Satpute K, Bedekar N, Hall T Mulligan manual therapy added to exercise improves headache frequency, intensity and disability more than exercise alone in people with cervicogenic headache: a randomised trial. J Physiother. 2024 Jul;70(3):224-233. doi: 10.1016/j.jphys.2024.06.002. Epub 2024 Jun 19. (Original study)

QUESTION: What is the effect of a 4-week regimen of Mulligan manual therapy (MMT) plus exercise compared with exercise alone for managing cervicogenic headache? Is MMT plus exercise more effective than sham MMT plus exercise? Are any benefits maintained at 26 weeks of follow-up?

DESIGN: A three-armed, parallel-group, randomised clinical trial with concealed allocation, blinded assessment of some outcomes and intention-to-treat analysis.

PARTICIPANTS: Ninety-nine people with cervicogenic headache as per International Classification of Headache Disorders (ICHD-3).

INTERVENTIONS: Participants were randomly allocated to 4 weeks of: MMT with exercise, sham MMT with exercise or exercise alone.

OUTCOME MEASURES: The primary outcome was headache frequency. Secondary outcomes were headache intensity, headache duration, medication intake, headache-related disability, upper cervical rotation range of motion, pressure pain thresholds and patient satisfaction. Outcome measures were collected at baseline and at 4, 13 and 26 weeks.

RESULTS: MMT plus exercise reduced headache frequency more than exercise alone immediately after the intervention (MD between groups in change from baseline: 2 days/month, 95% CI 2 to 3) and this effect was still evident at 26 weeks (MD 4 days, 95% CI 3 to 4). There were also benefits across all time points in several secondary outcomes: headache intensity, headache duration, headache-related disability, upper cervical rotation and patient satisfaction. Pressure pain thresholds showed benefits at all time points at the zygapophyseal joint and suboccipital areas but not at the upper trapezius. The outcomes in the sham MMT with exercise group were very similar to those of the exercise alone group.

CONCLUSIONS: In people with cervicogenic headache, adding MMT to exercise improved: headache frequency, intensity and duration; headache-related disability; upper cervical rotation; and patient satisfaction. These benefits were not due to placebo effects.


Discipline Area Score
Rehab Clinician (OT/PT) 6 / 7
Physician 6 / 7
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Comments from MORE raters

Rehab Clinician (OT/PT) rater

The study has a very well-executed methodological design. My only concern is about the placebo group. The placebo group received a replication of SNAG techniques without manual force. Although the success of blinding has been assessed, I think that especially conscious patients or patients who have previously received similar manual treatments may have questions about the placebo applications, and this may affect the results. Nevertheless, the study provides important results regarding the effectiveness of the Mulligan concept in patients with cervicogenic headache.

Rehab Clinician (OT/PT) rater

Aside from labelling this intervention, 'Mulligan manual therapy', one is mindful that such therapeutic intervention is standard fare across a broad spectrum of disciplines utilising physical manipulative intervention. A valuable study would be the comparative evaluation of such interventions, asserting a claim of 'difference' while potentially likely to be recruiting similar central and peripheral influences.

Rehab Clinician (OT/PT) rater

As an orthopaedic and sports physiotherapist whose clients regularly include those with complaints consistent with cervicogenic headaches, I find the results of this well-designed study support my treatment approach for these clients, which includes manual therapy (including Mulligan techniques) in addition to targeted therapeutic exercise. This will assist me in both client and caregiver education, as well as in education and consulting with referral sources, namely primary care, orthopaedic, and neurologic providers.
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