Effectiveness of multimodal treatment with neck muscle exercises, manual therapy, or therapeutic pain neuroscience education on headache impact of migraine patients: a three-arm randomized clinical trial.

Editor’s note: The research described below comes from a recipient of a 2024 MSC Travel Grant supporting travel to the 66th Annual Scientific Meeting of the American Headache Society. These grants reimburse travel expenses for those who have had their abstract for a presentation or poster accepted at a meeting.

By Gabriella de Almeida Tolentino, PhD student, University of São Paulo, Brazil, and University of Utah, US

What is the research gap that your study addresses?

Non-drug treatments for migraine are not very effective and there aren’t many good studies. The difference between combined therapy and isolated techniques in migraine treatment had not been established. This randomized clinical trial aimed to demonstrate the effect of a multimodal protocol combining manual therapy, exercise, and pain neuroscience education versus manual therapy or pain neuroscience education alone in migraine patients.

What is your research hypothesis?

The multimodal physical therapy protocol, which combines different types of treatments with education, may help people with migraine feel better.

What methodology did you use to address your research hypothesis?

A clinical trial with a 12-week treatment protocol and follow-up assessments after 1, 2, and 4 months was conducted. It included individuals of both sexes, aged between 18 and 55 years, diagnosed with migraine according to ICHD-III, who had at least three days of migraine per month in the previous month. At the start, volunteers filled out the Headache Impact Test (HIT-6™). After that, they were put into three groups: Therapeutic Education Pain Neuroscience Group (TEG) had participants receive a single consultation to address headache and chronic pain; Manual Therapy Group (MTG) were participants who received treatment once a week for 12 weeks, with diaphragmatic respiratory training, mobilization of cervical spine traction, deep massage and myofascial release of the craniocervical muscles, ischemic trigger point compression, and passive stretching of the neck muscles; and Multimodal Group (MUG), where participants received combined techniques for relaxation, stretching, and myofascial release, focusing primarily on craniocervical muscles, with an exercise program for the cervical muscles, as well as therapeutic education in pain neuroscience.

What are the main results of your study?

Groups had similar characteristics at the start. All groups improved on the HIT-6 over time (p<0.001). The Multimodal Group improved more on headache impact than the Manual Therapy Group at follow-up 1 and 2. The Therapeutic Education pain neuroscience group improved more than the Manual Therapy group at the end of the treatment.

What conclusions did you reach based on your results?

Multimodal therapy was more effective than manual therapy alone and manual therapy was more effective than education in improving headache impact in migraine patients.

What are the limitations of your study?

The pandemic delayed data collection and affected patients’ adherence to treatment. Patients were monitored for about eight months, attending five face-to-face visits, completing three online forms, and filling out a daily headache diary. Some people dropped out because the study was time consuming. We reminded participants to do their home exercises and record their headaches, but we can’t guarantee they did. Also, we couldn’t do a double-blind study because of the treatments.

What is the relevance of your study to migraine?

This study shows that different ways of treating migraine can help with the pain. It also explains that a combination of treatments can be the best way to treat migraine.