Reviewed by Tyler Tice, PT, DPT, OCS, ATC


Cervicogenic headaches are a common form of headache that impacts up to 20% of the population. These headaches commonly come from the musculoskeletal components surrounding the cervical spine and are exacerbated by neck movements. Current clinical practice guidelines suggest manual technique usage in conjunction with exercise as the best course of treatment, with some of the most common manual techniques utilized being mobilizations and manipulations. This study intended to determine which method is more effective in reducing patient discomfort and improving function in patients who have cervicogenic headaches.


The study was a randomized pragmatic clinical trial that required all patients to be diagnosed with cervicogenic headaches, have tenderness to palpation in at least one joint in the upper cervical spine region, a neck disability index (NDI) of at least 20% or greater, and at least a 2/10 level of pain on the NPRS pain scale. All patients completed several self-report measures including the NDI, Headache impact test, and NPRS pain scale. The study compared upper cervical spine (C0-C3) mobilizations versus manipulations of the same area.

Conclusions of the Study:

The study concluded there was no difference in the patient’s perceived improvements in pain and function and objective ROM. This contradicts previous evidence stating that manipulations provided greater improvements in patient-reported outcomes than mobilizations. However, many previous studies utilized a prescriptive approach that had all manipulations and mobilizations performed at the same location, whereas this study utilized a pragmatic approach that allowed the treating therapists to use their own clinical judgment to determine where to perform manual techniques. It can be concluded from this study that despite there being some limitations, especially the smaller sample size of 45 people, that when treating patients with cervicogenic headaches both manipulations and mobilizations are viable options to improve patient pain and disability.  

Clinical Implications:

This study provides some evidence for the idea that manipulation or mobilization for cervicogenic headache patients can have nearly the same effect on patient perceived functionality. Given the increased risks of performing upper cervical spine manipulations it may be better to defer to mobilizations when deciding on manual treatments for patients with cervicogenic headaches, unless mobilizations have otherwise been unsuccessful. The similar improvements seen may be due to the neurophysiological input to the brain that is improving patient functionality, rather than any increases in motion after mobilization or manipulation. The key part of this study that differs from previous research is its allowance of the PT’s clinical judgment to determine what the patient needs during treatment. This highlights the importance of reassessing from session to session to determine exactly what the patient may benefit from more, it is important to keep in mind the differences in the methods of this study compared to previous iterations.


Lerner-Lentz, A., O’Halloran, B., Donaldson, M., & Cleland, J. A. (2020). Pragmatic application of manipulation versus mobilization to the upper segments of the cervical spine plus exercise for treatment of cervicogenic headache: A randomized clinical trial. Journal of Manual & Manipulative Therapy, 29(5), 267–275.