Neck Manipulation vs. Ibuprofen: New Evidence on Dissection Risk

Millions of Americans suffer from neck pain and headaches each year. Two common treatment approaches are NSAIDs, such as ibuprofen, and cervical manipulation. In a 2023-2024 survey of U.S. adults, 22.3% reported using ibuprofen during the preceding week,² while approximately 10% of US adults see a chiropractor each year.

Clinical guidelines recommend both treatments because they are effective and among the safest options available. But safe doesn’t mean without the risk of side effects. For ibuprofen, mild side effects include Gl issues, headaches, and dizziness. Rarer, but also more serious risks, include severe stomach bleeding and an increased risk of heart attack and stroke.¹

A U.S. modeling study of nonprescription pain relievers estimated 64 additional deaths per million ibuprofen users per year even when used according to label directions, drawing on 2006-2008 mortality data and published risk estimates for gastrointestinal hemorrhage and kidney failure.⁷ Current OTC ibuprofen labeling warns that severe stomach bleeding and cardiovascular events, including heart attack and stroke, can be fatal.¹

Regarding cervical manipulation, common side effects include temporary musculoskeletal pain, stiffness, dizziness, and headache. Although there are case reports of vertebral artery dissection (VAD) or stroke following cervical manipulation, a recent study concluded “the likely risk of dissection associated with chiropractic manipulations is very low.”¹⁰

The question is whether or not cervical manipulation causes VAD or a VAD is already in progress when the patient presents for chiropractic care. A new study comparing cervical artery dissection risk among patients receiving cervical manipulation and those prescribed ibuprofen sheds new light on this question.

SMT vs. Ibuprofen: New Findings

Published in Chiropractic & Manual Therapies, this retrospective cohort study, co-authored by Robert J. Trager, DC; Anthony N. Baumann; Christine M. Goertz, DC, PhD; and colleagues, used linked U.S. health records and insurance claims from 2010-2025 to identify adults seeking care for a new episode of neck pain or headache. They compared chiropractor-administered cervical spinal manipulative therapy (SMT) with outpatient ibuprofen prescribing over a 30-day window following treatment. The study included a matched cohort of nearly 863,000 patients, with approximately 431,500 in each group.⁶

During those 30 days, cervical artery dissection (CeAD) was diagnosed in 31 patients in the SMT group (0.007%) and 58 in the ibuprofen group (0.013%), a difference that was not statistically significant. Study authors concluded that they found no evidence of increased CeAD risk after chiropractor-administered cervical SMT compared with an ibuprofen prescription.⁶

Although the new study’s observational design cannot rule out that there were unmeasured differences between groups, its results align with earlier evidence against the proposed causal relationship between cervical manipulation and VAD.⁶

The Evidence Before This Study

Regarding cervical manipulation, Cassidy and colleagues examined vertebrobasilar stroke across more than 100 million person-years. They found that the association with a recent chiropractic visit in younger patients resembled the association with a recent primary care visit. They concluded that patients with an evolving dissection may seek care for its early neck pain or headache.³

Haldeman and colleagues showed how referral and selection bias can shape clinicians’ perceptions of rare events reported after manipulation.⁴ Herzog and colleagues measured vertebral artery strain during cervical manipulation and found it substantially below strain during ordinary neck movement and reported arterial failure thresholds.⁵ A later U.S. case-control study by Kosloff and colleagues likewise found no significant association between chiropractic visits and vertebrobasilar stroke.⁸ Together, these studies address epidemiologic, perceptual and biomechanical aspects of the claimed causal link.

What This Study Adds

Neck pain and headache, both individually and co-occurring, are common reasons to seek chiropractic care. Each can also be an early sign of CeAD. An unrecognized dissection already in progress can bring a patient into a chiropractic clinic. If a stroke then occurs following cervical manipulation, some may assume that the manipulation caused the stroke.

The 2026 analysis brings a large matched cohort and a recognizable medical comparator to a debate too often framed around isolated temporal associations. Among these patients with new neck pain or headache, cervical SMT was not associated with a higher subsequent CeAD rate than care involving an ibuprofen prescription.⁶

Christine Goertz, DC, PhD, professor at Duke University School of Medicine and a co-author of this study, says she is often asked whether cervical manipulation is safe. As quoted in U.S. News & World Report, Dr. Goertz had this to say, "This study is some of the best evidence yet that the answer to that question is yes."⁹

References

1. Ibuprofen 200 mg tablet: OTC drug label. U.S. National Library of Medicine, 2026.
2. Green JL, Dailey-Govoni T, Kalidindi SD, Vosburg SK. Prevalence of over-the-counter and prescription medication use in the US. JAMA Netw Open, 2026;9(2):e2559479.
3. Cassidy JD, Boyle E, Côté P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine, 2008;33(4 Suppl):S176-S183.
4. Haldeman S, Carey P, Townsend M, Papadopoulos C. Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias. Spine J, 2002;2(5):334-342.
5. Herzog W, Leonard TR, Symons B, Tang C, Wuest S. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. J Electromyogr Kinesiol, 2012;22(5):740-746.
6. Trager RJ, Baumann AN, Labak CM, et al. Association between spinal manipulative therapy and cervical artery dissection in patients with neck pain or headache: a retrospective cohort study. Chiropr Man Therap, 2026;34:53.
7. Rothman KJ, Lanza LL. Estimated risks of fatal events associated with acetaminophen, ibuprofen, and naproxen sodium used for analgesia. Adv Pharmacoepidemiol Drug Saf, 2013;2(1):124.
8. Kosloff TM, Elton D, Tao J, Bannister WM. Chiropractic care and the risk of vertebrobasilar stroke: results of a case-control study in U.S. commercial and Medicare Advantage populations. Chiropr Man Therap, 2015;23:19.
9. “Chiropractic Neck Adjustments Do Not Raise Risk of Rare Artery Tear, Study Finds.” U.S. News & World Report, Sept. 23, 2026.
10. Aleyadeh R, Marialuisa Z, Pedro Marto J, et al. Abstract DP059: Incidence and clinical characteristics of cervical artery dissection following chiropractic cervical manipulation: a sub-analysis of the STOP-CAD study. Presented at the American Stroke Association's 2026 International Stroke Conference and State-of-the-Science Stroke Nursing Symposium 2026.