There are many types of headache and each has an underlying cause that must be addressed to achieve a satisfactory outcome. A 2020 review of research from the previous two decades suggests that the best conservative, non-pharmaceutical approach for headaches may involve either a top-down or bottom-up approach.

When the primary cause of a headache is musculoskeletal in nature, the review found that a bottom-up approach is more likely to benefit the patient. For example, cervicogenic headaches are headaches caused by dysfunction in the cervical spine. A headache in this category will likely respond well to cervical spinal manipulation and other forms of manual therapy provided by doctors of chiropractic. Tension-type headaches can have several underlying causes, but tight muscles in the back of the neck tend to be common, and treatment to relax the affected muscles can help reduce headache frequency and intensity.

While research to understand migraines is ongoing, the cause of this form of headache is believed to rest in chemical interactions in the brain. As such, the investigators reported that a top-down approach involving cognitive behavioral therapy, biofeedback, and neuroscience education may offer the most benefit to the patient.

Because each case is unique and headaches can have multiple underlying or contributing causes (they can also co-occur), the authors note that the ideal bottom-up/top-down treatments will depend on the doctor’s clinical reasoning and experience. That is, there is no one size fits all. For example, there are several studies showing that migraine headache patients may experience reduced headache frequency and intensity after receiving manual therapies to address trigger points in their cervical muscles (a bottom-up approach).

The authors conclude that a multi-modal approach may be the most effective way to manage migraine, tension-type, cervicogenic, and other types of headaches. Such an approach may include spinal manipulation, spinal mobilization (non-thrust), soft-tissue therapies (massage, trigger point therapy, stretching, myofascial release), needling (wet & dry needling of trigger points and/or acupuncture), general exercise, targeted exercise, and cognitive interventions.

Most chiropractors embrace and utilize all or at least many of these non-drug treatment strategies when managing patients with headaches, though they may co-manage with other healthcare providers if necessary.