Neck-shoulder region training for chronic headache in women: a randomized controlled trial

Key points

1. 01Headache frequency dropped by 47% in the exercise group versus 32% in the placebo control group, a statistically significant between-group difference (p = 0.017).
2. 02Pain intensity decreased slightly in both groups with no significant between-group difference (p = 0.66), so the exercise program did not reduce headache intensity more than placebo.
3. 03Neck disability (Neck Disability Index) improved more in the exercise group (between-group change -1.6 points, 95% CI -3.1 to -0.2).
4. 04Neck flexor endurance improved 60% in the exercise group versus 11% in the control group, and cervical rotation increased by 8 degrees more in the exercise group.
5. 05The program was well-tolerated with only two adverse events (worsened headache/neck pain and back pain) in the exercise group.

How it was conducted

Design

Two-center randomized controlled trial, 6 months

Participants

116 working-age women aged 18-60 with chronic headache (at least 8 headache days per 4 consecutive weeks, Headache Impact Test score 56+)

Exercise group (n=57)

Home-based progressive 6-module neck-shoulder training program performed 4-6 times per week, instructed by physical therapists

Control group (n=59)

Six monthly sessions of placebo-dosed transcutaneous electrical nerve stimulation (less than 10 mA) plus stretching exercises from session 3 onward

Primary outcome

Headache pain intensity via Numeric Pain Rating Scale (0-10), captured in weekly diaries

Secondary outcomes

Headache frequency and duration per week; neck disability via Neck Disability Index; neck muscle endurance and range of motion

What they found

• Headache frequency decreased from 4.5 to 2.4 days/week in the exercise group versus 4.4 to 3.0 days/week in the control group (between-group p = 0.017, effect size d = 0.53).
• Headache frequency reduction was 47% in the exercise group and 32% in the control group.
• Pain intensity decreased by -0.6 (SD 1.3) in the exercise group and -0.4 (SD 1.3) in the control group, with no between-group difference (p = 0.66, effect size d = 0.17).
• Headache duration decreased by 11.3 hours/week in the exercise group and 5.6 hours/week in the control group, with no significant between-group difference (p = 0.24, effect size d = 0.27).
• Neck flexor endurance time increased 22 seconds more in the exercise group than controls (95% CI 11 to 33, p < 0.0002).
• Neck extensor test: 93% of the exercise group versus 71% of controls achieved the 180-second maximum after 6 months (odds ratio 9.2, 95% CI 2.0 to 42.1).
• Cervical spine rotation improved 8 degrees more in the exercise group (95% CI 1 to 15).
• Neck Disability Index declined 1.6 points more in the exercise group (95% CI -3.1 to -0.2).
• Headache Impact Test declined -2.0 points more in the exercise group (95% CI -4.3 to 0.2, not statistically significant).

Limitations

• Headache intensity was chosen as the primary outcome based on older guidance; more recent literature recommends headache frequency as the primary endpoint, meaning the trial was not powered or primarily designed around its most clinically meaningful finding.
• Physical therapists assessing outcomes were not blinded to group assignment, introducing potential measurement bias.
• The sample included mixed headache types (tension-type, cervicogenic, and migraine), and results may not apply equally to each subgroup.
• The placebo control received individual attention from a therapist, which may have contributed to the 32% improvement in headache frequency in the control group, making it harder to isolate the specific effect of exercise.

Why it matters

For patients

Women with chronic headache who want a non-drug option may find that a structured home neck-shoulder exercise program can meaningfully reduce how many days per week they experience headache, even if it does not reduce how painful each episode feels.

For clinicians

A progressive 6-month neck-shoulder strengthening program can be recommended as a safe adjunct treatment for working-age women with chronic headache; the program almost halved weekly headache frequency with a moderate effect size (d = 0.53) and improved neck function.

For readers

This is one of the largest RCTs applying a single-component progressive exercise program for chronic headache, supporting exercise as a feasible and safe treatment, though the lack of effect on pain intensity and mixed headache diagnoses limit generalisability.