Tension-type headache and cervicogenic headache an

FCER DUKE UNIVERSITY EVIDENCE REPORT

Tension-type headache and cervicogenic headache are two of the most common non-migraine headaches. Population-based studies suggest that a large proportion of adults experience mild and infrequent (once per month or less) tension-type headaches, and that the one-year prevalence of more frequent headaches (more than once per month) is 20%-30%; a smaller percentage of the population (roughly 3%) has been estimated to have chronic tension-type headache (³ 180 days per year). Estimates of the prevalence of cervicogenic headache have varied considerably, due in large part to disagreements about the precise definition of the condition. A recent population-based study, which used the diagnostic criteria of the International Headache Society (IHS), found that 17.8% of subjects with frequent headache (³ 5 days per month) fulfilled the criteria for cervicogenic headache; this was equivalent to a prevalence of 2.5% in the larger population. This agrees with an earlier clinic-based study which found that 14% of headache patients treated had cervicogenic headache.

The impact of tension-type headache on individuals and society appears to be significant. According to one population-based study, regular activities were limited during 38% of tension-type headache attacks, and 4% of respondents indicated that their headaches affected their attendance at work. Eighty-nine percent of tension-type headache sufferers reported that their headaches had negatively affected their relationships with friends, colleagues, and family. Little is known about the personal and societal impact of cervicogenic headache.

Nearly all patients with tension-type headache have used medications at one time or another to treat their headaches. But pharmacological treatments are not suitable for all patients, nor are they universally effective. Drug treatments may also produce undesired side effects. Partly for these reasons, significant interest has developed among both patients and health care providers in alternative treatments for tension-type headache, including behavioral and physical interventions. Cervicogenic headache, when diagnosed as such, is commonly treated with non-pharmacological interventions, especially physical treatments.

Seventeen controlled trials of physical treatments were reviewed. The main findings were as follows:

Chiropractic was associated with improvement in headache outcomes in two trials involving patients with neck pain and/or neck dysfunction and headache. Manipulation appeared to result in immediate improvement in headache severity when used to treat episodes of cervicogenic headache when compared with an attention-placebo control. Furthermore, when compared to soft-tissue therapies (massage), a course of Chiropractic care resulted in sustained improvement in headache frequency and severity. However, among patients without a neck pain/dysfunction component to their headache syndrome – that is, patients with episodic or chronic tension-type headache – the effectiveness of cervical spinal manipulation was less clear. No placebo or no-treatment control studies of manipulation have been performed in these populations. In one trial conducted among patients with episodic tension-type headache, manipulation conferred no extra benefit when added to a soft-tissue therapy (deep friction massage). In another trial conducted among patients with tension-type headache, amitriptyline was significantly better than manipulation at reducing headache severity during the 6-week treatment period; there was no significant difference between the two treatments for headache frequency during the same period. Interpretation of these results is difficult because all patients received the same relatively low dose of amitriptyline (30 mg). Despite the uniform and relatively low dose of amitriptyline, however, adverse effects were much more common with amitriptyline (82% of patients) than with manipulation (4%). During the 4-week period after both treatments ceased, patients who had received manipulation were significantly better than those who had taken amitriptyline for both headache frequency and severity. Although amitriptyline is usually continued for longer than 6 weeks, the return to near-baseline values for headache outcomes in this group contrasts with a sustained reduction in headache frequency and severity in those who had received manipulation.

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