Manual therapy for post-concussion headaches

post-traumatic headaches

One of the most persistent symptom after a mild traumatic brain injury is post-traumatic headaches. 

It is proposed that a portion of post traumatic headaches are cervicogenic in nature, due in part to the concomitant whiplash injury suffered at the same time of the concussive force. Any “Acceleration/deceleration of the head–neck complex of sufficient magnitude to cause mTBI is also likely to cause concurrent injury to the joints and soft tissues of the cervical spine. These types of injuries have been shown to cause headaches, dizziness, loss of balance, nausea and many other signs and symptoms considered synonymous with concussion.” (Marshall et al. 2015)

Researchers classify post-concussion headaches as migraine headaches or tension-type headaches. 

In these demographics soft tissue irritation and subsequent nerve sensitization may be a major contributor to symptoms (Arendt-Nielsen et al. 2016, Fakhran et al. 2016, Fumal et al. 2008, Nöbel et al. 2016, Schueler et al. 2013). There is also evidence that temporomandibular disorder may be a contributing factor to these types of headaches (Piekartz et al. 2013).

What role can manual therapy play in post-traumatic headaches?

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 and called for the use of a number of non-pharmacological management strategies including but not limited to education, reassurance, exercise and manual therapy.

Manual therapy is often used as a broad title, that includes joint manipulation/mobilization and soft tissue interventions.

With the high impact nature of most concussive injuries, the assessment and rehabilitation of cervical spine and associated soft tissue should be considered. Early interventions may decrease the likelihood that an individual will develop chronic headaches and neck pain. 

With manual therapy the goal is to decrease the individual’s headache frequency, intensity, headache duration and acute medication requirements. Treatment focus on the impairments that may be related to or irritating, and dosage is based on patient-specific assessment findings and patient tolerance. For those who suffer from headaches, these treatments have been shown to be an effective non-pharmacological option by a number of randomized control trials and systematic reviews:

  • tension type headaches (Chaibi et al. 2014, Ferragut-Garcías et al. 2016, Nahin et al. 2016)

  • migraines (Chaibi et al. 2011, Happe et al. 2016)

  • neck pain (Bussières et al. 2016, Cook et al. 2015, Costello et al. 2016, Furlan et al. 2012, Gross 2015, Haller et al. 2016, Nahin et al. 2016, Nee et al 2012, Sherman et al. 2014, Sherman et al. 2009, Sutton et al. 2014, Wong et al. 2015)

  • temporomandibular disorder (Martins et al. 2016, Piekartz et al. 2013, Randhawa et al. 2015)


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.

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, 39(8).

Chaibi, A., Tuchin, P. J., & Russell, M. B. (2011). Manual therapies for migraine: A systematic review. The Journal of Headache and Pain.

Chaibi, A., & Russell, M. (2014). Manual therapies for primary chronic headaches: A systematic review of randomized controlled trials. The Journal of Headache and Pain.

Cook, A. J., Wellman, R. D., Cherkin, D. C., Kahn, J. R., & Sherman, K. J. (2015). Randomized clinical trial assessing whether additional massage treatments for chronic neck pain improve 12- and 26-week outcomes. The Spine Journal.

Costello, M., Puentedura, E. ‘, Cleland, J., & Ciccone, C. D. (2016). The immediate effects of soft tissue mobilization versus therapeutic ultrasound for patients with neck and arm pain with evidence of neural mechanosensitivity: A randomized clinical trial. Journal of Manual & Manipulative Therapy.

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.

Ferragut-Garcías, A., Plaza-Manzano, G., Rodríguez-Blanco, C., Velasco-Roldán, O., Pecos-Martín, D., Oliva-Pascual-Vaca, J., . . . Oliva-Pascual-Vaca, Á. (2016). Effectiveness of a Treatment Involving Soft Tissue Techniques and/or Neural Mobilization Techniques in the Management of the Tension-Type Headache: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation.

Frieden, T. R., & Houry, D. (2016). Reducing the Risks of Relief — The CDC Opioid-Prescribing Guideline. New England Journal of Medicine.

Furlan, A. D., Yazdi, F., Tsertsvadze, A., Gross, A., Tulder, M. V., Santaguida, L., . . . Tsouros, S. (2012). A Systematic Review and Meta-Analysis of Efficacy, Cost-Effectiveness, and Safety of Selected Complementary and Alternative Medicine for Neck and Low-Back Pain. Evidence-Based Complementary and Alternative Medicine.

Fumal, A., & Schoenen, J. (2008). Tension-type headache: Current research and clinical management. The Lancet Neurology.

Gross, A., Langevin, P., Burnie, S. J., Bédard-Brochu, M., Empey, B., Dugas, E., . . . Leblanc, F. (2015). Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. Cochrane Database of Systematic Reviews.

Haller, H., Lauche, R., Cramer, H., Rampp, T., Saha, F. J., Ostermann, T., & Dobos, G. (2016). Craniosacral Therapy for the Treatment of Chronic Neck Pain. The Clinical Journal of Pain.

Happe, S., Peikert, A., Siegert, R., & Evers, S. (2016). The efficacy of lymphatic drainage and traditional massage in the prophylaxis of migraine: A randomized, controlled parallel group study. Neurological Sciences.

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

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.

Martins, W. R., Blasczyk, J. C., Oliveira, M. A., Gonçalves, K. F., Bonini-Rocha, A. C., Dugailly, P., & Oliveira, R. J. (2016). Efficacy of musculoskeletal manual approach in the treatment of temporomandibular joint disorder: A systematic review with meta-analysis. Manual Therapy.

Morin, M., Langevin, P., & Fait, P. (2016). Cervical Spine Involvement in Mild Traumatic Brain Injury: A Review. Journal of Sports Medicine.

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.

Nee, R.J., Vicenzino, B., Jull, G.A., Cleland, J.A., & Coppieters, M.W. (2012). Neural tissue management provides immediate clinically relevant benefits without harmful effects for patients with nerve-related neck and arm pain: a randomised trial. Journal of Physiotherapy .

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.

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.

Randhawa, K., Bohay, R., Côté, P., Velde, G., Sutton, D., Wong, J., . . . Taylor-Vaisey, A. (2015). The Effectiveness of Non-invasive Interventions for Temporomandibular Disorders. The Clinical Journal of Pain.

Russo, A., D’Onofrio, F., Conte, F., Petretta, V., Tedeschi, G., & Tessitore, A. (2014). Post-traumatic headaches: A clinical overview. Neurological Sciences.

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

Schueler, M., Messlinger, K., Dux, M., Neuhuber, W. L., & De, R. (2013). Extracranial projections of meningeal afferents and their impact on meningeal nociception and headache. Pain.

Sherman, K. J., Cook, A. J., Wellman, R. D., Hawkes, R. J., Kahn, J. R., Deyo, R. A., & Cherkin, D. C. (2014). Five-Week Outcomes From a Dosing Trial of Therapeutic Massage for Chronic Neck Pain. The Annals of Family Medicine.

Sherman, K. J., Cherkin, D. C., Hawkes, R. J., Miglioretti, D. L., & Deyo, R. A. (2009). Randomized Trial of Therapeutic Massage for Chronic Neck Pain. The Clinical Journal of Pain.

Sutton, D. A., Côté, P., Wong, J. J., Varatharajan, S., Randhawa, K. A., Yu, H., . . . Stupar, M. (2014). Is multimodal care effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. The Spine Journal.

Wong, J. J., Shearer, H. M., Mior, S., Jacobs, C., Côté, P., Randhawa, K., . . . Taylor-Vaisey, A. (2015). Are manual therapies, passive physical modalities, or acupuncture effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? an update of the bone and joint decade task force on neck pain and its associated disorders by the optima collaboration. The Spine Journal.