Effects of combining manual therapies, neck muscle exercises, and therapeutic education pain neuroscience in patients with migraine: a 3-armed randomized clinical trial

Gabriella de Almeida Tolentino; Lidiane Lima Florencio; Juliana Pradela; Carina Ferreira Pinheiro-Araújo; Jaqueline Martins; Adrila de Cassia Cabral Norato; Felipe Daniel Sambini; José Lucas Malosti Teodoro Rodrigues; César Fernández-de-Las-Peñas; Fabiola Dach; Débora Bevilaqua-Grossi

doi:10.1016/j.msksp.2025.103360

Effects of combining manual therapies, neck muscle exercises, and therapeutic education pain neuroscience in patients with migraine: a 3-armed randomized clinical trial

Musculoskelet Sci Pract. 2025 Aug:78:103360. doi: 10.1016/j.msksp.2025.103360. Epub 2025 May 28.

Affiliations

¹ Department of Health Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Department of Neurology, University of Utah, Salt Lake City, UT, USA.
² Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcón, Spain. Electronic address: lidiane.florencio@urjc.es.
³ Department of Health Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
⁴ Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
⁵ Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcón, Spain.

PMID: 40460766
DOI: 10.1016/j.msksp.2025.103360

Abstract

Background: Physical therapy is a non-pharmacological approach for migraine management. However, the effectiveness of a multimodal approach combining manual therapies, cervical exercises, and therapeutic education, compared to these interventions individually, remains unclear.

Objectives: to investigate the effects of a multimodal approach versus manual therapies or pain neuroscience education alone in migraine patients.

Methods: A three-arm, parallel, single-blind, randomized clinical trial was conducted over 12 weeks, with assessments at baseline, 4, 8, and 12 weeks, and follow-up assessments at 1, 2, and 4 months. Seventy-five participants were randomly allocated to the Therapeutic Education Pain Neuroscience Group (TEG), Manual Therapies Group (MTG), or Multimodal Group (MUG). The primary outcome was the Headache Impact Test (HIT-6). Secondary outcomes included headache frequency, intensity, and duration; neck disability index (NDI); Allodynia Symptom Checklist (ASC-12); maladaptive beliefs; pain catastrophizing; quality of life; dizziness; and cervical assessments. Mixed models were analyzed in SPSS, considering group, time, and group-by-time interactions.

Results: All groups demonstrated significant HIT-6 improvement (p < 0.001). MTG showed greater improvement at week 4, while TEG surpassed MTG by week 12. At follow-up, MUG demonstrated superior reduction in headache impact. Significant group-by-time interactions favored multimodal treatment for headache frequency, intensity, neck pain, ASC-12, NDI, quality of life, and Flexion Rotation Test (p < 0.01). Also, MUG showed clinically relevant changes in NDI, Pain Catastrophizing Scale, quality of life, ASC-12, and Tampa Scale for Kinesiophobia.

Conclusion: Although all treatments were effective, MUG was superior in sustaining reductions in headache impact at follow-up, and improving psychosocial, headache and neck-related outcomes.

Keywords: Craniocervical exercises; Manual therapy; Migraine disorders; Pain education; Physiotherapy.

Publication types

Randomized Controlled Trial
Research Support, Non-U.S. Gov't

MeSH terms

Adult
Combined Modality Therapy
Exercise Therapy* / methods
Female
Humans
Male
Middle Aged
Migraine Disorders* / therapy
Musculoskeletal Manipulations* / methods
Neck Muscles* / physiopathology
Neck Pain / therapy
Pain Management* / methods
Pain Measurement
Patient Education as Topic* / methods
Single-Blind Method
Treatment Outcome
Young Adult