title: A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache.
abstract: METHODS
  A multicenter, randomized controlled trial with unblinded treatment and blinded outcome assessment was conducted. The treatment period was 6 weeks with follow-up assessment after treatment, then at 3, 6, and 12 months.
  
  
  OBJECTIVE
  To determine the effectiveness of manipulative therapy and a low-load exercise program for cervicogenic headache when used alone and in combination, as compared with a control group.
  
  
  BACKGROUND
  Headaches arising from cervical musculoskeletal disorders are common. Conservative therapies are recommended as the first treatment of choice. Evidence for the effectiveness of manipulative therapy is inconclusive and available only for the short term. There is no evidence for exercise, and no study has investigated the effect of combined therapies for cervicogenic headache.
  
  
  METHODS
  In this study, 200 participants who met the diagnostic criteria for cervicogenic headache were randomized into four groups: manipulative therapy group, exercise therapy group, combined therapy group, and a control group. The primary outcome was a change in headache frequency. Other outcomes included changes in headache intensity and duration, the Northwick Park Neck Pain Index, medication intake, and patient satisfaction. Physical outcomes included pain on neck movement, upper cervical joint tenderness, a craniocervical flexion muscle test, and a photographic measure of posture.
  
  
  RESULTS
  There were no differences in headache-related and demographic characteristics between the groups at baseline. The loss to follow-up evaluation was 3.5%. At the 12-month follow-up assessment, both manipulative therapy and specific exercise had significantly reduced headache frequency and intensity, and the neck pain and effects were maintained (P < 0.05 for all). The combined therapies was not significantly superior to either therapy alone, but 10% more patients gained relief with the combination. Effect sizes were at least moderate and clinically relevant.
  
  
  CONCLUSIONS
  Manipulative therapy and exercise can reduce the symptoms of cervicogenic headache, and the effects are maintained.
authors.affiliation: Department of Physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia. g.jull@shrs.uq.edu.au
authors.forename: Gwendolen
authors.initials: G
authors.lastname: Jull
authors.forename: Patricia
authors.initials: P
authors.lastname: Trott
authors.forename: Helen
authors.initials: H
authors.lastname: Potter
authors.forename: Guy
authors.initials: G
authors.lastname: Zito
authors.forename: Ken
authors.initials: K
authors.lastname: Niere
authors.forename: Debra
authors.initials: D
authors.lastname: Shirley
authors.forename: Jonathan
authors.initials: J
authors.lastname: Emberson
authors.forename: Ian
authors.initials: I
authors.lastname: Marschner
authors.forename: Carolyn
authors.initials: C
authors.lastname: Richardson
mesh_terms: D000328:Adult; D001676:Biofeedback, Psychology; D002908:Chronic Disease; D015444:Exercise; D005260:Female; D005500:Follow-Up Studies; D020773:Headache Disorders / Q000628:therapy*; D006801:Humans; D008297:Male; D026201:Musculoskeletal Manipulations / Q000379:methods*; D010147:Pain Measurement; D011446:Prospective Studies; D016896:Treatment Outcome