Mulligan Technique Versus Proprioceptive Training in Cervicogenic Headache

Cervicogenic headache (CGH) is a type of headache, and it occurs commonly due to neck dysfunctions. Many studies found positive association between the neck dysfunction and CGH. The prevalence of this problem is more common in women than men. Headache disorders are classified as primary, such as migraine or tension-type headache, or secondary, such as CGH. The one-year prevalence of CGH in the adult population varies between 0.2 and 2.2%.

It is severely impacts the general public, burdening public health and putting pressure on the local economy and community.

The International Classification of Headache Disorders (ICHD BETA 3) defined cervicogenic headache as "Headache caused by a disorder of the cervical spine and its component bony, disc and/or soft tissue elements, usually but not always accompanied by neck pain.

No drugs are effective for cervicogenic headache. Studies showed that treatment with manual therapy, specific exercises, or manual therapy plus exercises was significantly more effective at reducing headache frequency and intensity than was no treatment. Manual therapy alone, however, was not more effective than exercises alone, and combining the two interventions did not achieve better outcomes than either intervention alone. About 76% of patients achieved a more than 50% decrease in headache frequency and 35% achieved complete relief at the 7-week follow-up. At 12 months, 72% had a more than 50% decrease in headache frequency, but the proportion that had complete relief was not reported.

A recent systematic review concluded that manual therapy may be effective in the short term and neck exercise in the long term in treating adults with cervicogenic headache.

A popular method for mobilizing joints is the Mulligan Mobilization Technique (MMT), in which the patient moves actively as the therapist slides the affected joint. Efficacy of MMT has been proven in patients experiencing acute to subacute CGH for both short and long-term periods.

There is a link between proprioceptive afferent information and the ability to maintain body posture and good balance. Patients with neck pain have reduced proprioceptive abilities and balance training can improve deficits in proprioception and balance.

A correlation was seen between CGH and a rise in cervical reposition error as well as restricted range of motion as compared to healthy individuals. Patients with CGH should have their rehabilitation programs take these effects into account.

A case report shows that we can effectively enhance overall balance control when we combine balance training with conventional manual therapy methods for the treatment of cervicogenic headache.

Despite studies demonstrating the effectiveness of balance training regimens for cervicogenic dizziness, there is no studies done on patient with CGH except one case report and it seems to be effective. there is no current literature addressing the addition of a proprioceptive training added to mulligan mobilization for patients with cervicogenic headache. Therefore, the aim of this case study was to identify if proprioceptive training exercise in addition to mulligan mobilization had an impact on the headache frequency, pain, disability and overall quality of life in a patient with CGH.

Inclusion criteria

• CGH pain intensity between 3 and 8 on 10-point pain scale.
• CGH due to cervical spine dysfunction.
• Reduced cervical motion.
• Neck pain followed by headache.
• Unilateral pain starting in the neck and radiating to the frontotemporal region.
• Reproduction of the headache on palpation of the upper cervical spine (C0 to C3).

Exclusion criteria

• Participants with other types of headache (migraine).
• Headache due to other causes (sinus, tumor, neural, or temporomandibular joint issues), and any type of physical therapy treatment in the past three months.
• Any contraindications to manual and manipulative therapy (fracture, instability, osteoporosis, arthropathy, or neural symptoms).
• Using analgesics or corticosteroids.
• Metastasis.
• Cardiac conditions (stroke, hypertension, or syncope).
• Neurological conditions (radiculopathy, myelopathy, or disc problems).
• Spinal cord problem.
• Previous brain and spinal cord surgery.