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