Coverage from EHF 2019

At a teaching course at the 13th annual congress of the European Headache Federation, Prof. George Georgoudis (University of West Attica, Greece) described a biopsychosocial approach to treating headache, as well as clinical research to evaluate the benefits of this approach. In Prof. Georgoudis’ opinion, there is an opportunity for patients to benefit from a supplementary approach to headaches that incorporates physiotherapy.

Prof. Georgoudis described how patients attending headache clinics may present with a number of symptoms, including intense, bilateral pain that fails to deteriorate with regular physical activity. While patients often receive pharmacological interventions, incorporating physical therapy into patient management could provide a second opportunity to improve health outcomes. He further described targets for the management of physical therapy, including cervical spine manipulation or mobilisation,1 exercise to strengthen deep neck flexors and upper quarter muscles, thoracic spine thrust manipulation and exercise, and C1–C2 self-sustained natural apophyseal glide (SNAG).2 These treatments combine physiological benefits with cognitive and psychological benefits in patients.

During the presentation, Prof. Georgoudis described a pragmatic, randomised, controlled trial designed to investigate whether a biopsychosocial approach provides benefits for patients with TTH (tension-type headache) cephalagia.3 In the study, patients received ten treatment sessions within a four-week period, alongside a daily stretching regimen. Treatment sessions consisted of either acupuncture alone (control group) or acupuncture and physiotherapy (experimental group). Acupuncture was conducted at 17–20 acupuncture sites, of which 15–17 remained constant across patients, with the remainder being decided based on individual symptoms. Physiotherapy consisted of microwave diathermy and myofascial release with manual techniques. The primary outcome was mechanical pressure pain threshold (PPT) using a mechanical algometer to measure seven bilateral points, which were measured at baseline, after five treatments and after ten treatments.

Prof. Georgoudis described how a significant improvement on the primary outcome of PPT score was observed for patients in the control group, who received acupuncture treatment alongside stretching, as well as patients in the experimental group, who received treatment incorporating acupuncture, stretching and manual physiotherapy. A significant change from baseline was observed at both week five and week ten. However, at week ten, an augmented benefit on the primary outcome of PPT score was observed in the experimental group compared with the control group. A similar pattern of benefits was observed for all secondary outcomes, including reduction of pain, anxiety and depression, catastrophising, functioning and quality of life.

In the opinion of Prof. Georgoudis, the observed results demonstrate that hands-on physiotherapy techniques, alongside acupuncture and stretching, can produce desireable physiological improvements in patients with TTH, alongside providing cognitive and psychological benefits. Considering this, a biopsychosocial approach to treating patients in the headache clinic could, therefore, complement existing pharmacological interventions.


  1. Cleland JA, et al. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a general cervical range of motion exercise: multi-center randomized clinical trial. Phys Ther. 2010;90:1239–1250.
  2. Hall T, et al. Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache. J Ortho Sport Phys Ther. 2007;37:100–107.
  3. Georgoudis G, et al. The effect of myofascial release and microwave diathermy combined with acupuncture versus acupuncture therapy in tension-type headache patients: A pragmatic randomized controlled trial. Physiother Res Int. 2018;23:e1700.