An interventional study of Post Isometric Relaxation and Strain Counterstrain in Cervicogenic Headache, sponsored by Qurat Ul Ain Ashfaq. Completed at 1 site in Pakistan. Open to female participants aged 18 Years to 45 Years. Per ClinicalTrials.gov, last updated 2026-10-27.
Sponsored by Qurat Ul Ain Ashfaq · Not applicable, Interventional, and Treatment
Cervicogenic headache is a secondary headache disorder associated with dysfunction of the cervical spine and surrounding muscles. It may cause neck pain, muscle tenderness, recurrent headaches, and limitations in daily activities, ultimately affecting quality of life. The study aimed to determine whether Strain Counterstrain (SCS) or Post-Isometric Relaxation (PIR) produces better outcomes in reducing pain intensity, decreasing headache frequency, and improving headache-related quality of life.
A randomized clinical trial was conducted in the Physiotherapy Department of Sir Ganga Ram Hospital, Lahore, involving 34 female participants who were randomly allocated into two equal groups of 17 participants each. Group A received Strain Counterstrain, while Group B received Post-Isometric Relaxation. Strain Counterstrain is a passive manual therapy technique in which the therapist positions the affected cervical tissues in a comfortable position to reduce tenderness and abnormal muscle activity.
Participants were assessed using three outcome measures: the Numeric Pain Rating Scale (NPRS) to measure pain intensity, a Headache Frequency Diary to record headache episodes, and the Headache Impact Test (HIT-6) to assess the effect of headaches on daily functioning and quality of life. Assessments were conducted at baseline, after six weeks, and at twelve weeks, as reported in the results section.
The study aimed to determine whether Strain Counterstrain (SCS) or Post-Isometric Relaxation (PIR) produces better outcomes in reducing pain intensity, decreasing headache frequency, and improving headache-related quality of life.
Cervicogenic headache (CGH) is a secondary headache disorder associated with dysfunction of the cervical spine and its surrounding musculoskeletal structures. It occurs when a problem involving the neck joints, muscles, ligaments, or upper cervical region contributes to pain that radiates from the neck toward the head. The upper cervical vertebrae, particularly C1, C2, and C3, play an important role in the development of cervicogenic headache because sensory pathways from the upper cervical region converge with pathways associated with the trigeminal nerve. This convergence helps explain why pain originating in the neck may be perceived in the head. Patients commonly experience unilateral headache, neck pain, restricted cervical range of motion, and tenderness in the upper cervical muscles. The headache may be aggravated by neck movements, sustained neck positions, or pressure over sensitive cervical structures. Commonly involved muscles include the suboccipital muscles, upper trapezius, and levator scapulae. Unlike primary headache disorders, such as migraine, cervicogenic headache is associated with an underlying cervical musculoskeletal source. Clinical assessment may include evaluation of cervical mobility, muscle tenderness, headache characteristics, and the Flexion-Rotation Test (FRT), which helps identify restricted movement of the upper cervical spine. Accurate diagnosis is important because other conditions, including migraine, cluster headache, cervical radiculopathy, and structural cervical disorders, may produce similar symptoms. Cervicogenic headache can interfere with daily activities, concentration, physical functioning, and overall quality of life.
The study is a randomized control trail. Participants are selected from the Physiotherapy Department of Sir Ganga Ram Hospital, Lahore. Thirty-four participants will be recruited from this hospital. Adult females from 18 to 45 years of age suffering from cervicogenic headache (CGH) are included in this study. The participants will experience a headache for a minimum period of 3 months and palpable tenderness of upper cervical muscles. Those who had migraine, previous cervical surgery, cervical fracture, tumor, infection, radiculopathy, or disc herniation are excluded.
The intervention is conducted over a period of six weeks among 34 female participants with cervicogenic headache, who were randomly allocated into two equal groups: Group A received Strain Counterstrain (SCS), and Group B received Post-Isometric Relaxation (PIR), with 17 participants in each group. In Group A, the therapist identified tender myofascial points in the upper cervical region, particularly around C1-C3, including the suboccipital muscles, upper trapezius, and levator scapulae. The cervical spine is gently positioned in a comfortable position of ease using appropriate flexion, extension, rotation, or side-bending until tenderness decreased by approximately 70% or more. This position is maintained for approximately 90 seconds while the participant remained relaxed, after which the neck was slowly returned to the neutral position. In Group B, the therapist positioned the cervical spine toward the first restrictive barrier, and participants performed gentle isometric contractions against manual resistance at approximately 10-25% of maximum voluntary effort for 7-10 seconds, followed by 2-3 seconds of relaxation. The therapist then moved the cervical segment gently toward the new restrictive barrier, and the contraction-relaxation cycle was repeated three to five times according to the participant's tolerance and clinical response. Outcomes will be assessed at baseline, at the end of the third week, and at the end of the sixth week using the Numeric Pain Rating Scale (NPRS), Headache Impact Test-6 (HIT-6), and Headache Frequency Diary to evaluate changes in pain intensity, headache-related functional impact, and headache frequency.
192 studies on the registry are indexed under Post-Traumatic Headache; 54 are open to participants now.
This study's enrollment of 34 is below the median of 44 across 169 interventional studies indexed under Post-Traumatic Headache.
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Exclusion Criteria:
Strain Counterstrain (SCS) is provided over a period of six weeks, and the outcomes were assessed at baseline, the end of the third week, and the end of the sixth week. During each treatment session, the physiotherapist identified tender myofascial points in the upper cervical region, particularly around C1-C3, including the suboccipital, upper trapezius, and levator scapulae muscles. The therapist then gently positioned the participant's neck into a comfortable position of ease using appropriate side-bending, rotation, flexion, or extension, depending on the location of the tender point. The position was adjusted until tenderness decreased by approximately 70% or more and was maintained for about 90 seconds while the participant remained relaxed and avoided voluntary muscle movements. Afterward, the therapist slowly and passively returned the neck to the neutral position. The procedure was performed gently.
Other: Strain Counterstrain
Post-Isometric Relaxation (PIR) was provided over a period of six weeks, and the outcomes were assessed at baseline, at the end of the third week, and at the end of the sixth week. During each treatment session, the physiotherapist positioned the participant's cervical spine toward the first restrictive barrier in the direction of the identified movement restriction. The participant was then instructed to perform a gentle isometric contraction against the therapist's manual resistance, using approximately 10-25% of maximum voluntary effort, for 7-10 seconds while breathing normally and avoiding movement of other body parts. After the contraction, the participant was asked to relax the involved muscles completely for 2-3 seconds. The therapist then gently moved the cervical segment toward the new restrictive barrier without causing pain or overstretching. This contraction-relaxation cycle was repeated 3-5 times per treatment session, depending on the participant's tolerance and clinica
Other: Post Isometric Relaxation
Post-Isometric Relaxation (PIR) was provided over a period of six weeks, and the outcomes were assessed at baseline, at the end of the third week, and at the end of the sixth week. During each treatment session, the physiotherapist positioned the participant's cervical spine toward the first restrictive barrier in the direction of the identified movement restriction. The participant was then instructed to perform a gentle isometric contraction against the therapist's manual resistance, using approximately 10-25% of maximum voluntary effort, for 7-10 seconds while breathing normally and avoiding movement of other body parts. After the contraction, the participant was asked to relax the involved muscles completely for 2-3 seconds. The therapist then gently moved the cervical segment toward the new restrictive barrier without causing pain or overstretching. This contraction-relaxation cycle was repeated 3-5 times per treatment session, depending on the participant's tolerance and clinical
Strain Counterstrain (SCS) was provided over a period of six weeks, and the outcomes were assessed at baseline, the end of the third week, and the end of the sixth week. During each treatment session, the physiotherapist identified tender myofascial points in the upper cervical region, particularly around C1-C3, including the suboccipital, upper trapezius, and levator scapulae muscles. The therapist then gently positioned the participant's neck into a comfortable position of ease using appropriate side-bending, rotation, flexion, or extension, depending on the location of the tender point. The position was adjusted until tenderness decreased by approximately 70% or more and was maintained for about 90 seconds while the participant remained relaxed and avoided voluntary muscle movements
Pain Measured by Numeric Pain Rating Scale
It's an unidimensional pain scale, a self-reported measurement with an 11-point number rating that ranges from no pain (0) to the worst pain (10). Interpreted as mild (1-3), moderate (4-6), or severe (7-10).
Time frame: AT Baseline to 6 weeks
Headache episode measured by the Headache Frequency Diary
Headache episodes will be recorded using the Headache Frequency Diary each week, which includes the number, duration, characteristics, triggers, and functional impact of headache attacks. Headache frequency was classified into 4 groups: 0-1, 2-3, 4-5, and 6-7 episodes per week
Time frame: AT Baseline to 6 weeks
Headache-Related Quality of Life and Functional Impact
The overall effect of headache on participant's functioning and quality of life was measured using the Headache Impact Test (HIT-6™). The six items are answered on a scale ranging from never (6) to always (13) with five answer options for each item. The total score is from 36 points to 78 points, with higher scores representing a higher impact on headaches in daily life. A score of ≤49 indicates little or no impact, 50-55 indicates some impact, 56-59 indicates substantial impact, and 60-78 indicates severe impact. The HIT-6 has shown good psychometric properties, including high internal consistency (Cronbach's α = 0.89-0.90) and good test-retest reliability (ICC = 0.78-0.80) over 14 days. It has been validated by its correlation with known QOL instruments such as the SF-8, SF-36, and MIDAS. The instrument was 93.1% sensitive and 79.4% specific at a cut-off point of ≥56, with an overall classification accuracy of 88.7% for migraine impact.
Time frame: AT Baseline to 6 weeks
Plan to share: No
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