Instrumental assessment of physiotherapy and onabolulinumtoxin-A on cervical and headache parameters in chronic migraine

DOI: https://doi.org/10.1007/s10072-021-05491-w

Abstract-Summary The purpose of the present study is to compare the effect of the physiotherapy to onabolulinumtoxin-A, and their combination, in relation to cervical and headache parameters in patients with chronic migraine.

The patients were distributed in three groups of treatments for three months: onabolulinumtoxin-A only, physiotherapy only, and onabolulinumtoxin-A plus physiotherapy.

After 3 months of each treatment, the scores obtained for the headache-related disability and the frequency of migraine decreased significantly for all groups, but the pain intensity scores changed significantly only in the onabolulinum- toxin-A (p = 0.01) and in the onabolulinumtoxin-A plus physiotherapy groups (p = 0.007).

The forward head posture was reduced significantly in the physiotherapy (p =

0.002) and in the onabolulinumtoxin- A plus physiotherapy groups (p = 0.003).

The cervical range of motion increased significantly in certain directions in the

physiotherapy group and in the onabolulinumtoxin-A plus physiotherapy groups.

From our results, it can be concluded that onabolulinumtoxin-A plus physio-

therapy could be a good option in the management of chronic migraine.

Extended: The patients were allowed to take symptomatic medications in case of

severe headache, according to the international guidelines [118].

Exclusion criteria were as follows: pregnancy; serious psychiatric pathologies; serious pathologies such as traumas, tumors, or infections; significant surgical pro- cedures during the previous 12 months; physiotherapy or other prophylactic treat- ment in the previous 3 months; and patients with cervical spine diseases.

We found that the intensity of migraine decreased significantly for the BoNT- A

only group, but not for the PT only group.

Introduction A primary concern of headache is migraine that represents one of the most severe headache in terms of pain intensity and of headache related disability.

The present study focuses on chronic migraine. It is based on a considerable amount of literature that highlights the key aspect of musculoskeletal dysfunctions in the trigeminal sensitization and, consequently, in the increase of frequency and intensity of migraine [286–290].

As regards non-pharmacological treatments, physiotherapy is also helpful in pri- mary headaches, and it increases the effectiveness of pharmacological treatments [291, 292].

4.3 Results

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No studies have been conducted previously that compare the effects of these two kinds of therapies on chronic migraine, nor the possible added value of their combination.

The first aim of the present study is to compare the efficacy of physiotherapy and onabotulinumtoxin-A in chronic migraine on cervical parameters, such as FHP and CROM, and on headache parameters, such as headache- related disability, the migraine frequency, and intensity.

Methods An observational cohort study was performed on 3 groups of patients with chronic migraine.

Exclusion criteria were as follows: pregnancy; serious psychiatric patholo- gies; serious pathologies such as traumas, tumors, or infections; significant sur- gical procedures during the previous 12  months; physiotherapy or other prophylactic treatment in the previous 3 months; and patients with cervical spine diseases.

The CROM was repeated actively in all directions by the patients twice; the aver-

age of the two measurements was considered for the data analysis.

After the first data collection, the cohort was divided into the 3 groups, according to the patient’s choice and the specialist’s opinion as per normal clinical practice: physical therapy only (PT) (mono-therapy), onabotulinumtoxin- A only (BoNT-A) (mono-therapy), and onabotulinumtoxin-A plus physical therapy (BoNT-A+PT) (combined therapy).

The final evaluation was performed (T2) after 3 months of each of the 3 kinds of treatment with the same outcomes: FHP; CROM; and the MIDAS, MIDAS-A, and MIDAS-B questionnaires.

Results No statistical differences were registered among the three groups at T1 in terms of age (p = 0.9); CVA (p = 0.7); range of motion (flexion p = 0.5; extension p = 0.2; right lateral flexion p = 0.7; left lateral flexion p = 0.6; right rotation p = 0.18; left rotation p = 0.7); MIDAS score (p = 0.9); MIDAS-A (p = 0.5); MIDAS-B (p = 0.1); medication intake per month (p = 0.9); and frequency of migraine at baseline (p = 0.6).

To this, the difference among groups was significant in lateral flexion right p = 0.03 (PT vs. BoNT-A 7.85 ns p > 0.05; PT vs. BoNT-A+PT -1.55 ns p > 0.05; BoNT-A vs. BoNT-A+PT 9.4 ns p > 0.05), but not quite significant (p = 0.07) in lateral flexion left.

Discussion The present study for the first time has investigated, in patients with chronic migraine, the effect on both cervical and headache parameters of 3 different types of treatments, that are as follows: (1) onabolulinumtoxin-A only; (2) physiotherapy integrated protocol (i.e., manual therapy and active exercise) only; and (3) onabolu- linumtoxin-A plus physiotherapy.

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4 Treatment

The BoNT-A+PT group showed an improvement for cervical as well as for head- ache parameters, according to the idea that migraine responds better to combined treatments [293].

It can therefore be assumed that if long-term treatment of BoNT-A has resulted in better benefits and prolonged efficacy in patients [294], the repetitive cycles of BoNT-A+PT could lead to better outcomes in terms of frequency, intensity, and duration of the pain but also in terms of cervical parameters.

Conclusions This combined multi-professional approach is potentially very useful for both the patients and the health systems, because it may offer a more complete clinical man- agement of the outcomes related to the complex multifactorial disorder that chronic migraine represents.

A large randomized controlled trial could provide better evidence concerning the correlation between the cervical parameters and the headache parameters; more- over, it would be interesting to know if early finds are maintained or improved over time.

Acknowledgement A machine generated summary based on the work of Deodato, Manuela; Granato, Antonio; Borgino, Caterina; Galmonte, Alessandra; Manganotti, Paolo. 2021  in Neurological Sciences.

Onabotulinumtoxin A for the management of chronic migraine in current clinical practice: results of a survey of sixty-three Italian headache centers