutierrez-Vega, M. (2009). Thoracic spine manipulation for the

management of patients with neck pain: a randomized clinical trial. Journal of Orthopaedic & Sports Physical Therapy, 39(1), 20-27.

19. Conlin A, Bhogal S, Sequeira K, Teasell R. Treatment of whiplash- associated disorders, part I: non-invasive interventions. Pain Res Manag. 2005;10:21-32.

20. Rosenfeld M, Gunnarsson R, Borenstein P. Early intervention in whiplash-associated disorders: a comparison of two treatment protocols. Spine. 2000;25:1782-1787.

21. Skyba D, Radhakrishnan R, Rohlwing J. Joint manipulation reduces hyperalgesia by activation of monoamine receptors but not opioid or GABA receptors in the spinal cord. Pain 2003;106:159e68.

22. Cassidy, J.D., Lopes, A.A., Young-Hing, K. The immediate effect of manipulation vs mobilization on pain and range of motion in the cervical spine: a randomized control trial. Journal of Manipulative and Physiological Therapeutics. 1992. 15:9.

23. Cleland, J.A., Mintken, P.E., Carpenter, K., Fritz, J.M., Glynn, P., Whitman, J., Childs, J. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a generally cervical range of motion exercise: multi-center randomized control trial. Physical Therapy. 2010. 90: 9.

24. Ingeborg, B.C., Korthals-de Bos, Hoving, J.L., Tulder, M.W., Rutten-van Molken, M., Ader, H.J., CW de Vet, H., Koes, B.W., Vondelling, K., Bouter, L.M. Cost effectiveness of physiotherapy, manual therapy, and general practicioner care for neck pain: economic evaluation alongside a randomized control trial. British Medical Journal. 2003. 326:911 


Headaches and Physical Therapy Solutions
Headaches and Physical Therapy solutions

Headache Background

Headaches cause nearly $31 billion in indirect costs annually in the US (10).

Within patients with headaches, a cervicogenic source can be found in 4% of the general population, 17.5% of those with severe headaches, and up to 53% of those with headache post whiplash injury(11).

The upper cervical (C2/C3) facet joints have been shown to be the source of 70% of cervicogenic headaches with the majority of headaches being experienced within the C1-C4 dermatomes(11).

Clinical diagnosis can be made with 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 pain by neck movement                                                                                                                5. History of neck pain 

headache interventions

Physical Therapy Interventions 

Cervicogenic headaches are effectively treated by Physical Therapists using a multimodal approach including thrust and non thrust mobilization of the cervical and thoracic spine, as well as, low load endurance exercises for the upper quarter musculature(4).
Physical Therapists' unique education and experience in manual therapy and exercise make them an ideal treatment option for patients with cervicogenic headache. 

Physical Therapy Evidence

Evidence: Oxford Evidence Grade = A (level 1A studies)

Manual Physical Therapy & Exercise management ($400) is 1/3 the cost of standard physical therapy ($1,200) and primary care management ($1,300) over the course of one year(7).

A combination of manual physical therapy and exercise is more beneficial than primary care management (PCM), medication, modalities, manual therapy, or exercise alone in patients with neck pain, with or without headache(1-3).

30% of patients treated with manual therapy and exercise experience a clinically important reduction in pain than would have occurred otherwise if patients were receiving an alternative treatment approach(1, 2).

10% of patients treated with manual physical therapy and exercise experience a complete reduction in headache frequency than would have occurred if patients were receiving an alternative treatment approach(4).

The beneficial effects of manual therapy and exercise continue to be observed at one year2, 4, 5 and at two years more patients remain satisfied with their care compared to alternative treatment approaches at 2 years(6).

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 were receiving an alternative treatment approach(2). 

headache symptoms, pain, and Physical Therapy Interventions

When to seek Physical Therapy care

A critical review done by Pollmann, found that “physical therapy is recommended as the first line of management” in patients who suffer from cervicogenic headaches.

Physicians should look to refer those patients who present to their clinic with unilateral dominant side-consistent headaches associ- ated with neck pain which are aggravated by neck postures or movement and present with joint tenderness in at least one of the upper three cervical joints(8).

Patients who may not be appropriate for PT include those presenting with bilateral headaches, migraines, nausea and vomiting, traumatic injury/accident, or headaches with an aura(9).