Multi-Segmental Spinal Manual Therapy in Women With Episodic Migraine

The Visual Analog Scale (VAS) will be used in this study to assess headache intensity. It is defined as a 10-cm line anchored at one end by "no pain" (a value of 0) and at the other end by "severe, unbearable pain" (a value of 10), yielding a total score ranging from 0 to 10 (where 0 indicates no pain and 10 indicates the worst imaginable pain; higher scores indicate a worse outcome). Patients will be asked to rate their pain intensity before and after the intervention by placing a vertical mark on the line corresponding to their perceived pain level. This clinical pain assessment method has generally been reported to be reliable and valid, providing a robust and reproducible way for patients to express pain intensity, with results shown to correlate well with other pain measurement methods. It can be applied regardless of language and used by individuals aged 5 years and older.

The Migraine Disability Assessment (MIDAS) questionnaire, originally developed by Stewart et al. and validated in Turkish by Ertaş et al. (Cronbach's alpha = 0.87), was used to evaluate headache-related functional disability. The instrument comprises five items that quantify the total number of days with lost or substantially reduced performance across work, school, and household activities over the preceding three months. The MIDAS total score is calculated by summing the reported lost days (range: 0 to 270 days, where higher scores indicate greater headache-related disability/worse outcome). Overall scores are categorized into four severity grades: Grade I (0-5 days; little or no disability), Grade II (6-10 days; mild disability), Grade III (11-20 days; moderate disability), and Grade IV (21 days or more; severe disability).

Cutaneous allodynia severity will be assessed using the Allodynia Symptom Checklist-12 (ASC-12), Turkish-adapted by Yalın et al. in 2017 (37). The ASC-12 consists of 12 items assessing symptoms of static, dynamic, and thermal allodynia. Items are answered using the responses "Not applicable to me," "Never," "Rarely," "Less than half the time," and "Half the time or more." The total score is calculated by assigning 0 points for "Not applicable to me," "Never," and "Rarely"; 1 point for "Less than half the time"; and 2 points for "Half the time or more," yielding a total score ranging from 0 to 24 (where higher scores indicate a greater degree of cutaneous allodynia/worse outcome). A score of 0-2 indicates the absence of cutaneous allodynia, whereas scores above 2 indicate its presence-specifically, 3-5 indicates "mild cutaneous allodynia," 6-8 indicates "moderate cutaneous allodynia," and 9-24 indicates "severe cutaneous allodynia."

Sensorimotor dysfunctions-including impairments in balance, proprioception, motor performance, and multimodal processing-were assessed using the Sensory-Motor Dysfunction Questionnaire (SMD-Q), originally developed by Ambalavanar et al. and validated in Turkish by Arslan et al. (Cronbach's alpha = 0.85). The questionnaire evaluates discrepancies between motor intent and sensory feedback via 12 items, each scored on a 4-point Likert scale (0 to 3) based on weekly symptom frequency. The total score is calculated by summing item responses (range: 0 to 36, where higher scores indicate greater sensorimotor dysfunction/worse outcome).