FEATURE improvements among SMT patients involved cervical SMT that was per-formed by medical physicians rather than chiropractors, and this may have attenuated the outcome. Second, the pooled results in the Su-thisisang et al. review(7) showed that patients taking Ibuprofen (400 mg) ex-perienced statistically and clinically sig-nificant reductions in headache pain within 2 hours compared to placebo. The risk ratios (RRs) for Ibuprofen (400 mg) showed patients on average were 89% more likely to have pain relief (i.e., pain intensity that reduced from severe or moderate down to mild or none) after 2 hours (RR = 1.89; 95% confidence interval [CI], 1.45 to 2.46) and greater than twice as likely to be pain-free at 2 hours (RR = 2.15; 95% CI, 1.24 to 3.73). Extrapolating these findings to the gen-eral population, we can be 95% confi-dent that had the total population of acute migraine patients been included (iii) Are the valid, important results of these systematic reviews applica-ble to this patient? In the Chiabi and Russell review(6), cervical SMT was performed in 5 of the 6 studies on adults (age 18 or older) who had not received manipulative therapy in the last 12 months and had suffered from cervicogenic headache, as diag-nosed according to Cervicogenic Head-ache International Study Group (CHISG) criteria. Therefore, the age and symptomatology of patients in these 5 studies were similar to the age and headache symptomatology of our pa-tient. In Suthisisang et al.(7), all study participants were 16 years of age or older and suffered from migraine attacks, an analogous headache condition with similar symptomatology to cervicogenic headache. Therefore, because of their clinical commonality, we can assume that the evidence of effectiveness of Ibuprofen on migraines likely provides headache symptoms, whether that be for pain intensity or headache duration. However, this patient is worried about the potential risks or complications of NSAID use during pregnancy. In our review of Chiabi and Russell (6) data from 4 studies of nearly 400 patients showed the following: (1) cervi-cal SMT resulted in a 50% decrease in pain for between 47% and 71% of cases, while 33% had complete resolution of pain symptoms; (2) by 4-week follow-up, the duration of cervicogenic headaches decreased in 60% of those treated, and 53% still had a decrease in headache duration after 12 weeks; and (3) the in-tensity of headaches decreased in 36% to 58% of patients by 4 weeks, with 56% having a decrease in headache frequency as well. Therefore, because SMT has the potential to provide patients with clini-cally meaningful pain relief – although with less certainty or magnitude than that of Ibuprofen (400 mg) – including in some cases, sustained effects (i.e., weeks of positive benefits versus hours), we would have recommended that this patient consider a trial of chiropractic care, as there is good potential it could give her pain relief and decreased head-ache frequency without the use of NSAID medications. For instance, the findings of Chiabi and Russell(6) also demonstrated that in 1 study of 200 patients, the consumption of NSAIDs was significantly reduced from pre-treat-ment to post-treatment (i.e., 93% of patients had a reduced median medica-tion intake after 12 months in the study). SUMMARY In this case, a 28-year-old woman pre-sented with signs and symptoms sugges-tive of cervicogenic headache while pregnant. By using the results of 2 sys-tematic reviews, in combination with the patient’s values and clinical circum-stances, we deemed that cervical SMT was the preferred treatment option over anti-inflammatory medication. Our re-port illustrates how research literature can be used in clinical practice, particu-larly for helping to inform the manage-ment of an individual patient. Please note the full article, including Evaluation of the Outcome, Limitations, and full Reference List is available at cndoctor.ca/EBreport-cervicogenic-headache www.Cndoctor.ca “...this patient is worried about the potential risks...of NSAID use during pregnancy.” in this systematic review, headache suf-ferers would be between 45% and nearly 2.5 times more likely to have pain relief, or between 24% and 3.7 times more likely to have been pain-free, within 2 hours of taking Ibuprofen (400 mg) as opposed to taking a placebo. The RR for sustained pain-relief (i.e., headache re-lief beyond 24 hours) was even higher, but not statistically significant because its 95% CI range included the value of 1.0, which in this case equates to no difference (RR = 3.26; 95% CI, 0.48 to 22.08). This demonstrated that not every patient in these studies was able to stop the headaches from reoccurring long-term with Ibuprofen (400 mg). However, some patients did achieve clinically significant sustained pain-re-lief, as evidenced by the wide CI range that included values of 30% or greater. Therefore, both systematic reviews showed statistically and/or clinically significant improvements in headache symptoms or frequency with their inter-ventions. evidence of effectiveness of NSAIDs on cervicogenic headaches. As such, the results from the 2 systematic reviews were deemed applicable to our patient. APPLICATION OF THE EVIDENCE Had this case report been written for the purposes of managing an actual patient, we would have told our patient that, based on research evidence from over 3,500 patients( 7), taking 400 mg of Ibu-profen will result in between a 45% and 2.5-fold greater likelihood of getting pain relief, or between a 24% and 3.7-fold greater likelihood of being pain-free, within 2 hours compared to taking a placebo. There is also potential for sus-tained relief of their headaches beyond 24 hours (i.e., up to over 22 times as likely), but there is also a chance their headaches will reoccur within 24 hours if they do not continue to take Ibuprofen (i.e., 52% increased risk of recurrence). Therefore, there is a good likelihood of at least temporary and clinically signifi-cant pain relief with Ibuprofen for 22 Chiropractic and Naturopathic Doctor March/April 2022
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