A multidisciplinary expert panel and members from the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration have released an updated evidence-based clinical practice guideline on the nonpharmacologic management of persistent headache associated with neck pain. The guideline was published in the European Journal of Pain.

The OPTIMa task force was convened to review the literature systematically for high-quality studies focused on the nonpharmacologic management of tension-type headache (TTH) or cervicogenic headache associated with neck pain. Researchers evaluated the evidence for treatment strategies in which clinical benefits, cost-effectiveness, societal and ethical values, and patient experiences were examined.

Nonpharmacologic approaches evaluated in the studies included in the review were acupuncture, exercise, manual therapy, multimodal care, passive physical modalities, soft tissue therapies, structured patient education, and work disability prevention. These interventions were compared with placebo/sham interventions, no intervention, or other noninvasive interventions. Primary outcomes of interest were self-rated recovery, functional recovery, disability, pain intensity, health-related quality of life, psychological outcomes, or adverse events.

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Recommendation 1: Evaluation of the Etiology of Headaches

Clinicians are advised to start patient evaluation by ruling out the involvement of other causes of persistent headache, including those of major structural origin or migraine. Headaches are further classified as TTH or cervicogenic headaches.

Recommendation 2: Management of Headache Associated With Neck Pain

Clinicians should involve the patient in decision making and the care-planning process as much as possible to address any misconceptions or fears regarding the person’s condition. Patients should be advised to stay physically active and should receive information and education about the pain and its mechanism. In addition, physicians should identify and discuss with the patient any factors that may result in delayed recovery (eg, psychosocial factors, demographics, headache characteristics).

Recommendation 3: Management of Episodic TTH Associated With Neck Pain

Clinicians should provide structured headache education to patients with episodic TTH. Such an approach may consist of providing patients with information on the nature, management, and course of the headache type. Clinicians can also recommend low load endurance craniocervical and cervicoscapsular exercises, both supervised and/or home based, with a maximum of 8 sessions over a 6-week period. Initially taught to the patient by a qualified healthcare practitioner, these exercises allow patients to gain muscular control of the craniocervical and cervicoscapular regions. The review indicates that these exercises, in combination with physiotherapy, may be superior to a physiotherapy-only approach.

In addition, manipulation of the cervical spine should not be done for those with episodic TTH associated with neck pain. This recommendation is based on evidence from randomized controlled trials with low risk for bias.

Recommendation 4: Management of Chronic TTH Associated With Neck Pain

In addition to providing structured patient education, evidence suggests that clinicians should consider recommending participation in a clinic- and home-based exercise program to patients with chronic TTH associated with neck pain. The program should include a warm-up, neck and shoulder stretching and strengthening, and aerobic exercises. The program should be limited to a maximum of 25 sessions over a 12-week period. Supervised and home-based low load endurance craniocervical and cervicoscapsular exercises can also be recommended to these patients.

Healthcare professionals can also administer a maximum of 9 sessions of multimodal care over 8 weeks to patients with chronic TTH. Multimodal care may involve spinal mobilization, craniocervical exercises, and postural correction, with each session lasting 30 minutes. A total of eight 45-minute sessions of clinical massages, twice weekly over a 4-week period is also recommended for these patients. Cervical spinal manipulation is not recommended.

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Recommendation 5: Management of Persistent Cervicogenic Headaches

Patient education as well as low load endurance craniocervical and cervicoscapular exercises (with a maximum of 8 sessions over a 6-week period) are recommended for patients with persistent cervicogenic headaches.

Manual therapy with or without mobilization of the cervical and thoracic spine (with a maximum of 10 sessions over a 6-week period) is recommended for these patients. Spinal manipulation with light massage and moist heat may be more effective than light massage plus moist heat only for improving headache pain, frequency, and associated disability.

A multimodal care program consisting of exercise, spinal manipulation, and spinal mobilization is not recommended for patients with persistent cervicogenic headaches.

Recommendation 6: Reassessment and Hospital Discharge

Clinicians should reassess patients during each visit to determine whether additional care is necessary, whether the condition is worsening, or whether the patient has recovered. When patients report substantial recovery, discharge is indicated. This question may be asked to patients when assessing recovery: “How well do you feel you are recovering from your injuries?” Discharge is indicated when the patient responds “better,” or “much improved.”

Guidelines limitations include the limited amount and quality of available evidence, little evidence in which the cost-effectiveness of nonpharmacologic interventions for these conditions was examined, and the lack of research indicating superior efficacy of recommended interventions over placebo or sham interventions.

“It is important to note that all recommended interventions provide small benefits at best,” noted the guideline authors.

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Côté P, Yu H, Shearer HM, et al. Non-pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration [published online February 1, 2019]. Eur J Pain. doi: 10.1002/ejp.13