Headache Medicine 2020, 11(4):90-94 ISSN 2178-7468, e-ISSN 2763-6178

ASAA

DOI: 10.48208/HeadacheMed.2020.26

Headache Medicine

Review

Physiotherapy in reducing migraine symptoms: literature review

Sharles Henry Brito-de-Freitas

International College of Paraíba, Physiotherapy, João Pessoa, Paraiba, Brazil

Abstract

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.

sharleshenry11@gmail.com

Edited by

Mario Fernando Prieto Peres

Keywords:

Physiotherapy

Treatment

Migraine

Received: December 12, 2020

Accepted: December 30, 2020

ASAA

Brito-de-Freitas SH

Physiotherapy in reducing migraine symptoms: literature review

Introduction

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.

NeuroAnchieta

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.

Methods

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.

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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

medicine.

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.

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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

physiotherapy

treatment

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

pain.

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.

Physiotherapy

Intervention in

chronic migraine

patients.

Cabbaz BEB 2016

Verify the efcacy of the

Physiotherapy Intervention

in chronic migraine

patients.

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

decreased.

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

suggested.

Static ultrasound

and manual

therapy for

treatment of

refractory

migraine. Case

report

Gonçalves

MC, Silva

ERT, Chaves

TC, Dach F,

Speciali JG,

Guirro RRJ,

Bevilaqua-

Grossi D.

2014

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.

Clinical

effectiveness

of osteopathic

treatment

in chronic

migraine:

randomized

controlled

clinical trial:

Cerritelli F,

Ginevri L,

Messi G,

Caprari E, Di

Vincenzo M.

Renzetti C,

Cozzolino V,

Barlafante G,

Fochi N.

2016

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.

Additional

effects of a

physical therapy

protocol on

headache

frequency,

pressure pain

threshold,

and perceived

improvement

in patients with

migraine and

associated

neck pain: a

randomized

clinical trial.

Bevilaqua-

Grossi D,

Gonçalves

MC, Carvalho

GF, Florencio

LL, Dach F,

Speciali JG,

Bigal ME,

Chaves TC.

2016

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

groups.

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

Cabbaz

, 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.

Alves

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

ASAA

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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