Impacts of cervical exercise and Mulligan manual therapy on headache frequency, intensity, and disability for people with episodic migraine – a randomized clinical trial

OBJECTIVE: To compare the addition of Mulligan manual therapy (MMT) or sham MMT to neck exercise for the management of people with episodic migraine. METHODS: Ninety-nine adult patients (mean 41.5 years, SD 13.3) with episodic migraine were allocated to six sessions of neck exercise alone, exercise + MMT, or exercise + sham MMT. Migraine frequency was the primary outcome measure. Headache intensity and duration, medication, disability, upper cervical range of motion (CROM), pressure-pain thresholds of cervical and tibialis anterior muscle areas, as well as patient satisfaction score were secondary outcome measures evaluated at baseline, 4, 13, and 26 weeks. RESULTS: Headache frequency was not significantly improved when comparing exercise + MMT to exercise alone (4-week MD: 0.57, 95%CI: -0.30 to 1.43; 13-week MD: 0.90, 95%CI: 0.01 to 1.79; 26-week MD: 0.66, 95%CI: -0.31 to 1.62) and to exercise + sham MMT (4-week MD: -2.28, 95%CI: -1.35 to 0.79; 13-week MD: -0.88, 95%CI: -1.81 to 0.06; 26-week MD: -0.81, 95%CI: -1.77 to 0.15). For secondary outcome of disability, a statistically significant improvement was observed for exercise + MMT only at 4-week over exercise alone (MD: 5.59, 95%CI: 3.06 to 8.11) and over exercise + sham MMT (MD: -3.57, 95%CI: -6.12 to -1.03) but not at 13 and 26 weeks. Statistically significant improvement in CROM was observed at 13‑ and 26-week follow-up over the other two groups. CONCLUSION: MMT combined with exercise did not result in a significant reduction in headache frequency compared to exercise alone or exercise with sham. The results could be attributed to the lack of subgrouping migraine subjects based on the presence of articular impairments.