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Dynamic Chiropractic – July 16, 2005, Vol. 23, Issue 15

FCER Responds to New Guidelines on Headache Standards of Care

By Editorial Staff
Editor's note: The Foundation for Chiropractic Education and Research (FCER) posted the following on its Web site in response to recent guidelines on headache standards of care issued by the National Guideline Clearinghouse (NGC). An initiative of the Agency for Healthcare Research and Quality, the NGC is essentially a database of evidence-based clinical practice guidelines. Its stated mission is "to provide physicians and other health professionals, health care providers, health plans, integrated delivery systems, purchasers, and others an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines and to further their dissemination, implementation and use."

A recent set of guidelines posted by the National Guideline Clearinghouse and bearing the seal of the Agency for Healthcare Research and Quality1 is both mystifying and distressing in its conclusions. Based upon a chapter by Mauskop and Graff-Radford,2 these guidelines review seven primary headache types and conclude that spinal manipulation (chiropractic and osteopathic care) is not effective and of "questionable" safety, whereas full endorsement seems to be apparent for such alternative interventions as the use of feverfew, riboflavin, or botulinum toxin type A.

Mauskop's chapter states that "the value and cost-effectiveness of chiropractic, osteopathic medicine, and physical therapy in migraine [emphasis added] have not been proven in clinical trials. Conflicting results and poor clinical trial design limit the ability to judge the effectiveness of manipulative treatments. Physical therapy, although limited in its study, has proven more effective than manipulative treatment in such cases."1

To begin, it is unclear how these National Headache Guidelines have extrapolated Mauskop's statement specifically addressing migraine to encompass seven primary headache types regarding spinal manipulation.

Regarding spinal manipulation - particularly that administered by chiropractic - this assessment is so much in conflict with the preceding indexed literature and its methodological quality that its gross inaccuracy must be brought to light. A wealth of information regarding efficacy, safety, cost, and distinction from physical therapy exists in the literature to seriously question all aspects of Mauskop's assessment as it pertains to chiropractic care. Each of these elements is discussed in a detailed report currently under review for publication in a journal. (When published, information on finding the full report will be available at

In contrast and also bearing the AHRQ imprimatur is the Duke headache study, which recognizes evidence supporting spinal manipulation, but not physical therapy.3 Since the Duke study was issued, no published evidence has appeared to suggest that physical therapy rather than spinal manipulation now profits from even a limited superior evidence base, as implied by both the National Headache Foundation Web site1 and its core report.2 Why the AHRQ should now endorse this report, which seems to provide diametrically opposing conclusions to those of its previous publication3 regarding spinal manipulation, without a convincing literature foundation is beyond comprehension.

Numerous arguments from studies conducted from the viewpoints of insurers, workers' compensation plans, and economists all provide ample refutation to the contention of this report2 and its Web site1 that spinal manipulation is not cost-effective. In the absence of convincing studies to the contrary, the null hypothesis must therefore remain in contention.

The National Headache Foundation also seems to believe that physical therapy rather than spinal manipulation may be of possible benefit. However, from the combined vantage points of volume of procedure, safety and performance evaluation, chiropractors rather than physical therapists would appear to be the clinicians of choice to perform spinal manipulation - the clinical value of which is amply supported in the medical literature.

Indeed, from the clinical evidence reported to date, in no instance does it seem warranted to suggest that spinal manipulation is less documented than physiotherapy for managing headaches. In overall terms of efficacy, safety and cost drawn from the back pain, as well as the headache literature, there is every reason to suggest that spinal manipulation is in fact a viable and well-documented alternative to managing at least some types of headache (cervicogenic, tension, and migraine), at a minimum. The conclusions of both the National Headache Foundation Web site1 and the report on which it is based2 regarding spinal manipulation have thus been found to be largely unfounded as well as misleading. They must therefore be greeted with extreme skepticism.


  1. Retrieved May 10, 2005.
  2. Mauskop A, Graff-Radford S. Special treatment situations: alternative headache treatments. In: Standards of Care for Headache Diagnosis and Treatment. Chicago, IL: National Headache Foundation, 2004, pp. 115-121.
  3. McCrory DC, Penzien DB, Hasselblad V, Gray RN. Evidence Report: Behavioral and Physical Treatments for Tension-Type and Cervicogenic Headache. Des Moines, IA: Foundation for Chiropractic Education and Research, 2001.

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