Comparative Effectiveness of Intermittent Neuromuscular Electrical Stimulation Versus High-Fruit-and-Vegetable Dietary Intervention as Complementary Therapies in Cervicogenic Headache Management: A Randomized Controlled Trial with Mechanistic Outcomes

Abstract

Cervicogenic Headache (CGH), originating from cervical musculoskeletal dysfunction and associated neuropathological cascades, represents a significant clinical burden affecting 2.5-4.1% of the global population with limited evidence-based complementary intervention strategies. This randomized controlled trial evaluated the comparative effectiveness of Intermittent Neuromuscular Electrical Stimulation (INES) versus High Fruit-and-Vegetable (HFV) dietary intervention as adjuncts to standard physiotherapy in 84 adults with chronic cervicogenic headache (mean duration 18.4±5.2 months).

Participants were stratified and allocated to three parallel groups: standard care alone (SC, n=28), SC combined with INES (n=28), or SC combined with HFV dietary protocol (n=28) for 12 weeks with 4-week follow-up assessment. Primary outcome measures encompassed headache intensity (Numerical Pain Rating Scale, NRS 0-10), headache frequency (days per month), and cervical range of motion. Secondary measures included Neck Disability Index (NDI), Pressure Pain Threshold (PPT) at cervical landmarks, upper cervical mobility (flexion-rotation test), serum inflammatory biomarkers (interleukin-6, C-reactive protein, tumor necrosis factor-alpha), and cervical proprioception assessed via active head repositioning test. Quantitative outcome assessment occurred at baseline, 6 weeks, 12 weeks, and 4-week follow-up. Both interventions significantly outperformed standard care (p<0.001). INES demonstrated superior efficacy for acute pain reduction, with mean NRS improvement of 4.2±1.1 points compared to HFV reduction of 2.9±1.0 points (p=0.002) and headache frequency decrease of 12.3±3.2 days/month versus 9.1±2.8 days for HFV (p=0.003). Conversely, HFV intervention yielded enhanced anti-inflammatory benefits, reducing serum CRP by 2.1±0.7 mg/L and IL-6 by 1.9±0.6 pg/mL (p <0.05), with sustained pressure pain threshold improvements of 1.8±0.5 kPa. INES facilitated faster neuromuscular modulation with trajectory superiority evident by week 6, whereas HFV demonstrated progressive systemic anti-inflammatory effects with delayed but durable outcomes. Graph analysis revealed distinct intervention trajectories: INES showed acute neuromuscular benefits with plateau at week 8, while HFV exhibited linear progressive improvement throughout the 12-week intervention period. Combined analysis suggests complementary mechanistic pathways - INES addressing neuromuscular dysfunction and proprioceptive deficiency, while HFV targets systemic neurogenic inflammation and central sensitization mechanisms. These findings support investigation of combined approaches for comprehensive cervicogenic headache management addressing both immediate neuromuscular dysfunction and underlying inflammatory pathophysiology [1-4].

Keywords: Cervicogenic Headache; Neuromuscular Electrical Stimulation; Dietary Intervention; Polyphenol-Rich Diet; Inflammatory Biomarkers; Cervical Proprioception; Mechanistic Outcomes; Complementary Physiotherapy

Citation

Nagamanikandan R, Muthukrishnan P. Comparative Effectiveness of Intermittent Neuromuscular Electrical Stimulation Versus High-Fruit-and Vegetable Dietary Intervention as Complementary Therapies in Cervicogenic Headache Management: A Randomized Controlled Trial with Mechanistic Outcomes. WebLog J Musculoskelet Disord. wjmd.2026. b2602. https://doi.org/10.5281/zenodo.18870263