Neck exercises Versus Myofascial Release for Chronic Tension-Type Headache and Posture: A Randomized Controlled Trial Protocol
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Abstract
Background: Tension-Type Headache (TTH) is recognized as the most common type of headache worldwide causing significant psychological, physical, financial, and societal consequences. One of the activating factors of Chronic Tension-Type Headache (CTTH) is cervical dysfunction such as Forward Head Posture (FHP) leading to suboccipital muscle tenderness and Deep Neck Flexor (DNF) muscles weakness. Physiotherapy affect these patients through two mechanisms: top-down (e.g., DNF exercises) and bottom-up (e.g., suboccipital Myofascial Release (MFR)), but their relative effectiveness in reducing headache-related parameters remains unclear.
Methods: This randomized, parallel-group, assessor blind, double-dummy clinical trial includes 44 participants divided into two groups: one receiving MFR with sham exercise and the other DNF exercises with sham MFR. Interventions will be carried out over four weeks, followed by a six-week follow-up. Primary outcomes include headache intensity and craniovertebral angle (CVA), while secondary outcomes assess headache frequency, duration, pressure pain threshold, disability and quality of life.
Conclusion: This study aims to compare the effectiveness of a top-down versus a bottom-up physiotherapy approache in CTTH patients with FHP. If a significant difference is found, the study will identify the superior approach for short- and medium-term outcomes, providing valuable insights for clinicians and health managers.
1. Pryse-Phillips W, Findlay H, Tugwell P, Edmeads J, Murray TJ, Nelson RF. A Canadian population survey on the clinical, epidemiologic and societal impact of migraine and tension-type headache. The Canadian journal of neurological sciences Le journal canadien des sciences neurologiques. 1992;19(3):333-9.
2. Rasmussen BK, Jensen R, Schroll M, Olesen J. Epidemiology of headache in a general population--a prevalence study. Journal of clinical epidemiology. 1991;44(11):1147-57.
3. Edmeads J, Findlay H, Tugwell P, Pryse-Phillips W, Nelson RF, Murray TJ. Impact of migraine and tension-type headache on life-style, consulting behaviour, and medication use: a Canadian population survey. The Canadian journal of neurological sciences Le journal canadien des sciences neurologiques. 1993;20(2):131-7.
4. Rasmussen BK, Jensen R, Olesen J. Impact of headache on sickness absence and utilisation of medical services: a Danish population study. Journal of epidemiology and community health. 1992;46(4):443-6.
5. GBD 2016 Headache Collaborators. “Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.” The Lancet. Neurology vol. 17,11 (2018): 954-976. doi:10.1016/S1474-4422(18)30322-3
6. Ashina S, Buse DC, Bjorner JB, Bendtsen L, Lyngberg AC, Jensen RH, et al. Health-related quality of life in tension-type headache: a population-based study. Scandinavian journal of pain. 2021;21(4):778-87.
7. Headache Classification Committee of the International Headache Society (IHS). “The International Classification of Headache Disorders, 3rd edition (beta version).” Cephalalgia : an international journal of headache vol. 33,9 (2013): 629-808. doi:10.1177/0333102413485658
8. Yoo YM, Kim KH. Current understanding of nociplastic pain. Korean J Pain. 2024;37(2):107-18.
9. Rasmussen BK. Migraine and tension-type headache in a general population: precipitating factors, female hormones, sleep pattern and relation to lifestyle. Pain. 1993;53(1):65-72.
10. Wöber C, Holzhammer J, Zeitlhofer J, Wessely P, Wöber-Bingöl C. Trigger factors of migraine and tension-type headache: experience and knowledge of the patients. The journal of headache and pain. 2006;7(4):188-95.
11. Marcus DA, Scharff L, Mercer S, Turk DC. Musculoskeletal abnormalities in chronic headache: a controlled comparison of headache diagnostic groups. Headache. 1999;39(1):21-7.
12. Chu ECP, Lo FS, Bhaumik A. Plausible impact of forward head posture on upper cervical spine stability. Journal of family medicine and primary care. 2020;9(5):2517-20.
13. Bendtsen L. Central sensitization in tension-type headache--possible pathophysiological mechanisms. Cephalalgia : an international journal of headache. 2000;20(5):486-508.
14. Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Gerwin RD, Pareja JA. Trigger points in the suboccipital muscles and forward head posture in tension-type headache. Headache. 2006;46(3):454-60.
15. Millea PJ, Brodie JJ. Tension-type headache. American family physician. 2002;66(5):797-804.
16. D'Amico D, Grazzi L, Leone M, Moschiano F, Bussone G. A review of the treatment of primary headaches. Part II: Tension-type headache. Italian journal of neurological sciences. 1998;19(1):2-9.
17. Victoria Espí-López G, Arnal-Gómez A, Arbós-Berenguer T, González Á AL, Vicente-Herrero T. Effectiveness of Physical Therapy in Patients with Tension-type Headache: Literature Review. Journal of the Japanese Physical Therapy Association = Rigaku ryoho. 2014;17(1):31-8.
18. Fernández-de-Las-Peñas C, Florencio LL, Plaza-Manzano G, Arias-Buría JL. Clinical Reasoning Behind Non-Pharmacological Interventions for the Management of Headaches: A Narrative Literature Review. Int J Environ Res Public Health. 2020;17(11).
19. Fernández-de-las-Peñas CS-M, J.; Ge, H.Y.; Dommerholt, J. Manual treatment of myofascial trigger points. In Manual Therapy for Musculoskeletal Pain Syndromes of the Upper and Lower Quadrants: An Evidence and Clinical-Informed Approach. London, UK: Elsevier; 2015.
20. Huguet A, McGrath PJ, Stinson J, Tougas ME, Doucette S. Efficacy of psychological treatment for headaches: an overview of systematic reviews and analysis of potential modifiers of treatment efficacy. The Clinical journal of pain. 2014;30(4):353-69.
21. Lai AKM, Arnold AS, Wakeling JM. Why are Antagonist Muscles Co-activated in My Simulation? A Musculoskeletal Model for Analysing Human Locomotor Tasks. Annals of biomedical engineering. 2017;45(12):2762-74.
22. Schleip R. Fascial plasticity - A new neurobiological explanation: Part 1. Journal of Bodywork and Movement Therapies. 2003;7:11-9.
23. Cerritelli F, Chiacchiaretta P, Gambi F, Perrucci MG, Barassi G, Visciano C, et al. Effect of manual approaches with osteopathic modality on brain correlates of interoception: an fMRI study. Sci Rep. 2020;10(1):3214.
24. Häkkinen K, Komi PV. Electromyographic changes during strength training and detraining. Med Sci Sports Exerc. 1983;15(6):455-60.
25. Vaegter HB, Handberg G, Graven-Nielsen T. Similarities between exercise-induced hypoalgesia and conditioned pain modulation in humans. Pain. 2014;155(1):158-67.
26. Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Pareja JA. Neck mobility and forward head posture are not related to headache parameters in chronic tension-type headache. Cephalalgia : an international journal of headache. 2007;27(2):158-64.
27. Cho SH. The effect of suboccipital muscle inhibition and posture correction exercises on chronic tension-type headaches. Journal of back and musculoskeletal rehabilitation. 2021.
28. Choi W. Effect of 4 Weeks of Cervical Deep Muscle Flexion Exercise on Headache and Sleep Disorder in Patients with Tension Headache and Forward Head Posture. Int J Environ Res Public Health. 2021;18(7).
29. Lee E, Lee S. Impact of Cervical Sensory Feedback for Forward Head Posture on Headache Severity and Physiological Factors in Patients with Tension-type Headache: A Randomized, Single-Blind, Controlled Trial. Med Sci Monit. 2019;25:9572-84.
30. Elizagaray-Garcia I, Beltran-Alacreu H, Angulo-Díaz S, Garrigós-Pedrón M, Gil-Martínez A. Chronic Primary Headache Subjects Have Greater Forward Head Posture than Asymptomatic and Episodic Primary Headache Sufferers: Systematic Review and Meta-analysis. Pain Med. 2020;21(10):2465-80.
31. Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, et al. A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache. Spine. 2002;27:1835-43; discussion 43.
32. Vincent K, Maigne J-Y, Fischhoff C, Lanlo O, Dagenais S. Systematic review of manual therapies for nonspecific neck pain. Joint, bone, spine : revue du rhumatisme. 2012;80.
33. Meisam N, Seyed Asadullah A, Mohammad Reza H, Behnaz G. Effect of Corrective Exercises on Cervicogenic Headache in Office Workers With Forward Head Posture. Journal of Modern Rehabilitation. 2018;11(4).
34. Jeong ED, Kim CY, Kim SM, Lee SJ, Kim HD. Short-term effects of the suboccipital muscle inhibition technique and cranio-cervical flexion exercise on hamstring flexibility, cranio-vertebral angle, and range of motion of the cervical spine in subjects with neck pain: A randomized controlled trial. Journal of back and musculoskeletal rehabilitation. 2018;31(6):1025-34.
35. Kang HS, Kwon HW, Kim DG, Park KR, Hahm SC, Park JH. Effects of the Suboccipital Muscle Inhibition Technique on the Range of Motion of the Ankle Joint and Balance According to Its Application Duration: A Randomized Controlled Trial. Healthcare (Basel). 2021;9(6).
36. Faustino D, Vieira A, Candotti CT, Detogni Schmit EF, Rios Xavier MF, Lunelli VA, et al. Repeatability and reproducibility of the pressure biofeedback unit. J Bodyw Mov Ther. 2021;27:560-4.
37. Garrett TR, Youdas JW, Madson TJ. Reliability of measuring forward head posture in a clinical setting. J Orthop Sports Phys Ther. 1993;17(3):155-60.
38. Puig-Diví A, Escalona-Marfil C, Padullés-Riu JM, Busquets A, Padullés-Chando X, Marcos-Ruiz D. Validity and reliability of the Kinovea program in obtaining angles and distances using coordinates in 4 perspectives. PLoS One. 2019;14(6):e0216448.
39. Jabbari S, Salahzadeh Z, Sarbakhsh P, Rezaei M, Farhoudi M, Ghodrati M. Validity and Reliability of Persian Version of Henry Ford Hospital Headache Disability Inventory Questionnaire. Arch Iran Med. 2021;24(10):752-8.
40. Zandifar A, Banihashemi M, Haghdoost F, Masjedi SS, Manouchehri N, Asgari F, et al. Reliability and Validity of the Persian HIT-6 Questionnaire in Migraine and Tension-type Headache. Pain Pract. 2014;14(7):625-31.
41. Kim Y, Kim K. Abdominal examination using pressure pain threshold algometer reflecting clinical characteristics of complementary and alternative medicine in Korea: A systematic review and a brief proposal. Medicine. 2022;101(46).
42. Sawilowsky S. New Effect Size Rules of Thumb. Journal of Modern Applied Statistical Methods. 2009;8:597-9.
43. Fernández-de-las-Peñas C, Cuadrado ML, Arendt-Nielsen L, Simons DG, Pareja JA. Myofascial trigger points and sensitization: an updated pain model for tension-type headache. Cephalalgia: an international journal of headache. 2007;27(5):383-93.
44. Repiso-Guardeño A, Moreno-Morales N, Armenta-Pendón MA, Rodríguez-Martínez MDC, Pino-Lozano R, Armenta-Peinado JA. Physical Therapy in Tension-Type Headache: A Systematic Review of Randomized Controlled Trials. Int J Environ Res Public Health. 2023;20(5).
2. Rasmussen BK, Jensen R, Schroll M, Olesen J. Epidemiology of headache in a general population--a prevalence study. Journal of clinical epidemiology. 1991;44(11):1147-57.
3. Edmeads J, Findlay H, Tugwell P, Pryse-Phillips W, Nelson RF, Murray TJ. Impact of migraine and tension-type headache on life-style, consulting behaviour, and medication use: a Canadian population survey. The Canadian journal of neurological sciences Le journal canadien des sciences neurologiques. 1993;20(2):131-7.
4. Rasmussen BK, Jensen R, Olesen J. Impact of headache on sickness absence and utilisation of medical services: a Danish population study. Journal of epidemiology and community health. 1992;46(4):443-6.
5. GBD 2016 Headache Collaborators. “Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.” The Lancet. Neurology vol. 17,11 (2018): 954-976. doi:10.1016/S1474-4422(18)30322-3
6. Ashina S, Buse DC, Bjorner JB, Bendtsen L, Lyngberg AC, Jensen RH, et al. Health-related quality of life in tension-type headache: a population-based study. Scandinavian journal of pain. 2021;21(4):778-87.
7. Headache Classification Committee of the International Headache Society (IHS). “The International Classification of Headache Disorders, 3rd edition (beta version).” Cephalalgia : an international journal of headache vol. 33,9 (2013): 629-808. doi:10.1177/0333102413485658
8. Yoo YM, Kim KH. Current understanding of nociplastic pain. Korean J Pain. 2024;37(2):107-18.
9. Rasmussen BK. Migraine and tension-type headache in a general population: precipitating factors, female hormones, sleep pattern and relation to lifestyle. Pain. 1993;53(1):65-72.
10. Wöber C, Holzhammer J, Zeitlhofer J, Wessely P, Wöber-Bingöl C. Trigger factors of migraine and tension-type headache: experience and knowledge of the patients. The journal of headache and pain. 2006;7(4):188-95.
11. Marcus DA, Scharff L, Mercer S, Turk DC. Musculoskeletal abnormalities in chronic headache: a controlled comparison of headache diagnostic groups. Headache. 1999;39(1):21-7.
12. Chu ECP, Lo FS, Bhaumik A. Plausible impact of forward head posture on upper cervical spine stability. Journal of family medicine and primary care. 2020;9(5):2517-20.
13. Bendtsen L. Central sensitization in tension-type headache--possible pathophysiological mechanisms. Cephalalgia : an international journal of headache. 2000;20(5):486-508.
14. Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Gerwin RD, Pareja JA. Trigger points in the suboccipital muscles and forward head posture in tension-type headache. Headache. 2006;46(3):454-60.
15. Millea PJ, Brodie JJ. Tension-type headache. American family physician. 2002;66(5):797-804.
16. D'Amico D, Grazzi L, Leone M, Moschiano F, Bussone G. A review of the treatment of primary headaches. Part II: Tension-type headache. Italian journal of neurological sciences. 1998;19(1):2-9.
17. Victoria Espí-López G, Arnal-Gómez A, Arbós-Berenguer T, González Á AL, Vicente-Herrero T. Effectiveness of Physical Therapy in Patients with Tension-type Headache: Literature Review. Journal of the Japanese Physical Therapy Association = Rigaku ryoho. 2014;17(1):31-8.
18. Fernández-de-Las-Peñas C, Florencio LL, Plaza-Manzano G, Arias-Buría JL. Clinical Reasoning Behind Non-Pharmacological Interventions for the Management of Headaches: A Narrative Literature Review. Int J Environ Res Public Health. 2020;17(11).
19. Fernández-de-las-Peñas CS-M, J.; Ge, H.Y.; Dommerholt, J. Manual treatment of myofascial trigger points. In Manual Therapy for Musculoskeletal Pain Syndromes of the Upper and Lower Quadrants: An Evidence and Clinical-Informed Approach. London, UK: Elsevier; 2015.
20. Huguet A, McGrath PJ, Stinson J, Tougas ME, Doucette S. Efficacy of psychological treatment for headaches: an overview of systematic reviews and analysis of potential modifiers of treatment efficacy. The Clinical journal of pain. 2014;30(4):353-69.
21. Lai AKM, Arnold AS, Wakeling JM. Why are Antagonist Muscles Co-activated in My Simulation? A Musculoskeletal Model for Analysing Human Locomotor Tasks. Annals of biomedical engineering. 2017;45(12):2762-74.
22. Schleip R. Fascial plasticity - A new neurobiological explanation: Part 1. Journal of Bodywork and Movement Therapies. 2003;7:11-9.
23. Cerritelli F, Chiacchiaretta P, Gambi F, Perrucci MG, Barassi G, Visciano C, et al. Effect of manual approaches with osteopathic modality on brain correlates of interoception: an fMRI study. Sci Rep. 2020;10(1):3214.
24. Häkkinen K, Komi PV. Electromyographic changes during strength training and detraining. Med Sci Sports Exerc. 1983;15(6):455-60.
25. Vaegter HB, Handberg G, Graven-Nielsen T. Similarities between exercise-induced hypoalgesia and conditioned pain modulation in humans. Pain. 2014;155(1):158-67.
26. Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Pareja JA. Neck mobility and forward head posture are not related to headache parameters in chronic tension-type headache. Cephalalgia : an international journal of headache. 2007;27(2):158-64.
27. Cho SH. The effect of suboccipital muscle inhibition and posture correction exercises on chronic tension-type headaches. Journal of back and musculoskeletal rehabilitation. 2021.
28. Choi W. Effect of 4 Weeks of Cervical Deep Muscle Flexion Exercise on Headache and Sleep Disorder in Patients with Tension Headache and Forward Head Posture. Int J Environ Res Public Health. 2021;18(7).
29. Lee E, Lee S. Impact of Cervical Sensory Feedback for Forward Head Posture on Headache Severity and Physiological Factors in Patients with Tension-type Headache: A Randomized, Single-Blind, Controlled Trial. Med Sci Monit. 2019;25:9572-84.
30. Elizagaray-Garcia I, Beltran-Alacreu H, Angulo-Díaz S, Garrigós-Pedrón M, Gil-Martínez A. Chronic Primary Headache Subjects Have Greater Forward Head Posture than Asymptomatic and Episodic Primary Headache Sufferers: Systematic Review and Meta-analysis. Pain Med. 2020;21(10):2465-80.
31. Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, et al. A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache. Spine. 2002;27:1835-43; discussion 43.
32. Vincent K, Maigne J-Y, Fischhoff C, Lanlo O, Dagenais S. Systematic review of manual therapies for nonspecific neck pain. Joint, bone, spine : revue du rhumatisme. 2012;80.
33. Meisam N, Seyed Asadullah A, Mohammad Reza H, Behnaz G. Effect of Corrective Exercises on Cervicogenic Headache in Office Workers With Forward Head Posture. Journal of Modern Rehabilitation. 2018;11(4).
34. Jeong ED, Kim CY, Kim SM, Lee SJ, Kim HD. Short-term effects of the suboccipital muscle inhibition technique and cranio-cervical flexion exercise on hamstring flexibility, cranio-vertebral angle, and range of motion of the cervical spine in subjects with neck pain: A randomized controlled trial. Journal of back and musculoskeletal rehabilitation. 2018;31(6):1025-34.
35. Kang HS, Kwon HW, Kim DG, Park KR, Hahm SC, Park JH. Effects of the Suboccipital Muscle Inhibition Technique on the Range of Motion of the Ankle Joint and Balance According to Its Application Duration: A Randomized Controlled Trial. Healthcare (Basel). 2021;9(6).
36. Faustino D, Vieira A, Candotti CT, Detogni Schmit EF, Rios Xavier MF, Lunelli VA, et al. Repeatability and reproducibility of the pressure biofeedback unit. J Bodyw Mov Ther. 2021;27:560-4.
37. Garrett TR, Youdas JW, Madson TJ. Reliability of measuring forward head posture in a clinical setting. J Orthop Sports Phys Ther. 1993;17(3):155-60.
38. Puig-Diví A, Escalona-Marfil C, Padullés-Riu JM, Busquets A, Padullés-Chando X, Marcos-Ruiz D. Validity and reliability of the Kinovea program in obtaining angles and distances using coordinates in 4 perspectives. PLoS One. 2019;14(6):e0216448.
39. Jabbari S, Salahzadeh Z, Sarbakhsh P, Rezaei M, Farhoudi M, Ghodrati M. Validity and Reliability of Persian Version of Henry Ford Hospital Headache Disability Inventory Questionnaire. Arch Iran Med. 2021;24(10):752-8.
40. Zandifar A, Banihashemi M, Haghdoost F, Masjedi SS, Manouchehri N, Asgari F, et al. Reliability and Validity of the Persian HIT-6 Questionnaire in Migraine and Tension-type Headache. Pain Pract. 2014;14(7):625-31.
41. Kim Y, Kim K. Abdominal examination using pressure pain threshold algometer reflecting clinical characteristics of complementary and alternative medicine in Korea: A systematic review and a brief proposal. Medicine. 2022;101(46).
42. Sawilowsky S. New Effect Size Rules of Thumb. Journal of Modern Applied Statistical Methods. 2009;8:597-9.
43. Fernández-de-las-Peñas C, Cuadrado ML, Arendt-Nielsen L, Simons DG, Pareja JA. Myofascial trigger points and sensitization: an updated pain model for tension-type headache. Cephalalgia: an international journal of headache. 2007;27(5):383-93.
44. Repiso-Guardeño A, Moreno-Morales N, Armenta-Pendón MA, Rodríguez-Martínez MDC, Pino-Lozano R, Armenta-Peinado JA. Physical Therapy in Tension-Type Headache: A Systematic Review of Randomized Controlled Trials. Int J Environ Res Public Health. 2023;20(5).
| Issue | Articles in Press | |
| Section | Research Article(s) | |
| Keywords | ||
| Tension-Type Headache Posture; Myofascial Release Therapy; Exercise | ||
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How to Cite
1.
Ahmadi M, Pourahmadi M, Togha M, Salehi R. Neck exercises Versus Myofascial Release for Chronic Tension-Type Headache and Posture: A Randomized Controlled Trial Protocol. jmr. 2025;(-).
