Open Access

Objectives The aim of this Delphi survey was to establish an international consensus on the most useful outcome measures for research on the effectiveness of non-pharmacological interventions for migraine. This is important, since guidelines for pharmacological trials recommend measuring the frequency of headaches with 50% reduction considered a clinically meaningful effect. It is unclear whether the same recommendations apply to complementary (or adjunct) non-pharmacological approaches, whether the same cut-off levels need to be considered for effectiveness when used as an adjunct or stand-alone intervention, and what is meaningful to patients. Setting University-initiated international survey. Participants The expert panel was chosen based on publications on non-pharmacological interventions in migraine populations and from personal contacts. 35 eligible researchers were contacted, 12 agreed to participate and 10 completed all 3 rounds of the survey. To further explore how migraine patients viewed potential outcome measures, four migraine patients were interviewed and presented with the same measurement tools as the researchers. Procedures The initial Delphi round was based on a systematic search of the literature for outcome measures used in non-pharmacological interventions for headache. Suggested outcome measures were rated by each expert, blinded towards the other members of the panel, for its usefulness on a 5-point Likert scale ranging from definitely not useful to extremely useful. Results were combined using median values and IQRs. Tools rated overall as definitely or probably not useful were excluded from subsequent rounds. Experts further suggested additional outcome measures that were presented to the panel in subsequent rounds. Additionally, experts were asked to rank the most useful tools and provide information on feasible cut-off levels for effectiveness for the three highest ranked tools. Results Results suggest the use of the Migraine Disability Assessment (MIDAS), Headache Impact Test (HIT-6) and headache frequency as primary outcome measures. Patient experts suggested the inclusion of a measure of quality of life and evaluation of associated symptoms and fear of attacks. Conclusions Recommendations are for the use of the MIDAS, the HIT-6 and headache frequency, in combination with an outcome measure for quality of life. Associated symptoms and fear of attacks should also be considered as secondary outcomes, if relevant for the individual target population. The cut-off level for effectiveness should be lower for non-pharmacological interventions, especially when used as an adjunct to medication.

Background A wide range of physical tests have been published for use in the assessment of musculoskeletal dysfunction in patients with headache. Which tests are used depends on a physiotherapist's clinical and scientific background as there is little guidance on the most clinically useful tests. Objectives To identify which physical examination tests international experts in physiotherapy consider the most clinically useful for the assessment of patients with headache. Design/methods Delphi survey with pre-specified procedures based on a systematic search of the literature for physical examination tests proposed for the assessment of musculoskeletal dysfunction in patients with headache. Results Seventeen experts completed all three rounds of the survey. Fifteen tests were included in round one with eleven additional tests suggested by the experts. Finally eleven physical examination tests were considered clinically useful: manual joint palpation, the cranio-cervical flexion test, the cervical flexion-rotation test, active range of cervical movement, head forward position, trigger point palpation, muscle tests of the shoulder girdle, passive physiological intervertebral movements, reproduction and resolution of headache symptoms, screening of the thoracic spine, and combined movement tests. Conclusions Eleven tests are suggested as a minimum standard for the physical examination of musculoskeletal dysfunctions in patients with headache.

An der 3-dreimonatigen Studie nahmen 43 Patienten (16 Männer) mit nach der International Classification of Diagnostic Criteria of Headaches (ICDH-ll) diagnostizierten zervikogenen Kopfschmerzen teil. Die Probanden wurden randomisiert in 2 Gruppen eingeteilt. Bei der Kontrollgruppe wurde nur die Zervikalregion manualtherapeutisch, bei der TMD-Gruppe zusätzlich die temporomandibuläre Region mit weiteren manuellen Therapietechniken behandelt, um einen zusätzlichen Einfluss auf die temporomandibulären Störungen auszuüben. Bei allen Patienten erfolgte eine Untersuchung vor der Behandlung, nach 6 Behandlungssitzungen und bei einem Follow-up nach 6 Monaten. Die Ergebniskriterien waren Intensität der Kopfschmerzen (gemessen anhand einer farbigen Analogskala), Neck Disability Index (niederländische Version), Conti Anamnestic Questionnaire, Abhorchen des Kiefergelenks mit dem Stethoskop, Graded Chronic Pain Status (niederländische Version), mandibuläre Deviation, Umfang der Mundöffnung und Druckschmerzschwelle der Kaumuskulatur. Den Ergebnissen zufolge litten 44,1 % der Studienteilnehmer mit zervikogenen Kopfschmerzen an TMD. Die TMD-Gruppe wies nach der Behandlungsperiode eine signifikant verringerte Kopfschmerzintensität und eine verbesserte Nackenfunktion auf. Die Verbesserungen blieben während der behandlungsfreien Zeit bis zum Follow-up erhalten und traten bei der Kontrollgruppe nicht auf. Dieser Trend spiegelte sich auch in den Fragebögen und den klinischen temporomandibulären Zeichen wider. Die Beobachtungen lassen die Schlussfolgerung zu, dass die Behandlung der temporomandibulären Region bei Patienten mit zervikogenen Kopfschmerzen eine positive und langfristig anhaltende Wirkung hat.

Objective A mechanism-based clinical framework for spine-related pain differentiates (i) somatic referred pain, ii) heightened nerve mechanosensitivity, iii) radicular pain, iv) radiculopathy and mixed-pain. This study aimed to determine the reliability of proposed framework. Method Fifty-one people with unilateral spine-related neck-arm pain were assessed and categorized by examiner-1. The classifications were compared to those made by two other examiners, based on written documentation of examiner-1. Cohens kappa was calculated between examiner-pairs; Fleiss Kappa among all examiners to assess agreement in classifying subgroups and entire framework. Result Inter-rater-reliability showed moderate to almost perfect reliability (somatic: no variation, mechanosensitivity: 0.96 (95% CI 0.87–1.0) to 1.0 (95% CI: 1.0–1.0), radicular pain: 0.46 (95% CI: 0.19–0.69) to 0.62 (95% CI: 0.42–0.81), radiculopathy: 0.65 (95% CI: 0.43–0.84) to 0.80 (95% CI: 0.63–0.96) mixed-pain: 0.54 (95% CI: 0.21–0.81) to 0.75 (95% CI: 0.48–0.94). There was almost perfect to moderate reliability among all examiners (somatic: no variation, mechanosensitivity: 0.97 (95% CI: 0.82–1.0), radicular pain: 0.56 (95% CI: 0.40–0.71), radiculopathy: 0.74 (95% CI: 0.58–0.90), mixed-pain: 0.63 (95% CI: 0.47–0.79), entire framework: 0.64 (95% CI: 0.57–0.71)). Intra-rater-reliability showed substantial to almost perfect reliability (somatic: no variation, mechanosensitivity: 0.96 (95% CI: 0.87–1.0), radicular pain: 0.76 (95% CI: 0.57–0.92), radiculopathy: 0.84 (95% CI: 0.67–0.96), mixed-pain: 0.83 (95% CI: 0.60–1.0), entire framework: 0.80 (95% CI: 0.61–0.92). Conclusion Moderate to almost perfect reliability in subgrouping people with spine-related neck-arm pain and substantial reliability for entire framework support this classification's reliability.