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Spinal manipulation for migraine mostly ineffective in unusually good trial

PainSci » bibliography » Chaibi et al 2016
Tags: spinal adjustment, hda, headache, bad news, modalities, manual therapy, treatment, spine, head, head/neck, pain problems

Three articles on PainSci cite Chaibi 2016: 1. The Complete Guide to Chronic Tension Headaches2. The Complete Guide to Neck Pain & Cricks3. Does Spinal Manipulation Work?

PainSci commentary on Chaibi 2016: ?This page is one of thousands in the bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.

This paper reports on the results of a good quality test of the efficacy of three months of regular chiropractic therapy for migraine, with follow-up for a year afterwards. Over one hundred patients participated, divided into three groups: one that received spinal manipulative therapy (SMT), another that received a sham treatment consisting of irrelevant manipulations, and a control group that continued with their standard medications and no other treatments. The number of migraine days per month was the main way that improvements were measured, but they also looked at migraine duration, intensity, headache index, and medication consumption.

Days with migraine went down modestly and about equally in all groups by the end of treatment. In other words, spinal manipulation for migraine was no better than the sham (on any measure, primary or secondary).

There was some minor good news for SMT: migraine intensity and headache index were modestly lower. These results are highlight by chiropractors keen to salvage scraps of good news from this study, but this is a form of cherry picking — and picking very small cherries. The effect sizes were modest, and only superior to the control group, not the sham.

Therefore, no measures, primary or secondary, produced any sign that SMT has any meaningful effect on migraine compared to a sham, and so the authors concluded that “the effect of chiropractic spinal manipulative therapy observed in our study is probably due to a placebo response.”

Why would anyone do SMT for migraine in the first place? The usual rationale is that “scratching” some musculoskeletal “itch” in the cervical spine — a source of chronic irritation that SMT can soothe — removes a potential migraine trigger. Another story is that stimulation of the spine has reflex effects on the neurology of migraine. These are highly speculative but plausible explanations for an effect that doesn’t seem to exist. There’s always the possibility that it actually does work like that for a few patients. But this evidence suggests that they are few and far between.

~ Paul Ingraham

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

BACKGROUND AND PURPOSE: To investigate the efficacy of chiropractic spinal manipulative therapy (CSMT) for migraineurs.

METHODS: This was a prospective three-armed, single-blinded, placebo, randomized controlled trial (RCT) of 17 months duration including 104 migraineurs with at least one migraine attack per month. The RCT was conducted at Akershus University Hospital, Oslo, Norway. Active treatment consisted of CSMT, whereas placebo was a sham push manoeuvre of the lateral edge of the scapula and/or the gluteal region. The control group continued their usual pharmacological management. The RCT consisted of a 1-month run-in, 3 months intervention and outcome measures at the end of the intervention and at 3, 6 and 12 months follow-up. The primary end-point was the number of migraine days per month, whereas secondary end-points were migraine duration, migraine intensity and headache index, and medicine consumption.

RESULTS: Migraine days were significantly reduced within all three groups from baseline to post-treatment (P < 0.001). The effect continued in the CSMT and placebo group at all follow-up time points, whereas the control group returned to baseline. The reduction in migraine days was not significantly different between the groups (P> 0.025 for interaction). Migraine duration and headache index were reduced significantly more in the CSMT than the control group towards the end of follow-up (P = 0.02 and P = 0.04 for interaction, respectively). Adverse events were few, mild and transient. Blinding was strongly sustained throughout the RCT.

CONCLUSIONS: It is possible to conduct a manual-therapy RCT with concealed placebo. The effect of CSMT observed in our study is probably due to a placebo response.

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