Traditional Chinese Cervical Manipulation for Cervicogenic Headache

The Effect of Traditional Chinese Cervical Manipulation for Cervicogenic Headache: a Pilot Randomized, Single-blind, Placebo-controlled Trial

Background Cervical spondylosis is a prevalent condition. Studies has shown that it is a leading cause for headache, which is termed cervicogenic headache (CGH). The prevlance of CGH among severe headache is 17.5%. While conventional treatments, such as physical therapy and surgery, is effective in controlling symptoms, the effect was found to be short-lasting. There is existing clinical evidence supporting traditional Chinese cervical manipulation (CCM) as a viable treatment for CGH.

Objective To preliminarily assess the feasibility, safety, and effectiveness of CCM on patients with CGH, and to optimize parameters for a future large-scale trial.

Method This study is a pilot randomized, controlled, single-blind trial. 84 participants will be randomized evenly to receive either CCM or sham manipulation for 4 weeks. Outcome measurements will be conducted at baseline, week 2, week 4 and week 8 on cervical functional disability, cervical range of motion, and data on headache onset and painkiller assumption. Adverse events will be recorded using the Common Terminology Criteria for Adverse Events (CTCAE).

Study Overview

• Status: Active, not recruiting
• Conditions: Cervicogenic Headache
• Intervention / Treatment: Other: Traditional Chinese cervical manipulation; Other: Sham manipulation

• Study Type: Interventional
• Enrollment (Estimated): 84
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Hong Kong
  • Hong Kong, Hong Kong
    • Hong Kong Baptist University
  • Hong Kong, Hong Kong
    • Lui Seng Chun,119 Lai Chi Kok Road, Mong Kok

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

1. The diagnostic criteria of cervical spondylosis according to "The expert consensus on the classification, diagnosis, and non-surgical treatment of cervical spondylosis (2018)" are as follows:

   1. Patients must have a chief complaint of abnormal sensations such as pain in the occipital, neck, or shoulder area, and can be accompanied by related localized pain and tenderness
   2. X-ray imaging shows degenerative changes in the cervical spine
   3. Other conditions that could cause symptoms of the neck are excluded

2. The diagnostic criteria of CGH as listed by ICHD-3:

   a. Any headache fulfilling criterion C b. Clinical and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck, known to be able to cause headache c. Evidence of causation demonstrated by at least two of the following: i. headache has developed in temporal relation to the onset of the cervical disorder or appearance of the lesion ii. headache has significantly improved or resolved in parallel with improvement in or resolution of the cervical disorder or lesion iii. cervical range of motion is reduced and headache is made significantly worse by provocative manoeuvre iv. headache is abolished following diagnostic blockade of a cervical structure or its nerve supply v. Not better accounted for by another ICHD-3 diagnosis

3. Of age between 18 to 65 years old
4. Headache recurs for at least three months
5. The frequency of headaches in the past three months is at least once a week
6. The frequency, dosage, and type of painkillers have remained stable over the past 6 weeks
7. Score at least 10 points on the Neck Disability Index -

Exclusion Criteria:

1. Presented with red flag presentations of headache listed in the SNNOOP10 list (systemic symptoms/signs and disease, neurologic symptoms or signs, onset sudden or onset after the age of 40 years, and change of headache pattern), including fever, vascular and non-vascular intracranial diseases, history of brain tumor, brain neurological dysfunction or disorder, etc.
2. With suspected cervical spinal stenosis, cervical spinal cord lesions, cervical vascular disease, cervical nerve root disease, cervical instability, or cervical fracture
3. Has suffered from a whiplash injury within the past 6 weeks
4. Had surgery on the neck or head
5. Currently pregnant or breastfeeding

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Traditional Chinese cervical manipulation; Initial Assessment: The participant will lie supine while the PI will perform the CFRT to identify the side with more restricted rotation. Positioning (Left Restriction Example): The PI will support the lower jaw with the right hand and will passively rotate the neck 70-80° (or to the limit of comfort) toward the unrestricted side. Hand Placement: The right fingers will support the right C1-C3 transverse processes, while the left thumb will stabilize the left C2 transverse process. Traction and Thrust: While maintaining rotation, the PI will apply a steady traction force to open the cranio-cervical and atlanto-axial joints. Once felt, a sudden high-velocity, low-amplitude (HVLA) pulling force will be delivered. Completion: The procedure will be repeated on the opposite side, followed by a 5-10 minute supine rest period for the participant.	Other: Traditional Chinese cervical manipulation; Initial Assessment: The participant will lie supine while the PI will perform the CFRT to identify the side with more restricted rotation. Positioning (Left Restriction Example): The PI will support the lower jaw with the right hand and will passively rotate the neck 70-80° (or to the limit of comfort) toward the unrestricted side. Hand Placement: The right fingers will support the right C1-C3 transverse processes, while the left thumb will stabilize the left C2 transverse process. Traction and Thrust: While maintaining rotation, the PI will apply a steady traction force to open the cranio-cervical and atlanto-axial joints. Once felt, a sudden high-velocity, low-amplitude (HVLA) pulling force will be delivered. Completion: The procedure will be repeated on the opposite side, followed by a 5-10 minute supine rest period for the participant.
Sham Comparator: Sham manipulation; Initial Positioning: Assuming a right-side rotation restriction, the PI will support the participant's lower jaw and will passively rotate the neck 70-80° toward the unrestricted side. Hand Placement: The PI will use the left fingers to support the right-side transverse processes of C4-C6 and the left thumb to support the left-side transverse process of C6. Traction Application: A steady traction force will be applied such that joint space increases are limited specifically to the C4/C5 level and below, avoiding the upper cervical region. The PI will then deliver a low-amplitude pulling force at a slower speed than the standard TCMT to prevent vertebral realignment or significant joint widening. Completion: The procedure will be repeated on the opposite side, after which the participant will rest supine for 5-10 minutes.	Other: Sham manipulation; Initial Positioning: Assuming a right-side rotation restriction, the PI will support the participant's lower jaw and will passively rotate the neck 70-80° toward the unrestricted side. Hand Placement: The PI will use the left fingers to support the right-side transverse processes of C4-C6 and the left thumb to support the left-side transverse process of C6. Traction Application: A steady traction force will be applied such that joint space increases are limited specifically to the C4/C5 level and below, avoiding the upper cervical region. The PI will then deliver a low-amplitude pulling force at a slower speed than the standard TCMT to prevent vertebral realignment or significant joint widening. Completion: The procedure will be repeated on the opposite side, after which the participant will rest supine for 5-10 minutes.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Neck Disability Index (NDI) scoring	It is used to evaluate cervical functional disability It has good reliability and validity, reflecting the degree of limitation on living ability and the impact on quality of life. The higher the score, the more severe the symptoms.	Baseline, week 2, week 4 and week 8

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Active cervical range of motion	to evaluate the range neck flexion, extension, left and right lateral flexion, left and right rotation. The measuring instrument will be the cervical goniometer.	Baseline, week 2, week 4 and week 8
Online headache diary:	All participants are required to complete an online headache diary daily. It will include the following items: the time of headache onset, duration, pain intensity, and the type and frequency of painkillers taken	Baseline, week 2, week 4 and week 8

Collaborators and Investigators

• Sponsor: Hong Kong Baptist University

Study record dates

Study Major Dates

• Study Start (Actual): November 1, 2024
• Primary Completion (Estimated): August 30, 2026
• Study Completion (Estimated): August 30, 2026

Study Registration Dates

• First Submitted: May 23, 2024
• First Submitted That Met QC Criteria: May 23, 2024
• First Posted (Actual): May 30, 2024

Study Record Updates

• Last Update Posted (Actual): May 11, 2026
• Last Update Submitted That Met QC Criteria: May 6, 2026
• Last Verified: November 1, 2025

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Headache Disorders; Headache Disorders, Secondary; Post-Traumatic Headache
• Other Study ID Numbers: Manipulation CGH

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No