Someone who is suspected of having cervical neck instability as the cause of their headaches is:

• Someone who is constantly self-manipulating or cracking their neck.
• Someone who gets manipulation from chiropractors for neck pain.
• Someone who suffers from constant muscle spasms in the neck.

An October 2018 study published in the journal BioMed Central Neurology, (1) describes the challenges faced by patients and chiropractors in helping patients with tension headaches, migraines, and cervicogenic headaches.

Here are the learning points from that research.

• The use of chiropractors for headache management appears to be significant. In a recent national US study, manipulative-based physical therapies were reported to be the most frequently used complementary and alternative treatments for migraine and headache patients.
• In North America, a general population study reported between 25.7–36.2% of migraine headache patients had sought help from chiropractors at some time.
• While the use of chiropractors for the management of headache disorders appears to be significant, little is understood about how this provider group manages this substantial patient population.

Number of chiropractic visits

For headaches suffering from less than 3 months duration:

• between 28 and 29.6% of participants reported providing less than 5 treatments,
• between 54.2–55.5% provided between 5 and 10 visits, and
• between 14.9–16.5% reported providing more than 10 visits across all 3 headache types.

How do chiropractors treat headache types?

• The most frequent therapeutic approach by participants for migraine management was advice on
  • headache triggers (94.1%),
  • stress management (89.4%)
  • and non-thrust spinal mobilization (88.4%).
• The most frequent therapeutic approach by participants for tension headache management was:
  • advice on headache triggers (90.9%),
  • stress management (90.1%)
  • and soft-tissue therapies (massage, myofascial, stretching, or trigger point therapy) to the neck/shoulder area (88.1%).
• The most frequent therapeutic approach by participants for cervicogenic headache management was:
  • prescription exercises for the neck/shoulders (91.7%),
  • spinal manipulation (90.6%)
  • and soft-tissue therapies (massage, myofascial, stretching, or trigger point therapy) to the neck/shoulder area (88.3%)

Why are so many visiting the chiropractor? The researchers suggest:

• “This substantial level of headache caseload within chiropractic clinical settings raises questions about the factors that influence the preference and use of chiropractors for the management of headaches compared to the use of other headache providers and treatments. Previous evidence suggests that patient dissatisfaction with preventative headache drug treatments is likely to be an important predictor for headache patient use of manual therapy providers.”

BUT,

• “While some aspects of chiropractic headache management, including the acceptance and use of headache diagnostic criteria, appear to be consistent with good clinical practice, other aspects of chiropractic headache management raise questions worthy of further research inquiry.”

What are we to make of this?

In December 2020, (2) doctors at the Hospital for Special Surgery, Weill Cornell Medical College, and the Department of Neurology, at the Icahn School of Medicine at Mount Sinai, New York embarked on the “first study to provide detailed information on the patient management features associated with primary headache diagnosis by chiropractors. The majority of chiropractors in our study report utilizing ICHD (The International Classification of Headache Disorders) criteria for the diagnosis of primary headaches, a finding which may suggest that chiropractors are sometimes the first point of provider contact for patients seeking help in the management of primary headache disorders.

There are a number of factors that can challenge healthcare providers in delivering an accurate primary headache diagnosis. These include the co-occurrence of migraine with both cervicogenic headache and tension-type headache, variations in headache characteristics found within headache types, and the high prevalence of co-occurring neck pain associated with common recurrent headaches. With misdiagnosis resulting in suboptimal headache patient management, poor standards of headache diagnosis have raised concerns about the current level of headache education within primary health care curriculums.

Again, what are we to make of this?

Chiropractors understand that there is a neck component to headache management, they may not have all the tools they need in their treatments to offer satisfactory relief for some patients who have underlying ligamentous cervical instability. If you are reading this article you may be one of these patients.

Chiropractors found headaches have a neck instability component and the treatments offered were at best symptom management techniques. For many, they were not long-lasting treatments.

In this study, researchers at the Canadian Memorial Chiropractic College wrote of the effectiveness or non-effectiveness of non-invasive and non-pharmacological interventions for the management of patients with headaches associated with neck pain. In this study, combination treatments were offered. Published in the European Spine Journal (3) the chiropractic team suggested that treatments should include exercise (to help stabilize), relaxation training with stress coping therapy (to reduce spasms), and perhaps manual therapy (chiropractic) to help get the neck back in its natural position. More specifically, these are the recommendations:

• “The evidence suggests that episodic tension-type headaches should be managed with low load endurance craniocervical and cervicoscapular exercises.
• Patients with chronic tension-type headaches may also benefit from low-load endurance craniocervical and cervicoscapular exercises; relaxation training with stress coping therapy; or multimodal care that includes spinal mobilization, craniocervical exercises, and postural correction.
• For cervicogenic headaches, low load endurance craniocervical and cervicoscapular exercises; or manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine may also be helpful.”

Chiropractic and acupuncture do they help?

An August 2021 study led by the California Institute of Behavioral Neurosciences & Psychology in the journal Cureus (4) offered this assessment of acupuncture and manual or chiropractic care.

“There are several non-pharmacologic treatment options suggested for tension-type headaches, such as cognitive behavioral therapy, relaxation, biofeedback, acupuncture, exercise, manual therapy, and even some home remedies.  . . Acupuncture was compared to routine care or sham (placebo acupuncture) intervention. Acupuncture was not found to be superior to physiotherapy, exercise, and massage therapy. . . Manual therapy has an efficacy that equals prophylactic medication (Angiotensin blockers, Antidepressants, Beta-blockers, NSAIDs, etc) and tricyclic antidepressants in treating tension-type headaches. The available data suggests that both acupuncture and manual therapy have beneficial effects on treating symptoms of tension-type headaches. However, further clinical trials looking at long-term benefits and risks are needed.”

Further research

Cervical spine instability induced Thunderclap headache

References

1 Moore C, Leaver A, Sibbritt D, Adams J. The management of common recurrent headaches by chiropractors: a descriptive analysis of a nationally representative survey. BMC Neurol. 2018;18(1):171. Published 2018 Oct 17. doi:10.1186/s12883-018-1173-6 [Google Scholar]
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3 Varatharajan S, Ferguson B, Chrobak K, Shergill Y, Côté P, Wong JJ, Yu H, Shearer HM, Southerst D, Sutton D, Randhawa K. Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. European Spine Journal. 2016 Jul 1;25(7):1971-99. [Google Scholar]
4 Turkistani A, Shah A, Jose AM, Melo JP, Luenam K, Ananias P, Yaqub S, Mohammed L. Effectiveness of Manual Therapy and Acupuncture in Tension-Type Headache: A Systematic Review. Cureus. 2021 Aug 31;13(8). [Google Scholar]