scapulae muscles. The patient also had tenderness upon palpation of the left C1-C3 facet joints. Based on her history and examination findings, our working diagnosis was cervicogenic headache. (Note: This case report was written as part of a third-year chiropractic course, Evi-dence-Informed Chiropractic Practice, at D’Youville College. As such, the report herein was based on a patient scenario rather than an actual patient.) Due to the patient’s concerns about her current treatment plan of prescribed NSAIDs during pregnancy, she sought out alternative treatment, specifically chiropractic, in the hope of finding an alternative to pharmaceuticals. To use an evidence-based approach to inform the management of this case, we posed the following foreground question: In a 28-year-old pregnant female with wors-ening chronic cervicogenic headaches, is cervical spinal manipulative therapy (SMT) more effective than NSAIDs at reducing the severity and frequency of headache symptoms? Using the mnemonic, PICO (i.e., P atient/problem, I ntervention, C om-parison, and O utcome[s] of interest), this question can be broken down as follows: P 28-year-old pregnant female with cervicogenic headaches; I Cervical SMT; C NSAIDs; O Reduced severity and frequency of headache symptoms CLINICAL QUESTION systematic review did not contain stud-ies directly comparing manual therapy to NSAIDs, we conducted an additional search using a combination of the key terms, ‘headache’ AND ‘NSAID.’ We filtered this search to systematic reviews and studies published between 2004 and 2021. This search resulted in 103 articles. We added the Boolean operator AND with the term ‘cervicogenic,’ but no additional articles were found. Therefore, the term ‘migraine’ was combined with ‘headache’ (in parenthe-ses) and connected using the Boolean operator OR, and we removed the term ‘NSAID’ from our search string, replac-ing it with the term ‘Ibuprofen.’ Because this search resulted in a large number of citations involving studies of children, the term ‘children’ was added and con-nected to our search string using the Boolean operator NOT. This resulted in 19 citations. A systematic review of low-dose Ibuprofen for the treatment of acute migraines7 was chosen because the other results either did not focus on headache conditions that were similar to cervicogenic headache (e.g., cluster, tension), or they involved post-operative pain management. The systematic re-view also focused on an NSAID that the patient was taking to relieve pain from a headache condition. The entire litera-ture search, including retrieval of man-uscripts, took less than 30 minutes. LITERATURE SEARCH The best evidence to answer a clinical question about therapy is a systematic review of randomized controlled trials.5 Therefore, a search of the English lan-guage literature (from January 1, 2012 to June 5, 2021) was conducted using the National Library of Medicine (Pu-bMed) database. Because our interest was in cervicogenic headaches, the key term ‘cervicogenic’ was used and our search settings were filtered to ‘system-atic reviews’ and studies published be-tween 2004 and 2021. This search yielded 65 results. The truncated term ‘chiropr*’ was then added with the Boolean operator ‘AND,’ bringing the search yield down to 13 citations. A systematic review of manual therapies for cervicogenic headache6 published in 2012 was chosen because, of the 13 ci-tations, it was most pertinent to our PICO question. However, because the www.Cndoctor.ca CRITICAL EVALUATION OF THE EVIDENCE Both systematic reviews retrieved showed evidence of reduced headache pain using manipulation or Ibuprofen. However, before these results could be applied to the current patient, both systematic reviews were first appraised using a template provided by the Criti-cal Appraisal Skills Program (CASP).8 Specifically, the papers were appraised with respect to their (i) validity, (ii) importance, and (iii) applicability to the treatment of cervicogenic headaches in the current patient. (i) Are the results of these system-atic reviews valid? Both articles by Chiabi and Russell(6) and Suthisisang et al.(7) were system-atic reviews that included patients with cervicogenic or migraine headache di-agnoses and who had received an inter-vention. Both included a methods sec-tion that described searching multiple databases and finding relevant rand-omized controlled trials, which are the most appropriate study design for evaluating interventions. However, Chi-abi and Russell(6) only evaluated stud-ies that were written in English while Suthisisang et al.(7) did not have any language restrictions, thereby reducing the potential for selection bias. Both reviews also assessed the quality of in-cluded articles using validated appraisal tools. In both reviews, the results of all included studies were clearly displayed in evidence tables or in a forest plot. Due to clinical heterogeneity however, the results were not combined in the Chiabi and Russell(6) review, whereas they were combined in the Suthisisang et al.(7) review using a meta-analysis. Therefore, based on the above criteria, the results of both reviews were deemed valid. (ii) Are the valid results of these systematic reviews important? The results were deemed important for 2 main reasons. First, in 5 out of 6 man-ual therapy trials in the Chiabi and Russell review patients receiving cervi-cal SMT, on average, experienced sta-tistically (p < 0.05) and/or clinically significant within-group improvements in headache symptoms (i.e., pain, dura-tion and/or frequency) from baseline to last follow-up. In terms of statistical significance, this means that the proba-bility the observed differences or out-comes occurred by pure chance was less than 5%. The follow-up periods in the included studies ranged anywhere from immediately post-treatment up to 12 months after. In 4 of these 5 studies, there were statistically and/or clinically significant between-group differences as well, favouring the SMT group. In fact, the magnitude of clinical improvements across these studies ranged anywhere from approximately 5% to greater than 50%. [A change of 30% or greater is generally considered to be a clinically meaningful improvement for patients with painful musculoskeletal conditions. (9)] In other words, across these 4 stud-ies, patients were consistently reporting a decrease in headache symptoms after receiving SMT, and in many cases by a clinically meaningful amount, while patients in the placebo or control groups were not reporting similar findings. The only study that did not show any statis-tically or clinically significant March/April 2022 Chiropractic and Naturopathic Doctor 21
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