Massage Therapy and Post-Concussion Headaches

Persistent symptoms’ does not reflect a single pathophysiological entity, but describes a constellation of non-specific post-traumatic symptoms that may be linked to coexisting and/or confounding factors, which do not necessarily reflect ongoing physiological injury to the brain (McCrory et al. 2017).

Persistent symptoms after concussive injuries often includes headaches and neck pain. 

With the high impact nature of most concussive injuries, the assessment and rehabilitation of cervical spine may decrease the likelihood that an individual will develop persistent headaches and neck pain (Kennedy et al. 2017).  

Post-Concussion Headaches are Often Classified as Migraine or Tension-Type Headaches

It is proposed that a portion of post-concussion headaches are cervicogenic in nature, due in part to the concomitant whiplash injury suffered at the same time of the concussive force. Researchers classify these post-traumatic headaches as migraine headaches or tension-type headaches (Lucas et al. 2017). 

In these demographics soft tissue irritation and subsequent nerve sensitization may be a major contributor to symptoms (Ferracini et al. 2017Fernández-De-Las-Peñas et al. 2017, Luedtke et al. 2017).

In some patients there is also evidence that temporomandibular disorder may be a contributing factor to headaches (von Piekartz & Hall 2013).

What role can massage therapists play?

In the past the primary management strategies for headaches and chronic pain was a pharmacological approach, but over time some of these treatments evolve into a health care crisis of their own. Early in 2016 The Center for Disease Control, expressed the need to move beyond a pharmacological approaches for symptom management (Frieden et al. 2016).

Physicians, now more than ever are recommending conservative treatment including manual therapy, acupuncture, education and exercise as part of a multi-modal approach for patients suffering from headaches and neck pain (Busse et al. 2017).

Why Does Massage Therapy Work?

With massage therapy the goal is to decrease the individual’s headache frequency, intensity, duration and acute medication requirements.

A biopsychosocial framework helps put into context the interconnected and multidirectional interaction between: physiology, thoughts, emotions, behaviors, culture, and beliefs. In terms of clinical responses to massage therapy there are a couple of proposed mechanisms of action, including but not limited to: neurodynamics, contextually aided recovery, neuromodulation, social grooming and mechanotherapy.

A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from cervicogenic headaches may include neurovascular structures and investing fascia of:

More to Explore

Arendt-Nielsen, L., Castaldo, M., Mechelli, F., & Fernández-De-Las-Peñas, C. (2016). Muscle Triggers as a Possible Source of Pain in a Subgroup of Tension-type Headache Patients? The Clinical Journal of Pain.

Bendtsen, L., Ashina, S., Moore, A., Steiner, T.J. (2016). Muscles and their role in episodic tension-type headache: implications for treatment. Eur J Pain.

Blanpied, P.R., Gross, A.R., Elliott, J.M., Devaney, L.L., Clewley, D., Walton, D.M., Sparks, C., Robertson, E.K. (2017). Neck Pain: Revision 2017. J Orthop Sports Phys Ther

Busse, J.W., Craigie, S., Juurlink, D.N, ... Guyatt GH. (2017). Guideline for opioid therapy and chronic noncancer pain. CMAJ.

Bussières, A. E., Stewart, G., Al-Zoubi, F., Decina, P., Descarreaux, M., Hayden, J., . . . Ornelas, J. (2016). The Treatment of Neck Pain–Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline. Journal of Manipulative and Physiological Therapeutics.

Castaldo, M., Catena, A., ..., Arendt-Nielsen, L. (2017). Association between Clinical and Neurophysiological Outcomes in Patients with Mechanical Neck Pain and Whiplash-associated Disorders. Clin J Pain.

Chen, L., Michalsen, A. (2017). Management of chronic pain using complementary and integrative medicine. BMJ.

Cheever, K., Kawata, K., Tierney, R., Galgon, A. (2016). Cervical Injury Assessments for Concussion Evaluation: A Review. J Athl Train.

Cohen, S.P., Hooten, W.M. (2017). Advances in the diagnosis and management of neck pain. BMJ.

Coeytaux, R. R., & Befus, D. (2016). Role of Acupuncture in the Treatment or Prevention of Migraine, Tension-Type Headache, or Chronic Headache Disorders. Headache.

Courtney, C.A., Fernández-de-Las-Peñas, C., Bond, S. (2017). Mechanisms of chronic pain - key considerations for appropriate physical therapy management. J Man Manip Ther.

Ellis, M.J., Leddy, J., Willer, B. (2016). Multi-Disciplinary Management of Athletes with Post-Concussion Syndrome: An Evolving Pathophysiological Approach. Front Neurol.

Fakhran, S., Qu, C., & Alhilali, L. M. (2016). Effect of the Suboccipital Musculature on Symptom Severity and Recovery after Mild Traumatic Brain Injury. American Journal of Neuroradiology.

Fernández-de-Las-Peñas, C., Courtney, C.A. (2014). Clinical reasoning for manual therapy management of tension type and cervicogenic headache. J Man Manip Ther. (OPEN ACCESS)

Fernández-de-Las-Peñas, C.. Myofascial Head Pain. (2015). Curr Pain Headache Rep.

Fernández-De-Las-Peñas, C., Arendt-Nielsen, L. (2017). Improving understanding of trigger points and widespread pressure pain sensitivity in tension-type headache patients: clinical implications. Expert Rev Neurother.

Ferracini, G.N., Florencio, L.L., ... Fernández-de-Las-Peñas, C. (2017). Musculoskeletal disorders of the upper cervical spine in women with episodic or chronic migraine. Eur J Phys Rehabil Med.

Ferragut-Garcías, A., Plaza-Manzano, G., ... Oliva-Pascual-Vaca, Á. (2017). Effectiveness of a Treatment Involving Soft Tissue Techniques and/or Neural Mobilization Techniques in the Management of Tension-Type Headache: A Randomized Controlled Trial. Arch Phys Med Rehabil.

Gandolfi, M., Geroin, C., Valè, N., ... Smania, N. (2017). Does myofascial and trigger point treatment reduce pain and analgesic intake in patients undergoing OnabotulinumtoxinA injection due to chronic intractable migraine? A pilot, single-blind randomized controlled trial. Eur J Phys Rehabil Med.

Iyengar, S., Ossipov, M.H., Johnson, K.W. (2017). The role of calcitonin gene-related peptide in peripheral and central pain mechanisms including migraine. Pain.

Kennedy, E., Quinn, D., Tumilty, S., Chapple, C.M. (2017). Clinical characteristics and outcomes of treatment of the cervical spine in patients with persistent post-concussion symptoms: A retrospective analysis. Musculoskelet Sci Pract.

Lal, A., Kolakowsky-Hayner, S.A., Ghajar, J., Balamane, M. (2017). The Effect of Physical Exercise After a Concussion: A Systematic Review and Meta-analysis. Am J Sports Med.

Leddy, J., Baker, J.G., Haider, M.N., Hinds, A., Willer, B. (2017). A Physiological Approach to Prolonged Recovery From Sport-Related Concussion. J Athl Train.

Lemeunier, N., da Silva-Oolup, S.,... Côté, P. (2017). Reliability and validity of clinical tests to assess the anatomical integrity of the cervical spine in adults with neck pain and its associated disorders: Part 1-A systematic review from the Cervical Assessment and Diagnosis Research Evaluation (CADRE) Collaboration. Eur Spine J.

Lucas, S. (2015). Posttraumatic Headache: Clinical Characterization and Management. Current Pain and Headache Reports.

Lucas, S., Blume, H.K. (2017). Sport-Related Headache. Neurol Clin.

Luedtke, K., Boissonnault, W., Caspersen, N., Castien, R., Chaibi, A., Falla, D., . . . May, A. (2016). International consensus on the most useful physical examination tests used by physiotherapists for patients with headache: A Delphi study. Manual Therapy.

Luedtke, K., Starke, W., May, A. (2017). Musculoskeletal dysfunction in migraine patients. Cephalalgia.

Makdissi, M., Schneider, K.J., ... Johnston, K.M. (2017). Approach to investigation and treatment of persistent symptoms following sport-related concussion: a systematic review. Br J Sports Med.

Manley, G.T., Gardner, A.J., Schneider, K.J., ...  Iverson, G.L. (2017). A systematic review of potential long-term effects of sport-related concussion. Br J Sports Med.

Marshall, C. M., Vernon, H., Leddy, J. J., & Baldwin, B. A. (2015). The role of the cervical spine in post-concussion syndrome. The Physician and Sportsmedicine.

Matuszak, J.M., McVige, J., McPherson, J., Willer, B., Leddy, J. (2016). A Practical Concussion Physical Examination Toolbox. Sports Health.

McCrory, P., Meeuwisse, W., Dvorak, J., ... Vos, P.E. (2017). Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med.

Meyfroidt, G., Baguley, I.J., Menon, D.K. (2017). Paroxysmal sympathetic hyperactivity: the storm after acute brain injury. Lancet Neurol.

Michiels, S., Van de Heyning, P., Truijen, S., Hallemans, A., De Hertogh, W. (2016). Does multi-modal cervical physical therapy improve tinnitus in patients with cervicogenic somatic tinnitus? Man Ther.

Michiels, S., Van de Heyning, P., Truijen, S., Hallemans, A., De Hertogh, W. (2017). Prognostic indicators for decrease in tinnitus severity after cervical physical therapy in patients with cervicogenic somatic tinnitus. Musculoskelet Sci Pract.

Millstine, D., Chen, C., Bauer, B. (2017). Complementary and integrative medicine in the management of headache. BMJ.

Nahin, R. L., Boineau, R., Khalsa, P. S., Stussman, B. J., & Weber, W. J. (2016). Evidence-Based Evaluation of Complementary Health Approaches for Pain Management in the United States. Mayo Clinic Proceedings.

Nöbel, M., Feistel, S., Ellrich, J., & Messlinger, K. (2016). ATP-sensitive muscle afferents activate spinal trigeminal neurons with meningeal afferent input in rat – pathophysiological implications for tension-type headache. The Journal of Headache and Pain.

Oostendorp RA, Bakker I, Elvers H, Mikolajewska E, Michiels S, De Hertogh W, Samwel H. (2016). Cervicogenic somatosensory tinnitus: An indication for manual therapy?  Part 1: Theoretical concept. Man Ther.

Oostendorp RA, Bakker I, Elvers H, Mikolajewska E, Michiels S, De Hertogh W, Samwel H. (2016). Cervicogenic somatosensory tinnitus: An indication for manual therapy plus education? Part 2: A pilot study. Man Ther.

Pareja, J.A., López-Ruiz, P., Cuadrado, M.L. (2017). Supratrochlear Neuralgia: A Prospective Case Series of 15 Patients. Headache.

Perry, C.J., Blake, P., Buettner, C., Papavassiliou, E., Schain, A.J., Bhasin, M.K., Burstein, R. (2016). Upregulation of inflammatory gene transcripts in periosteum of chronic migraineurs: Implications for extracranial origin of headache. Ann Neurol. (OPEN ACCESS)

Quatman-Yates, C., Cupp, A., Gunsch, C., Haley, T., Vaculik, S., Kujawa, D. (2016). Physical Rehabilitation Interventions for Post-mTBI Symptoms Lasting Greater Than 2 Weeks: Systematic Review. Phys Ther.

Schneider, K.J., Meeuwisse, W.H., ... Emery, C.A. (2014). Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. Br J Sports Med.

Schneider, K. J. (2016). Sport-Related Concussion: Optimizing Treatment Through Evidence-Informed Practice. Journal of Orthopaedic & Sports Physical Therapy.

Schneider, K.J., Leddy, J.J., ... Makdissi, M. (2017). Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med.

van der Meer, H.A., Speksnijder, C.M., ... Visscher, C.M. (2017) The Association Between Headaches and Temporomandibular  Disorders is Confounded by Bruxism and Somatic Symptoms. Clin J Pain.

Varatharajan, S., Ferguson, B., ... Taylor-Vaisey, A. (2016). Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J.

von Piekartz, H. V., & Hall, T. (2013). Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: A randomized controlled trial. Manual Therapy.

Waki, H., Suzuki, T., Hisajima, T. (2017). Effects of electroacupuncture to the trigeminal nerve area on the autonomic nervous system and cerebral blood flow in the prefrontal cortex. Acupunct Med.

Watson, D. H., & Drummond, P. D. (2012). Head Pain Referral During Examination of the Neck in Migraine and Tension-Type Headache. Headache: The Journal of Head and Face Pain.