Mechanisms of Recovery in Cervicogenic Headache: Mediating Effects of Cervical Mobility on Pain, Disability, and Quality of Life Following Manual Therapy

Abstract

Background: Cervicogenic headache is a disorder arising from dysfunction of the upper cervical spine. It is characterised by restricted cervical range of motion (ROM), neck pain, functional disability, and reduced quality of life. Although manual therapy has been shown to alleviate headache symptoms effectively, the mechanisms underlying its therapeutic effects remain poorly understood. Objective: This study aimed to investigate whether improvements in cervical ROM mediated the effects of manual therapy on pain intensity, neck disability, headache impact, and health-related quality of life in patients with cervicogenic headache. A secondary objective was to compare the mediating effect of cervical mobility between upper cervical manipulation alone and upper cervical manipulation combined with upper thoracic manipulation. Methods: This prospective, assessor-blinded, randomised controlled trial included 76 individuals with cervicogenic headache, who were randomly assigned to either Group A (upper cervical manipulation with conventional physiotherapy; n = 38) or Group B (upper cervical manipulation with upper thoracic manipulation plus conventional physiotherapy; n = 38). The primary outcomes were pain intensity, assessed using the Visual Analogue Scale (VAS), and neck disability, assessed using the Neck Disability Index (NDI). Secondary outcomes included the HIT-6, headache frequency, headache duration, the Short Form Health Survey (SF-36), patient satisfaction, and cervical ROM. Statistical analyses included repeated-measures ANOVA, correlation analysis, and mediation analysis. Results: Following treatment, all clinical outcomes improved significantly in both intervention groups. However, Group B achieved significantly greater reductions in pain, disability, headache impact, frequency, and duration, together with larger improvements in cervical ROM, quality of life, and patient satisfaction, than Group A. Mediation analysis indicated that manual therapy restored cervical ROM, which significantly mediated the association between manual therapy and improvements in pain, disability, and quality of life, supporting the interpretation that restoration of cervical mobility is a principal mechanism of clinical recovery. Conclusion: Manual therapy is effective for cervicogenic headache. In particular, combining upper cervical and upper thoracic manipulation produced superior clinical outcomes compared with upper cervical manipulation alone. Recovery of cervical range of motion appears to be a major biomechanical pathway through which manual therapy may reduce pain and disability while improving recovery and quality of life. The findings suggest that mechanism-based rehabilitation strategies aimed at enhancing cervical mobility should be considered an important component of cervicogenic headache management.