Headache Medicine 2020, 11(4):90-94 ISSN 2178-7468, e-ISSN 2763-6178
DOI: 10.48208/HeadacheMed.2020.26
Headache Medicine
© Copyright 2020
Physiotherapy in reducing migraine symptoms: literature review
Sharles Henry Brito-de-Freitas
International College of Paraíba, Physiotherapy, João Pessoa, Paraiba, Brazil
Migraine or megrim affects more than 31 million people in Brazil in all age groups, some with
a higher prevalence. In the search for new forms of treatment, physiotherapy is on the rise, with
promising results. In this context, this work aimed to investigate whether physical therapy adds
effective results in the treatment of migraine symptoms. A literary review was carried out, using
Scielo, PubMed, Virtual Health Library (VHL) and Google academic databases as review sources
of the research, using the descriptors: Migraine, treatment, and physiotherapy. More than 500
articles were found, which were submitted to pre-established criteria for inclusion and exclusion,
and, in the end, 5 articles were selected. The use of manual techniques, as stretching and mobi-
lization in the skull bones was highlighted among the physiotherapy techniques used. The results
obtained are encouraging, bringing benets to patients and opening doors for further studies
in the area.
Edited by
Mario Fernando Prieto Peres
Received: December 12, 2020
Accepted: December 30, 2020
Brito-de-Freitas SH
Physiotherapy in reducing migraine symptoms: literature review
urrently, about 150 types of headaches are known.
Among them, migraine or megrim appears amid the most
frequent ones affecting the general population, according to
studies conducted by the International Headache Society and
the Brazilian Headache Society1. In Brazil, this pathology
occurs in about 15% of the population, affecting 31 million
people. It strikes the general population nevertheless its higher
incidence happens in individuals aged 25 to 45 years old,
with a greater prevalence in females. In children before
puberty, both sexes are equally affected with about 5% of
this age group. In people over 50, the incidence decreases,
even in women.
The headache classication subcommittee of the International
Headache Society² developed a questionnaire to assess the
type of headache presented by patients. The criteria were
established by the international headache society. The exis-
tence of more than ve bouts of pain lasting between four and
seventy-two hours, with criteria of location, pain intensity, and
minimal presence of two factors such as nausea, vomiting,
phonophobia, and photophobia are the prerequisites for the
diagnosis of migraine.
According to Cabbaz³, the location of pain in migraine pain
is always unilateral, sometimes on the left side and other times
on the right side alternately, the patient feels pulsatile type
pain from moderate to severe, which can be described as a
throbbing pain reported by some people as if the heart were
beating in the head.
For Vincent
Migraine is not characterized by the presence
of headache, but by the state of constant susceptibility that
makes the migraine sufferer permanently subject to an attack,
by means of triggering factors. For a triggering factor to
ignite a crisis (and it is not mandatory that it always does),
the pre-existence of migraine susceptibility, common to all
patients, is required.
says that, in most cases, the diagnosis is
given quickly and simply clinically, from information collected
by the professional, i.e., the neurological examination in the
ofce and the symptomatology are sufcient, and there is no
need for additional tests to close the diagnosis of migraine,
but the physician may request additional tests to eliminate
other possibilities.
The pathophysiology of migraine is still not fully elucidated,
but several scholars follow lines of reasoning that end up
nding themselves in hypotheses of what may be the cause
of the problem. Among the possibilities, the one that has been
sustained is the trigemino-vascular system, with some factors
that directly inuence the triggering of pain.
For Vincent
, there is a genetic alteration in specic calcium
channels of the brain, causing hyper excitability, altering the
homeostasis, making the CNS more vulnerable to luminous,
sonorous stimuli (factors), and stress (intrinsic factor). The mid-
dle portion of the brainstem becomes particularly excitable,
being the triggering center of the crises; this area also causes
nausea and vomiting to occur (solitary tract). The trigeminal
vascular system is activated through the spreading Depression
(SD) caused by the hyperexcitability of the cerebral cortex,
causing pain through the trigeminal nucleus (brainstem) and
the peripheral vessels. In the meninges, it causes the release
of vasodilator neurotransmitters, which interact with other
substances released by vessels and nerve bers, spreading
the process and corroborating pain.
For Alves
, cerebral migraine has its origin linked to the limbic
system, composed of several structures of the neurological
system that are interconnected to the emotions and primitive
life responsible for initiating the progress and bringing the
crisis. This system belongs to the brainstem, in which are lo-
cated important structures responsible for initiating migraine
episodes, through medial proseencephalic bundles.
According to Whalen et al.
, in terms of treatment, several
drug protocols are known, but not all patients have satisfactory
results. A more recent idea is surgery, but like any intervention
of this type, it involves risks, and the cost is high, making it un-
feasible for most of the population that suffers from migraine.
On the other hand, physiotherapy comes as an alternative
means, in great ascent, bringing satisfactory results. In this
context, the following leading question arose: how can phys-
iotherapy act to minimize migraine symptoms? The purpose of
this paper was to investigate how physiotherapy adds effective
results in the treatment of migraine symptoms.
This is an integrative literature review, with the purpose of
knowing in-depth what the scientic texts say about the theme.
This methodological strategy consists of the systematic com-
pilation of studies on a particular research problem, to allow
a critical analysis of its objectives and methodological path,
generating contributions to the integration of knowledge and
its applicability, with a view to the development of the area
in question.
Brito-de-Freitas SH
Physiotherapy in reducing migraine symptoms: literature review
The integrative literature review is a distinct form of research
that synthesizes published results and generates new knowl-
edge about the reviewed topic.
For database searching purposes, three keywords were used:
Migraine, treatment, and physical therapy. The crossing of the
descriptors was done electronically in the indexing databases
Scielo, PubMed, Virtual Health Library (VHL), Google Scholar
and in the journal Headache Medicine.
Some inclusion criteria were pre-established to delineate the
search: (1) Year of publication from 2014 to 2020 (consid-
ering the year 2020 as atypical also in relation to research,
2014 was included to incorporate recent research from
the last ve years); (2) Language of publication, English,
Portuguese, and Spanish; (3) Being an original publication,
therefore, literature reviews were excluded.
Results and Discussion
In the literature search, 62 studies were found and accessed
in Scielo, 12 articles in PubMed, 47 publications in the Virtual
Health Library (VHL), 412 articles in Google Scholar, and 8
publications from other sources. Then some exclusion and
inclusion criteria were applied to obtain a direction to the nal
objective. In the end, 5 publications were left that qualied
under the proposed criteria.
In the process of ltering the publications, one of the main
reasons for exclusion was the central objective of the study,
because many only cited physical therapy or manual therapy
as a form of migraine treatment, but had not intensely explored
the theme, showing in a more detailed way only treatments
involving drugs or invasive processes, related to the area of
Figure 1 presents an explanatory way about the main forms of inclusion and exclusion by the characteristics and results of the reviewed
publications. The selected articles were published between 2014 and 2020. The articles were mostly Brazilian (80%) and Spanish (20%)
originally. The languages of the publications were 40% in English, 40% in Portuguese and 20% in Spanish. All focused on the area of
physical therapy and related areas.
Brito-de-Freitas SH
Physiotherapy in reducing migraine symptoms: literature review
Table 1. Title, authors, year of publication, objectives, method, main results, and conclusions of the studies reviewed
Title Authors Year Objectives Method Results Conclusion
Skull manual
therapy as
conduct in
chronic migraine
Alves PR 2018
Display the average
age of the patients,
gender prevalence,
greater incidence in the
professional category,
type and local of the
Descriptive exploratory
quantitative qualitative
research. Involving ten
patients, who were
applied 10 sessions
(twice a week) of the
manual therapy protocol.
The constant applicability of this
protocol for chronic migraine
sufferers collaborates for the
reduction of the pain, increasing
therefore the crises ’intervals,
enhancing the quality of life of
these patients and enabling the
return to their daily activities and
social interaction
This research observed the
importance of the manual
therapy as a rehabilitating
preventive measure, pinpointing
its benecial effects in these
people’s lives, Highlighting the
importance of the deepening of
this study with a larger sample
patient focused approach.
Intervention in
chronic migraine
Cabbaz BEB 2016
Verify the efcacy of the
Physiotherapy Intervention
in chronic migraine
Application of the
protocol involving manual
therapy techniques,
stretching, and
diaphragmatic breathing.
Ten patients were served
for four weeks.
The application of the proposed
protocol has brought good results
in improving the pain of volunteers
diagnosed with migraine over
four weeks. It is evident the
improvement in the impact of
social, family and work life,
because the pain that often makes
it impossible to perform tasks and
social and family life has its degree
It can be said that the migraine
sufferers who were part
of the sample of this study
presented an improvement in
pain and in the score of the
HIT-6 questionnaire, which
suggests improvements in the
social, physical, mental and
psychological areas of the
volunteers. Further studies with a
larger number of volunteers are
Static ultrasound
and manual
therapy for
treatment of
migraine. Case
MC, Silva
ERT, Chaves
TC, Dach F,
Speciali JG,
Guirro RRJ,
Grossi D.
Reduced pressure pain
thresholds (PPL) and the
presence of migraine
hotspots. Physiotherapy
is often helpful for these
patients. Muscle triggers
are often seen in patients
with migraine. Physical
therapy is often helpful
for these patients.
Case report: application
of a manual therapy
protocol and static
ultrasound over a period
of twenty sessions, with
ultrasound being inserted
from the 6th session on.
The association of the two types
of therapies, static ultrasound,
and manual therapy techniques,
reduced the duration and
frequency of migraine attacks
and the number of active trigger
points, and signicantly increased
pressure pain thresholds (PPL).
This case report demonstrated
that the combination of manual
therapy techniques and static
ultrasound is an interesting
non-pharmacological alternative
for patients with migraine and
myofascial involvement. Future
studies, such as randomized
clinical trials, should be
performed to conrm the results
on a large scale.
of osteopathic
in chronic
clinical trial:
Cerritelli F,
Ginevri L,
Messi G,
Caprari E, Di
Vincenzo M.
Renzetti C,
Cozzolino V,
Barlafante G,
Fochi N.
To evaluate the
effectiveness of OMT
(osteopathic manipulative
treatment) in patients with
chronic migraine.
Randomized controlled
trial, in a sample of 105
patients divided into three
groups. The OMT group
received 8 sessions over
24 weeks.
Based on this evidence, it may
be possible to hypothesize a
positive effect of the simulated
procedure on adults with migraine,
decreasing the incidence of crises
in the medium term, thus improving
the quality of life of migraineurs.
The present study showed
signicant differences between
the OMT group compared to the
other two groups, suggesting
that OMT can be considered
a clinically valid procedure for
treating patients with migraine.
effects of a
physical therapy
protocol on
pressure pain
and perceived
in patients with
migraine and
neck pain: a
clinical trial.
Grossi D,
MC, Carvalho
GF, Florencio
LL, Dach F,
Speciali JG,
Bigal ME,
Chaves TC.
To evaluate the additional
effect provided by
physical therapy in the
treatment of migraine.
Randomized controlled
trial. 300 patients, 50
women (age range, 18
and 55 years) with a
diagnosis of migraine
were approached. They
were randomized into 2
Physiotherapy plus medication
patients showed an additional
18% improvement at post-treatment
and 12% improvement at follow-up
compared to control patients.
The reduction observed in the
physiotherapy plus medication
patients was clinically relevant
at post-treatment, while clinical
relevance for the control patients
was demonstrated only at
follow-up. For pain intensity, the
physiotherapy plus medication
patients showed statistical
evidence and clinical relevance
with post-treatment reduction. In
addition, they showed a better self-
perception of overall change than
the control patients.
The physical therapy protocol
proposed in this study did
not enhance the effects of
conventional treatment for
migraine frequency and
intensity. However, the clinically
relevant changes in migraine
frequency and intensity
observed were associated with
better perceived change and
satisfaction with the treatment
received. Moreover, it was
evidenced that physical therapy
can be effective in reducing
nociceptive afferences in the
craniocervical region
Regarding the methodology of the selected articles, all of
them are in-house studies, so the literature review articles
were eliminated for a better analysis of the topic addressed,
bringing more reliability to the study, therefore. Among the
studies, manual therapy protocols were highlighted, such as
stretching of the cervical region and myofascial release by
, mobilization of the cranium bones and compression
of the fourth ventricle used by Alves.
Concepts of osteopathy
seeking the balance of the body with joint mobilizations and
manipulations as well as soft tissues, a method adopted by
Bevilaqua-Grossi et al.11. In all protocols, the work of breath-
ing (diaphragmatic pattern) was observed, associated with
manual therapy in the treatment of migraine.
talks about the benecial effects of manual therapy in
relation to the decrease and strong intensity of migraine, due
to the decay of nociceptive afferent ow within the trigemi-
nocervical nucleus, at the base of the brain and dura mater,
reducing the somatic dysfunctions located throughout the cra-
nial region, neck, upper back, and temporomandibular joint.
Bevilaqua-Grossi et al.
point out the additional benets of a
physiotherapy protocol concerning the frequency and intensity
of migraine crises could not be conrmed. However, clini-
cally relevant changes in headache frequency and intensity,
associated with improved patient perception of change and
satisfaction with treatment, were observed in the physiotherapy
Brito-de-Freitas SH
Physiotherapy in reducing migraine symptoms: literature review
plus medication group. In addition, signicant increases in
pain threshold to pressure in the temporalis muscle conrmed
that the proposed therapy improved craniocervical sensitivity.
They speculated two hypotheses for the mechanism of action
of manual therapy: rebalancing of the trigeminal nucleus and
reduction of pro-inammatory substances.
Therefore, the application of manual therapy in patients with
migraine could possibly reduce the release of pro-inamma-
tory substances, which in turn inuence the function of the
trigeminal nucleus. Consequently, a cascade of biological
and neurological events, potentially based on a rebalancing
of the abnormal activation of the habituation/sensitization
mechanism, even between crises, may occur resulting in an
overall improvement of clinical outcomes.
Final considerations
Physical therapy through manual techniques clearly brings
benecial effects to individuals affected by migraine; how-
ever, through this review, it is evident that the idea is still little
widespread, even though the physical therapy professional
can act to reduce migraine symptoms. Due to the scarcity of
studies, the discussion becomes limited to prompt more robust
results to guide the physical therapy practice.
It also becomes a milder way, since the use of drugs brings
within it adverse effects, which can be manifested in a more
accentuated way in individuals who have aversion to drug
treatments. There are also those who have allergies or sen-
sitivity to the medication used.
This article opens doors for new studies, because this is still
a poorly addressed area. There are still many aspects to be
elucidated, such as what really causes migraines, because
there are hypotheses and lines of reasoning, but nothing
concrete. Therefore, this is the right way to follow, as there
are positive results in patients subjected to the test. With more
studies, new applications and techniques will emerge, which
is good, because more solidness in the idea of treatment for
each individual will be achieved.
Financing source: No
Conflict of interests: No
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