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Headache and Chiropractic

This section was compiled by Frank M. Painter, D.C.
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Headache Information Articles

	Potential Effect Modifiers for Treatment with Chiropractic Manipulation Versus Sham Manipulation for Recurrent Headaches in Children Aged 7-14 Years: Development of and Results From a Secondary Analysis of a Randomised Clinical Trial   NCT02684916 Chiropractic & Manual Therapies 2023 (Jul 11); 31: 20~ FULL TEXT Five variables had a treatment effect difference of more than 0.7 points on the GPE scale between the lower and the upper end of the spectrum: Frequency of headache (p = 0.056), Sport activity (p = 0.110), Sleep duration (p = 0.080), History of neck pain (p = 0.011), and Headache in the family (0.050). A new summary index could be constructed giving highest weight to History of neck pain and Headache in the family and Frequency of headache. The index suggests a difference of about 1 point in GPE between low and high values of the index. Chiropractic manipulation offers a moderate benefit for a broad spectrum of children. However, it cannot be excluded that specific headache characteristics, family factors, or a history of neck pain may modify the effect. This question must be addressed in future studies.
	Description of Recurrent Headaches in 7-14-year-old Children: Baseline Data From a Randomized Clinical Trial on Effectiveness of Chiropractic Spinal Manipulation in Children with Recurrent Headaches   NCT02684916 Chiropractic & Manual Therapies 2023 (Jan 30); 31 : 5 ~ FULL TEXT This study describes a selected cohort of children with recurrent headaches and highlights that they are quite severely affected, has a rather large intake of medication and that there is a great variation in management. Although only questionnaire data could be used, requiring a modification of the ICHD criteria, it was feasible to distinguish between migraine and tension-type headaches in nearly half of the children. The large group of non-classifiable headaches might include probable migraines and probable tension-type headaches, as well as mixed, cervicogenic and medication overuse headaches. A migraine-tension-type-index can be generated allowing to include all children in the diagnostic assessment and may be used for further management decisions. Given the risk of lifelong trajectories of recurrent headaches, good diagnostic tools are essential to explore the options of best possible care and management as early as possible.
	Sources of Cervicogenic Headache Among the Upper Cervical Synovial Joints Pain Medicine 2022 (May 30); 23 (6): 1059–1065 ~ FULL TEXT Controlled diagnostic blocks can establish the source of pain in the majority of patients presenting with probable cervicogenic headache, with C2–3 being the most common source. On the basis of pretest probability, diagnostic algorithms should commence investigations at C2–3. Second and third steps in the algorithm should differ according to whether headache is the dominant or nondominant complaint.
	The Global Prevalence of Headache: An Update, with Analysis of the Influences of Methodological Factors on Prevalence Estimates J Headache and Pain 2022 (Apr 12); 23 (1): 34 ~ FULL TEXT The review confirms GBD in finding that headache disorders remain highly prevalent worldwide, and it identifies methodological factors explaining some of the large variation between study findings. These variations render uncertain both the increase in migraine prevalence estimates over time, and the geographical differences. More and better studies are needed in low- and middle-income countries.
	Effectiveness of Chiropractic Manipulation Versus Sham Manipulation for Recurrent Headaches in Children Aged 7-14 Years - A Randomised Clinical Trial   NCT02684916 Chiropractic & Manual Therapies 2021 (Jan 7); 29: 1~ FULL TEXT Chiropractic spinal manipulation resulted in fewer headaches and higher global perceived effect, with only minor side effects. It did not lower the intensity of the headaches. Since the treatment is easily applicable, of low cost and minor side effects, chiropractic spinal manipulation might be considered as a valuable treatment option for children with recurrent headaches.
	Development and Validation of a Model Predicting Post-Traumatic Headache Six Months After a Motor Vehicle Collision in Adults Accident Analysis and Prevention 2020 (May 20); 142: 105580 ~ FULL TEXT Post-traumatic headache is common and often persists beyond the acute period. Our model is useful in helping clinicians predict PTH six months after a traffic collision in primary care populations. The main priority for future research is to assess candidate interventions for people that are at high risk of PTH at six months. This work also suggests the potential usefulness of a prognostic approach to classifying PTH beyond the ICHD-3 Headache Classification Committee of the International Headache Society, 2013.
	The Features and Burden of Headaches Within a Chiropractic Clinical Population: A Cross-sectional Analysis Complementary Therapies in Medicine 2020 (Jan); 48: 102276 ~ FULL TEXT One in four participants (n = 57; 25.4%) experienced chronic headaches and 42.0% (n = 88) experienced severe headache pain. In terms of headache features, 20.5% (n = 46) and 16.5% (n = 37) of participants had discrete features of migraine and tension-type headache, respectively, while 33.0% (n = 74) had features of more than one headache type. 'Severe' levels of headache impact were most often reported in those with features of mixed headache (n = 47; 65.3%) and migraine (n = 29; 61.7%). Patients who were satisfied or very satisfied with headache management by a chiropractor were those who were seeking help with headache-related stress or to be more in control of their headaches. Many with headache who consult chiropractors have features of recurrent headaches and experience increased levels of headache disability. These findings may be important to other headache-related healthcare providers and policymakers in their endeavours to provide coordinated, safe and effective care for those with headaches.
	Chiropractic Treatment of Older Adults with Neck Pain with or without Headache or Dizziness: Analysis of 288 Australian Chiropractors' Self-reported Views Chiropractic & Manual Therapies 2019 (Dec 18); 27: 65 ~ FULL TEXT This is the first known study to investigate chiropractic care of older adults living with neck pain. The findings suggest that chiropractors use well-established manual and physical therapy techniques to manage neck pain in older adults. The favourable outcomes reported by participants highlight a potential role for using non-pharmacological multimodal therapeutic approaches for the management of neck pain in older adults. The findings also indicate that this target group of patients may frequently integrate chiropractic care with other health services in order to manage their neck pain. Understanding the patient’s motivation for using multiple services may shed light on the health care needs of this population. Further research should also explore how chiropractic treatment of neck pain in older adults impacts patient experience, and other patient-reported outcomes. Given the high prevalence of neck pain in older people, the evidence for the effectiveness of manual and physical treatments for neck pain, the reported demand for chiropractic care in this population, the barriers to pain relief, and concerns among older adults regarding polypharmacy, further studies are needed to provide a more solid evidence-base upon which clinical guidelines for chiropractic management and/or co-management of this condition can be developed. Until then, we recommend that the current clinical guidelines be followed.
	Effectiveness of Chiropractic Manipulation Versus Sham Manipulation on Recurrent Headaches in Children Aged 7-14 Years, Protocol for a Randomized Clinical Trial   NCT02684916 Chiropractic & Manual Therapies 2019 (Aug 23); 27: 40 ~ FULL TEXT Headache is one of the most common pain symptoms in childhood having a negative impact on many aspects of the lives of affected children, both short-term and long-term. Therefore, it is important to document safe and effective treatment options. Chiropractic spinal manipulation is a commonly used treatment option for these patients, although there are no randomized clinical trials documenting the effectiveness of this in pediatric headache. However, there is moderate evidence for effectiveness of spinal manipulation for adults with tension-type and cervicogenic headaches.This paper describes the protocol for a two-armed randomized superiority clinical trial aiming to investigate the effectiveness of chiropractic manipulation versus sham manipulation in the treatment of recurrent headache in children aged 7–14.
	Manual Therapy and Quality of Life in People with Headache: Systematic Review and Meta-analysis of Randomized Controlled Trials Curr Pain Headache Rep 2019 (Aug 10); 23 (10): 78 ~ FULL TEXT Manual therapy has shown better effects compared to usual care and placebo in terms of quality of life patients with tension-type headache (TTH) and migraine (MH) , but the results should be taken with caution due to the very low level of evidence and high risk of bias of the most influential studies. In patients with cervicogenic headache (CGH), the results are inconsistent, and there is a need to make new specific studies for this type of headache. In the face of significant improvements compared to baseline and the absence of adverse effects, manual therapy should, therefore, be considered as a valid approach, being able to positively affect the quality of life of patients with headache. To increase the level of evidence, researchers should in future design primary studies that provide appropriate control groups and follow-up periods, using valid and reliable disease-specific outcome measures.
	The Management of Common Recurrent Headaches by Chiropractors: A Descriptive Analysis of a Nationally Representative Survey BMC Neurology 2018 (Oct 17); 18 (1): 171 ~ FULL TEXT Our national-based sample suggests headache is a substantial proportion of chiropractic caseload. While some aspects of chiropractic headache management, including the acceptance and use of headache diagnostic criteria, appears to be consistent with good clinical practice, other aspects of chiropractic headache management raise questions worthy of further research enquiry. Critically, there is a need for more detailed information on the proportion of headache types and level of headache chronicity and disability found within chiropractic headache patient populations. This information will help practitioners, researchers and policy-makers to better understand the healthcare needs associated with headache patients who seek help from this common provider of headache management.
	Assessing the Impact of Headaches and the Outcomes of Treatment: A Systematic Review of Patient- reported Outcome Measures (PROMs) Cephalalgia 2018 (Jun); 38 (7): 1374–1386~ FULL TEXT Although many PROMs were reviewed following their evaluation in the headache and/or migraine population, study methodological quality was often poor and evidence of essential measurement properties largely unavailable or limited. Such limitations hinder PROM data interpretation from clinical trials, audit, or quality assurance initiatives. However, three measures – Headache Impact Test 6-item (HIT-6), Migraine-Specific Quality of Life Questionnaire (MSQ v2.1) Patient Perception of Migraine Questionnaire (PPMQ-R) – had acceptable, and often strong, evidence of reliability and validity following completion by patients with headache (HIT-6) or migraine (HIT-6, MSQv2.1, PPMQ-R), and are recommended for consideration in future clinical research and routine practice settings as measures of headache-specific impact, migraine-specific impact, or migraine-treatment response respectively. However, the similarity of item content across all three measures suggests that a further exploration of the attribution, relevance and acceptability of the measures with representative members of the patient population is warranted. Further comparative evidence of widely-used generic measures and evidence of measurement responsiveness of all measures is urgently required.
	Complementary and Integrative Medicine in the Management of Headache British Medical Journal 2017 (May 16); 357: j1805 ~ FULL TEXT Headaches, including primary headaches such as migraine and tension-type headache, are a common clinical problem. Complementary and integrative medicine (CIM), formerly known as complementary and alternative medicine (CAM), uses evidence informed modalities to assist in the health and healing of patients. CIM commonly includes the use of nutrition, movement practices, manual therapy, traditional Chinese medicine, and mind-body strategies. This review summarizes the literature on the use of CIM for primary headache and is based on five meta-analyses, seven systematic reviews, and 34 randomized controlled trials (RCTs).
	Variations in Patterns of Utilization and Charges for the Care of Headache in North Carolina, 2000-2009: A Statewide Claims' Data Analysis J Manipulative Physiol Ther. 2016 (May); 39 (4): 229–239 ~ FULL TEXT Overall utilization and average charges for the treatment of headache increased considerably from 2000 to 2005 and then decreased in each subsequent year. Policy changes that took place between 2005 and 2007 may have affected utilization rates of certain providers and their associated charges. MD care accounted for the majority of total allowed charges throughout the decade. In general, patterns of care involving multiple providers and referral care incurred the largest charges, whereas patterns of care involving single or nonreferral providers incurred the least charges. MD-only, DC-only, and MD-DC care were the least expensive patterns of headache care; however, risk-adjusted charges (available 2006-2009) were significantly lower for DC-only care compared with MD-only care. This is one of 3 of the Cost-Effectiveness Triumvirate articles.
	Development of the Headache Activities of Daily Living Index: Initial Validity Study J Manipulative Physiol Ther 2015 (Feb); 38 (2): 102–111 ~ FULL TEXT Five existing instruments for assessing headache-related disability were reviewed for content related to assessing self-rated disability related to the performance of ADLs and were found to be deficient in several important categories. This provided justification for the development of a new instrument, the Headache Activities of Daily Living Index (HADLI), which was created by significantly modifying the NDI. The face validity of the interim and final versions of the HADLI was confirmed by focus groups of patients and experts, resulting in a 9-item instrument consisting only of ADLs. The HADLI was then subjected to initial item analyses and found to have a strong single-component structure, strong internal consistency, and no floor or ceiling effects. As such, it is in suitable form for further psychometric and clinical research.
	Manual Therapies for Primary Chronic Headaches: A Systematic Review of Randomized Controlled Trials J Headache Pain. 2014 (Oct 2); 15: 67 ~ FULL TEXT This is to our knowledge the first systematic review regarding the efficacy of manual therapy randomized clinical trials (RCT) for primary chronic headaches. A comprehensive English literature search on CINHAL, Cochrane, Medline, Ovid and PubMed identified 6 RCTs all investigating chronic tension-type headache (CTTH). One study applied massage therapy and five studies applied physiotherapy. Four studies were considered to be of good methodological quality by the PEDro scale. All studies were pragmatic or used no treatment as a control group, and only two studies avoided co-intervention, which may lead to possible bias and makes interpretation of the results more difficult.
	An International Survey of Pain in Adolescents BMC Public Health. 2014 (May 13); 14 (1): 447 ~ FULL TEXT Adolescence marks the transition from childhood to adult life. Pain during adolescence is an important predictor of future pain. [1–3] A Danish twins study [4] found adolescents with persistent low back pain were 3.5 times more likely to have low back pain in adulthood. Co-occurrence of low back pain and headache in adolescence further increases the risk of developing future pain which draws attention to the significance of multiple pains. [4]
	Is There a Difference in Head Posture and Cervical Spine Movement in Children With and Without Pediatric Headache? European Journal of Pediatrics 2013 (Oct); 172 (10): 1349–1356 ~ FULL TEXT Cervical range of motion (ROM) in each cardinal plane was significantly less in the children with purported cervicogenic headache (CGH) compared to those without headache (Table 1). ROM values recorded in the asymptomatic group are comparable with a previous report for children. [3] While no previous studies have reported ROM values for children with CGH, these results are consistent with reports in adult populations. [23, 51, 52] Interestingly, ROM does not appear to be restricted in all directions in adults with headache [23, 51, 52], but the explanation for this is not clear. This study finding of reduced ROM in children with purported CGH supports the current criteria for CGH diagnosis. [20, 44]
	Combination of Acupuncture and Spinal Manipulative Therapy: Management of a 32-year-old Patient With Chronic Tension-type Headache and Migraine J Chiropractic Medicine 2012 (Sep); 11 (3): 192–201 A 32-year-old woman presented with chronic, daily headaches of 5 months' duration. After 5 treatments over a 2-week period (the first using acupuncture only, the next 3 using acupuncture and chiropractic spinal manipulative therapy), her headaches resolved. The patient had no recurrences of headaches in her 1-year follow-up.
	Chiropractic Management of Post-concussion Headache and Neck Pain In a Young Athlete and Implications For Return-To-Play Topics in Integrative Health Care 2011 (Oct 7); 2 (3) ~ FULL TEXT Each year there are an estimated 1.6 to 3.8 million sports-related brain injuries; 136,000 of which occur in young athletes in the course of high school sports. The purpose of this article is to discuss the management and outcome of a post-concussive headache and neck pain in a young athlete and implications for return to play.
	Symptomatic Reactions, Clinical Outcomes and Patient Satisfaction Associated with Upper Cervical Chiropractic Care: A Prospective, Multicenter, Cohort Study BMC Musculoskelet Disord. 2011 (Oct 5); 12: 219 ~ FULL TEXT A total of 1,090 patients completed the study having 4,920 (4.5 per patient) office visits requiring 2,653 (2.4 per patient) upper cervical adjustments over 17 days. Three hundred thirty- eight (31.0%) patients had symptomatic reactions (SRs) meeting the accepted definition. Intense SR (NRS ≥8) occurred in 56 patients (5.1%). Outcome assessments were significantly improved for neck pain and disability, headache, mid-back pain, as well as lower back pain and disability (p <0.001) following care with a high level (mean = 9.1/10) of patient satisfaction. The 83 chiropractors administered >5 million career upper cervical adjustments without a reported incidence of serious adverse event.
	Referred Pain from Myofascial Trigger Points in Head and Neck-shoulder Muscles Reproduces Head Pain Features in Children With Chronic Tension type Headache J Headache Pain. 2011 (Feb); 12 (1): 35–43 ~ FULL TEXT The current controlled and blinded study showed the existence of multiple active TrPs in head, neck and shoulder musculature in children with chronic tension type headache (CTTH). Both local and referred pain characteristics elicited by palpation of active muscle TrPs reproduced the head pain patterns in children with CTTH. Referred pain areas elicited by active TrPs were larger in children with CTTH as compared to healthy children. The size of referred pain areas of some muscles was positively related to some headache clinical parameters. Our results support a role of active TrP in children with CTTH.
	Prevalence of Headache and Migraine in Children and Adolescents: A Systematic Review of Population-based Studies Dev Med Child Neurol 2010 (Dec); 52 (12): 1088–1097 Headache is common across the world, with about 60% of children and adolescents being prone to it over at least a 3–month period. Migraine is also common, and despite small variations in reporting across the world it is safe to state that around 8% of children and adolescents suffer from it over periods ranging from 3?months to lifetime. This analysis confirms the frequently reported observation of a significantly lower prevalence of migraine in children under the age of 14?years than in the general childhood population. Small regional and possibly interracial differences in its prevalence are also evident. Migraine affects males and females equally at a young age (<14y), and more females than males in adolescence and young adulthood.
	Physical Examination and Self-Reported Pain Outcomes From a Randomized Trial on Chronic Cervicogenic Headache J Manipulative Physiol Ther. 2010 (Jun); 33 (5): 338–348 ~ FULL TEXT We have noted that, at baseline, the study participants' subjective headache experience was most associated with PE measures of inclinometric cervical active ROM and elicited pain. However, this pattern shifted at week 12, 4 weeks after the final treatment. At week 12, the measure most associated with study participants' CGH subjective outcomes was the final examination pain pressure threshold (algometric pain thresholds). You will also enjoy this PowerPoint Presentation by the authors.
	Cervicogenic Headache Revisited The Chiropractic Report 2010: Vol. 24 No. 5 “In my experience, cervical migraine is the type of headache most frequently seen in general practice and also the type most frequently misinterpreted. It is usually erroneously diagnosed as classical migraine, tension headache, vascular headache. Such patients have usually received an inadequate treatment and have often become neurotic and drug-dependent”. ~ Frykholm, neurosurgeon, Sweden (1972) [1]
	Illustrating Risk Difference and Number Needed to Treat from a Randomized Controlled Trial of Spinal Manipulation for Cervicogenic Headache Chiropractic & Osteopathy 2010 (May 24); 19 (9) ~ FULL TEXT Spinal manipulation demonstrated a benefit in terms of a clinically important improvement of cervicogenic headache pain. The use of adjusted NNT is recommended; however, adjusted RD may be easier to interpret than NNT. The study demonstrated how results may depend on the threshold for dichotomizing variables into binary outcomes.
	Intractable Migraine Headaches During Pregnancy Under Chiropractic Care Complementary Therapies in Clinical Practice 2009 (Nov); 15 (4): 192–197 The absence of hormone fluctuations and/or the analgesic effects of increased beta-endorphins are thought to confer improvements in headache symptoms during pregnancy. However, for a number of pregnant patients, they continue to suffer or have worsening headache symptoms. The use of pharmacotherapy for palliative care is a concern for both the mother and the developing fetus and alternative/complementary care options are sought. We present a 24-year-old gravid female with chronic migraine headaches since age 12years. Previous unsuccessful care included osteopathy, physical therapy, massage and medication. Non-steroidal anti-inflammatory medication with codeine provided minor and temporary relief. Chiropractic care involving spinal manipulative therapy (SMT) and adjunctive therapies resulted in symptom improvement and independence from medication. This document provides supporting evidence on the safety and possible effectiveness of chiropractic care for patients with headaches during pregnancy.
	Diagnosis and Chiropractic Treatment of Infant Headache Based on Behavioral Presentation and Physical Findings: A Retrospective Series of 13 Cases J Manipulative Physiol Ther. 2009 (Oct); 32 (8): 682–686 ~ FULL TEXT This case series offers information about potential signs of benign infant headache. The patients in this study responded favorably to chiropractic management.
	Recurrent Neck Pain and Headaches in Preadolescents Associated with Mechanical Dysfunction of the Cervical Spine: A Cross-Sectional Observational Study With 131 Students J Manipulative Physiol Ther 2009 (Oct); 32 (8): 625–634 ~ FULL TEXT Forty percent of the children (n = 52) reported neck pain and/or recurrent headache. Neck pain and/or headache were not associated with forward head posture, impaired functioning in cervical paraspinal muscles, and joint dysfunction in the upper and middle cervical Spine in these subjects. However, joint dysfunction in the lower cervical Spine was significantly associated with neck pain and/or headache in these preadolescents. Most of the students had nonsymptomatic biomechanical dysfunction of the upper cervical Spine. There was a wide variation between parental report and the child's self-report of trauma history and neck pain and/or headache prevalence.
	Headache in a National Sample of American Children: Prevalence and Comorbidity J Child Neurol 2009 (May); 24 (5): 536–543 ~ FULL TEXT The purpose of this study was to determine the prevalence, sociodemographic correlates, and comorbidity of recurrent headache in children in the United States. Participants were individuals aged 4 to 18 years (n = 10,198) who participated in the National Health and Nutrition Examination Surveys. Data on recurrent and other health conditions were analyzed. Frequent or severe headaches including migraine in the past 12 months were reported in 17.1% of children. Asthma, hay fever, and frequent ear infections were more common in children with headache, with at least 1 of these occurring in 41.6% of children with headache versus 25.0% of children free of headache. Other medical problems associated with childhood headaches include anemia, overweight, abdominal illnesses, and early menarche. Recurrent headache in childhood is common and has significant medical comorbidity. Further research is needed to understand biologic mechanisms and identify more homogeneous subgroups in clinical and genetic studies.
	Cervical Musculoskeletal Impairment in Frequent Intermittent Headache. Part 1: Subjects with Single Headaches Cephalalgia 2007 (Jul); 27 (7): 793–802 ~ FULL TEXT Musculoskeletal disorders are considered the underlying cause of cervicogenic headache, but neck pain is commonly associated with migraine and tension-type headaches. This study tested musculoskeletal function in these headache types. From a group of 196 community-based volunteers with headache, 73 had a single headache classifiable as migraine (n = 22), tension-type (n = 33) or cervicogenic headache (n = 18); 57 subjects acted as controls. Range of movement, manual examination of cervical segments, cervical flexor and extensor strength, the cranio-cervical flexion test (CCFT), cross-sectional area of selected extensor muscles at C2 (ultrasound imaging) and cervical kinaesthetic sense were measured by a blinded examiner. In all but one measure (kinaesthetic sense), the cervicogenic headache group were significantly different from the migraine, tension-type headache and control groups (all P < 0.001). A discriminant function analysis revealed that collectively, restricted movement, in association with palpable upper cervical joint dysfunction and impairment in the CCFT, had 100% sensitivity and 94% specificity to identify cervicogenic headache. There was no evidence that the cervical musculoskeletal impairments assessed in this study were present in the migraine and tension-type headache groups. Further research is required to validate the predictive capacity of this pattern of impairment to differentially diagnose cervicogenic headache.
	Cervical Musculoskeletal Impairment in Frequent Intermittent Headache. Part 2: Subjects with Concurrent Headache Types Cephalalgia 2007 (Aug); 27 (8): 891–898 ~ FULL TEXT A pattern of musculoskeletal impairment inclusive of upper cervical joint dysfunction, combined with restricted cervical motion and impairment in muscle function, has been shown to differentiate cervicogenic headache from migraine and tension-type headache when reported as single headaches. It was questioned whether this pattern of cervical musculoskeletal impairment could discriminate a cervicogenic headache as one type of headache in more complex situations when persons report two or more headaches. Subjects with two or more concurrent frequent intermittent headache types (n = 108) and 57 non-headache control subjects were assessed using a set of physical measures for the cervical musculoskeletal system. Discriminant and cluster analyses revealed that 36 subjects had the pattern of musculoskeletal impairment consistent with cervicogenic headache. Isolated features of physical impairment, e.g. range of movement (cervical extension), were not helpful in differentiating cervicogenic headache. There were no differences in measures of cervical musculoskeletal impairment undertaken in this study between control subjects and those classified with non-cervicogenic headaches.
	Chronic Daily Headache in Adolescents: Prevalence, Impact, and Medication Overuse Neurology 2006 (Jan 24); 66 (2): 193–197 Chronic daily headache (CDH) was common in a large nonreferred adolescent sample. Based on the International Classification of Headache Disorders, 2nd edition, criteria, chronic tension-type headache was the most common subtype; Although this article does not discuss care options for chronic tension-type headache, conservative chiropractic care is the natural choice.
	A Six-item Short-form Survey for Measuring Headache Impact: The HIT-6 Quality of Life Research 2003 (Dec); 12 (8): 963–794 ~ FULL TEXT The evidence presented from this study suggested that we successfully achieved our goals of developing a brief measure of headache impact that is (1)   psychometrically sound; and (2) clinically relevant. Our efforts resulted in a six-item questionnaire that proved to be reliable and valid for group-level comparisons, patient-level screening, and responsive to changes in headache impact. The HIT-6 items were shown to cover a substantial range of headache impact as defined by a much larger pool of items and include content areas found in most widely used tools for measuring headache impact. Modifications made to HIT-6 items resulted in an instrument that was more easily translated into other languages. Translations of HIT-6 are now available in 27 languages in total through QualityMetric and studies are currently being conducted to evaluate the performance of the translated forms in clinical studies.
	Headaches - Tension, Migraine and Cluster American Chiropractic Association A report released in 2001 by researchers at the Duke University Evidence-Based Practice Center in Durham, NC, found that spinal manipulation resulted in almost immediate improvement for those headaches that originate in the neck, and had significantly fewer side effects and longer-lasting relief of tension-type headache than a commonly prescribed medication.
	Musculoskeletal Abnormalities in Chronic Headache: A Controlled Comparison of Headache Diagnostic Groups Headache. 1999 (Jan); 39 (1): 21–27 There was a significant difference in the presence of postural abnormalities between the controls and the patients, with posture abnormalities more likely to be present in those with headache. The patients were also significantly more likely to have active trigger points and trigger points in the neck than were the control subjects. There were no significant group differences identified in the mechanical measures, nor were there any significant differences among the three headache categories.
	Four Articles Which Describe the Relationship Between the Upper Cervical Spine and Headaches and Chronic Head Pain Atrophy of Suboccipital Muscles in Chronic Pain Patients We have observed previously unreported muscle atrophy in the rectus capitis posterior minor (RCPMI) muscles of a group of chronic pain patients. We hypothesize that chronic pain, in this select group of patients, is a consequence of tramua that occurs to the C1 dorsal ramus during whiplash. Magnetic Resonance Imaging of the Upper Cervical Spine We are currently using MRI to investigate the functional integrity of the upper cervical Spine. We started out looking for hypertonic muscles in a population of patients who were suffering from chronic head and neck pain. My first task was to collect MRI data and to identify suboccipital muscles within the MR images. So I brought together a physician and an anatomy professor to see if they could help me out. Their comments were classic. The anatomy professor said, "The reason you can't find those muscles is because they are not there." The physician immediately responded by saying, "No wonder these patients don't get any better." I had been using images that were collected from a chronic pain patient, and it was apparent that the rectus capitis posterior minor muscles were missing. When we looked at images from a control subject it was very easy to locate these muscles. At that point, the focus of our research switched from looking for hypertonic muscles to comparing muscle density between the control group and the chronic pain group. Anatomic Relation Between the Rectus Capitis Posterior Minor Muscle and the Spinal Dura Mater We observed that the PAO membrane was securely fixed to the surface of the dural tube by multitudinous fine connective tissue fibers. There was no real interlaminar space between these two structures and they appeared to function as a single entity. The influence of the RCPMI muscle on the dura mater was artificially produced in the hemisected specimen. Artificially functioning the muscle produced obvious movement of the spinal dura between the occiput and the atlas, and resultant fluid movement was observed to the level of the pons and cerebellum. Visualization of the Muscle-Dural Bridge in the Visible Human Female Data Set Spine Journal 1995; 20 (23): 2484–2486 It has been speculated that the function of the muscle dural bridge may be to prevent folding of the dura mater during hyperextension of the neck. Also, clinical evidence suggests that the muscle dural bridge may play an important role the pathogenesis of the cervicogenic headaches.
	Upper Cervical Spine Information This remarkable website, designed by a former Microsoft employee, clearly defines many aspects of the Upper Cervical Subluxation, and it's impact on health.     The ANATOMY of the ATLAS SUBLUXATION     CERVICAL Spine BIOMECHANICS     IMAGING AND RADIOGRAPHS     SKULL BASE [Craniocervical] ANATOMY
	The Headache Diagnosis and Management Series for the Chiropractor by Darryl Curl, DDS, DC Part I Part II Part III Part IV Part V Part VI
	A Holistic Approach to Severe Headache Symptoms in a Patient Unresponsive to Regional Manual Therapy J Manipulative Physiol Ther 1996 (Mar); 19 (3): 202–207 This patient seemed to respond favorably to conservative care that included regions of Spine not traditionally associated with headache pain. This suggests that some individuals may require a more comprehensive evaluation if regional care fails to promote a positive response within a few weeks. Controlled, randomized trials will assist in comparing effectiveness of various treatment interventions.
	An Open Study Comparing Manual Therapy With the Use of Cold Packs in the Treatment of Post-traumatic Headache Cephalalgia 1990 Oct; 10(5): 241–250 It is concluded that the type of manual therapy used in this study seems to have a specific effect in reducing post-traumatic headache. The result supports the hypothesis of a cervical mechanism causing post-traumatic headache and suggests that post-traumatic dizziness, visual disturbances and ear symptoms could be part of a cervical syndrome.
	The Accuracy of Manual Diagnosis for Cervical Zygapophysial Joint Pain Syndromes Med J Aust. 1988 (Mar 7); 148 (5): 233–236 The manipulative therapist identified correctly all 15 patients with proven symptomatic zygapophysial joints, and specified correctly the segmental level of the symptomatic joint. None of the five patients with asymptomatic joints was misdiagnosed as having symptomatic zygapophysial joints. Thus, manual diagnosis by a trained manipulative therapist can be as accurate as can radiologically-controlled diagnostic blocks in the diagnosis of cervical zygapophysial syndromes.
	Subluxation and Neurology Articles A Chiro.Org article collection There are many other articles that explain the relationship between headaches and spinal subluxations on this page.

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