The effectiveness of physiotherapy and manipulation in patients with tension-type headache: a systematic review

Effectiveness of manual therapy for chronic tension-type headache: A pragmatic, randomised, clinical trial

Objective: To evaluate the effectiveness of manual therapy (MT) in participants with chronic tension-type headache (CTTH).

Subjects and Methods: We conducted a multicentre, pragmatic, randomised, clinical trial with partly blinded outcome assessment. Eighty-two participants with CTTH were randomly assigned to MT or to usual care by the general practitioner (GP). Primary outcome measures were frequency of headache and use of medication. Secondary outcome measures were severity of headache, disability and cervical function.

Results: After 8 weeks ( n = 80) and 26 weeks ( n = 75), a significantly larger reduction of headache frequency was found for the MT group (mean difference at 8 weeks, −6.4 days; 95% CI −8.3 to −4.5; effect size, 1.6). Disability and cervical function showed significant differences in favour of the MT group at 8 weeks but were not significantly different at 26 weeks.

Conclusions: Manual therapy is more effective than usual GP care in the short- and longer term in reducing symptoms of CTTH. Dutch Trial Registration no. TR 1074.

Physical examination and self-reported pain outcomes from a randomized trial on chronic cervicogenic headache

OBJECTIVE

Objective clinical measures for use as surrogate markers of cervicogenic headache (CGH) pain have not been established. In this analysis, we investigate relationships between objective physical examination (PE) measures with self-reported CGH outcomes.

METHODS

This is an exploratory analysis of data generated by attention control PE from an open-label randomized clinical trial. Of 80 subjects, 40 were randomized to 8 treatments (spinal manipulative therapy or light massage control) and 8 PE over 8 weeks. The remaining subjects received no PE. Physical examination included motion palpation of the cervical and upper thoracic regions, active cervical range of motion (ROM) and associated pain, and algometric pain threshold evaluated over articular pillars. Self-reported outcomes included CGH and neck pain and disability, number of CGH headaches, and related disability days. Associations between PE and self-reported outcomes were evaluated using generalized linear models, adjusting for sociodemographic differences and study group.

RESULTS

At baseline, number of CGH and disability days were strongly associated with cervical active ROM (P < .001 to .037). Neck pain and disability were strongly associated with ROM-elicited pain (P < .001 to .035) but not later in the study. After the final treatment, pain thresholds were strongly associated with week 12 neck pain and disability and CGH disability and disability days (P < or = .001 to .048).

CONCLUSIONS

Cervical ROM was most associated with the baseline headache experience. However, 4 weeks after treatment, algometric pain thresholds were most associated. No one PE measure remained associated with the self-reported headache outcomes over time.

Effectiveness of manual therapies: the UK evidence report

BACKGROUND

The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions.

METHODS

The conclusions are based on the results of systematic reviews of randomized clinical trials (RCTs), widely accepted and primarily UK and United States evidence-based clinical guidelines, plus the results of all RCTs not yet included in the first three categories. The strength/quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs.

RESULTS

By September 2009, 26 categories of conditions were located containing RCT evidence for the use of manual therapy: 13 musculoskeletal conditions, four types of chronic headache and nine non-musculoskeletal conditions. We identified 49 recent relevant systematic reviews and 16 evidence-based clinical guidelines plus an additional 46 RCTs not yet included in systematic reviews and guidelines.Additionally, brief references are made to other effective non-pharmacological, non-invasive physical treatments.

CONCLUSIONS

Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic.

Dose response and efficacy of spinal manipulation for chronic cervicogenic headache: a pilot randomized controlled trial

BACKGROUND CONTEXT

Systematic reviews of randomized controlled trials suggest that spinal manipulative therapy (SMT) is efficacious for care of cervicogenic headache (CGH). The effect of SMT dose on outcomes has not been studied.

PURPOSE

To compare the efficacy of two doses of SMT and two doses of light massage (LM) for CGH.

PATIENT SAMPLE

Eighty patients with chronic CGH.

MAIN OUTCOME MEASURES

Modified Von Korff pain and disability scales for CGH and neck pain (minimum clinically important difference=10 on 100-point scale), number of headaches in the last 4 weeks, and medication use. Data were collected every 4 weeks for 24 weeks. The primary outcome was the CGH pain scale.

METHODS

Participants were randomized to either 8 or 16 treatment sessions with either SMT or a minimal LM control. Patients were treated once or twice per week for 8 weeks. Adjusted mean differences (AMD) between groups were computed using generalized estimating equations for the longitudinal outcomes over all follow-up time points (profile) and using regression modeling for individual time points with baseline characteristics as covariates and with imputed missing data.

RESULTS

For the CGH pain scale, comparisons of 8 and 16 treatment sessions yielded small dose effects: |AMD|</=5.6. There was an advantage for SMT over the control: AMD=-8.1 (95% confidence interval=-13.3 to -2.8) for the profile, -10.3 (-18.5 to -2.1) at 12 weeks, and -9.8 (-18.7 to -1.0) at 24 weeks. For the higher dose patients, the advantage was greater: AMD=-11.9 (-19.3 to -4.6) for the profile, -14.2 (-25.8 to -2.6) at 12 weeks, and -14.4 (-26.9 to -2.0) at 24 weeks. Patients receiving SMT were also more likely to achieve a 50% improvement in pain scale: adjusted odds ratio=3.6 (1.6 to 8.1) for the profile, 3.1 (0.9 to 9.8) at 12 weeks, and 3.1 (0.9 to 10.3) at 24 weeks. Secondary outcomes showed similar trends favoring SMT. For SMT patients, the mean number of CGH was reduced by half.

CONCLUSIONS

Clinically important differences between SMT and a control intervention were observed favoring SMT. Dose effects tended to be small.

A randomized, placebo-controlled clinical trial of chiropractic and medical prophylactic treatment of adults with tension-type headache: results from a stopped trial

OBJECTIVES

Tension-type headache (TTH) is the most common headache experienced by adults in Western society. Only 2 clinical trials of spinal manipulation for adult tension-type headache have been reported, neither of which was fully controlled. In 1 trial, spinal manipulation was compared to amitriptyline. There is an urgent need for well-controlled studies of chiropractic spinal manipulation for TTH. This trial was stopped prematurely due to poor recruitment. The purposes of this report are (1) to describe the trial protocol, as it contained several novel features, (2) to report the limited data set obtained from our sample of completed subjects, and (3) to discuss the problems that were encountered in conducting this study.

METHODS

A randomized clinical trial was conducted with a factorial design in which adult TTH sufferers with more than 10 headaches per month were randomly assigned to four groups: real cervical manipulation + real amitriptyline, real cervical manipulation + placebo amitriptyline, sham cervical manipulation + real amitriptyline, and sham cervical manipulation + placebo amitriptyline. A baseline period of four weeks was followed by a treatment period of 14 weeks. The primary outcome was headache frequency obtained from a headache diary in the last 28 days of the treatment period.

RESULTS

Nineteen subjects completed the trial. In the unadjusted analysis, a statistically significant main effect of chiropractic treatment was obtained (-2.2 [-10.2 to 5.8], P = .03) which was just below the 3-day reduction set for clinical importance. As well, a clinically important [corrected] effect of the combined therapies was obtained (-9 [-20.8 [corrected] to 2.9], P = .13), but this did not achieve statistical significance. In the adjusted analysis, neither the main effects of chiropractic nor amitriptyline were statistically significant or clinically important; however, the effect of the combined treatments was -8.4 (-15.8 to -1.1) which was statistically significant (P = .03) and reached our criterion for clinical importance.

CONCLUSION

Although the sample size was smaller than initially required, a statistically significant and clinically important effect was obtained for the combined treatment group. There are considerable difficulties with recruitment of subjects in such a trial. This trial should be replicated with a larger sample.

Chronic tension-type headache: what is new?

PURPOSE OF REVIEW

This review discusses current data on nosological boundaries related to diagnosis, pathophysiology and therapeutic strategies in chronic tension-type headache (CTTH).

RECENT FINDINGS

Diagnostic criteria of CTTH should be adapted to improve its sensitivity against migraine. It seems that mechanical pain sensitivity is a consequence and not a causative factor of CTTH. Recent evidence is modifying previous knowledge about relationships between muscle tissues and CTTH, suggesting a potential role of muscle trigger points in the genesis of pain. An updated pain model suggests that headache perception can be explained by referred pain from trigger points in the craniocervical muscles, mediated through the spinal cord and the trigeminal nucleus caudalis rather than only tenderness of the muscles themselves. Different therapeutic strategies, pharmacological, physical therapy, psychological and acupuncture, are generally used. The therapeutic efficacy of nonsteroidal anti-inflammatory drugs remains incomplete. The tricyclic antidepressants are the most used first-line therapeutic agents for CTTH. Surprisingly, few controlled studies have been performed and not all of them have found an efficacy superior to placebo. Further, there is insufficient evidence to support/refute the efficacy of physical therapy in CTTH.

SUMMARY

Although there is an increasing scientific interest in CTTH, future studies incorporating subgroups of patients who will likely to benefit from a specific treatment (clinical prediction rules) should be conducted.

Pharmacotherapy and Lifestyle Interventions for Tension-Type Headaches

The objective of this review was to evaluate the efficacy of pharmacotherapy and lifestyle interventions for tension-type headaches. Literature was obtained through a MEDLINE (1966 to April 2008) search and a bibliographic review of published articles. Key terms searched included tension-type headaches, chronic tension-type headaches, pharmacotherapy, and lifestyle therapy. The search was further limited to the English language. Tension-type headaches are the most common and least studied primary headache disorder. These headaches are characterized by mild to moderate bilateral pain that is described as dull, aching, and bandlike. Episodic tension-type headaches may be treated with mild analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen; although treatment should be individualized, data suggest that NSAIDs may be considered first line. Chronic and frequent episodic tension-type headaches often require prophylactic therapy. Although tricyclic antidepressants are considered the drugs of choice for chronic tension-type headaches, preliminary trials with venlafaxine, mirtazapine, tizanidine, and topiramate have shown promise. Lifestyle interventions such as physical therapy, behavioral therapy, and acupuncture are often employed, despite the lack of sound clinical evidence to support their use. Preliminary data support the combination of a tricyclic antidepressant and behavioral therapy for chronic tension-type headache.

Effectiveness of manual therapy compared to usual care by the general practitioner for chronic tension-type headache: design of a randomised clinical trial

Background

Patients with Chronic Tension Type Headache (CTTH) report functional and emotional impairments (loss of workdays, sleep disturbances, emotional well-being) and are at risk for overuse of medication. Manual therapy may improve symptoms through mobilisation of the spine, correction of posture, and training of cervical muscles.

We present the design of a randomised clinical trial (RCT) evaluating the effectiveness of manual therapy (MT) compared to usual care by the general practitioner (GP) in patients with CTTH.

Methods and design

Patients are eligible for participation if they present in general practice with CTTH according to the classification of the International Headache Society (IHS).

Participants are randomised to either usual GP care according to the national Dutch general practice guidelines for headache, or manual therapy, consisting of mobilisations (high- and low velocity techniques), exercise therapy for the cervical and thoracic spine and postural correction. The primary outcome measures are the number of headache days and use of medication. Secondary outcome measures are severity of headache, functional status, sickness absence, use of other healthcare resources, active cervical range of motion, algometry, endurance of the neckflexor muscles and head posture. Follow-up assessments are conducted after 8 and 26 weeks.

Discussion

This is a pragmatic trial in which interventions are offered as they are carried out in everyday practice. This increases generalisability of results, but blinding of patients, GPs and therapists is not possible.

The results of this trial will contribute to clinical decision making of the GP regarding referral to manual therapy in patients with chronic tension headache.

Predictor variables for identifying patients with chronic tension-type headache who are likely to achieve short-term success with muscle trigger point therapy

To date, no studies have investigated the predictive validity of variables from the initial examination to identify patients with tension-type headache pain who are likely to benefit from muscle trigger point (TrP) therapy. The purpose of this study was to develop a preliminary clinical prediction rule (CPR) to identify chronic tension-type headache (CTTH) patients who are likely to experience a successful response from TrP therapy. Consecutive patients with CTTH underwent a standardized examination and then received six sessions of TrP therapy over 3 weeks (two sessions per week). They were classified as having experienced a successful outcome at short-term (1 week after discharge) and 1-month follow-up based on a 50% reduction on at least one headache parameter (intensity, frequency or duration) and self-report perceived recovery. Potential predictor variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for identifying treatment success. Data from 35 patients were included, of which 19 (55%) experienced a successful outcome. A CPR with four variables for short-term (headache duration < 8.5 h/day, headache frequency < 5.5 days/week, bodily pain < 47 and vitality < 47.5) and a CPR with two variables for 1-month (headache frequency < 5.5 days/week and bodily pain < 47) follow-up were identified. At short-term follow-up, if three of four variables [positive likelihood ratio (LR) 3.4] were present, the chance of experiencing a successful outcome improved from 54% to 80%, and if all the variables (positive LR 5.9) were present, the probability of success was 87.4%. At 1-month follow-up, if one of two variables (positive LR 2.2) was present, the probability of success increased from 54% to 72%, and if both variables (positive LR 4.6) were present, the probability of success was 84.4%. The present CPR provides the potential to identify CTTH patients who are likely to experience short-term and 1-month follow-up success with a muscle TrP therapy approach. Future studies are necessary to validate the CPR.

A meta-regression analysis shows no impact of design characteristics on outcome in trials on tension-type headaches

OBJECTIVES

In the conduct of a systematic review or meta-analysis, many possible sources of bias exist, such as bias caused by design characteristics. We studied the influence of the methodological study characteristics of randomized clinical trials (RCTs) on the outcome in a systematic review on conservative treatments in patients with tension-type headache (TTH).

STUDY DESIGN AND SETTING

Included were RCTs from a systematic review on TTH, which were a control group receiving a placebo or no treatment and presented data on recovery or headache severity, intensity, or frequency. Design characteristics were assessed using the Delphi list. Regression analysis is performed on separate design characteristics on size of treatment effect.

RESULTS

Out of the original data set of 146 trials, 61 trials fulfilled our selection criteria. The number of trials presenting only dichotomous data was larger than trials presenting only continuous data. All study characteristics show a nonsignificant relation with the effect estimate. Whether outcome is presented dichotomous or continuous appears to have a significant impact on treatment effect estimates.

CONCLUSION

In this study, sample design characteristics do not show to have an impact on treatment effect estimates, but the way the treatment effect is measured has a significant impact.

Tension-type headache: current research and clinical management

Tension-type headache (TTH) is the most common form of headache, and chronic tension-type headache (CTTH) is one of the most neglected and difficult types of headache to treat. The pathogenesis of TTH is multifactorial and varies between forms and individuals. Peripheral mechanisms (myofascial nociception) and central mechanisms (sensitisation and inadequate endogenous pain control) are intermingled: the former predominate in infrequent and frequent TTH, whereas the latter predominate in CTTH. Acute therapy is effective for episodes of TTH, whereas preventive treatment--which is indicated for frequent and chronic TTH--is, on average, not effective. For most patients with CTTH, the combination of drug therapies and non-drug therapies (such as relaxation and stress management techniques or physical therapies) is recommended. There is clearly an urgent need to improve the management of patients who are disabled by headache. This Review summarises the present knowledge on TTH and discusses some of its more problematic features.

Scales to assess the quality of randomized controlled trials: a systematic review

BACKGROUND AND PURPOSE

The methodological quality of randomized controlled trials (RCTs) is commonly evaluated in order to assess the risk of biased estimates of treatment effects. The purpose of this systematic review was to identify scales used to evaluate the methodological quality of RCTs in health care research and summarize the content, construction, development, and psychometric properties of these scales.

METHODS

Extensive electronic database searches, along with a manual search, were performed.

RESULTS

One hundred five relevant studies were identified. They accounted for 21 scales and their modifications. The majority of scales had not been rigorously developed or tested for validity and reliability. The Jadad Scale presented the best validity and reliability evidence; however, its validity for physical therapy trials has not been supported.

DISCUSSION AND CONCLUSION

Many scales are used to evaluate the methodological quality of RCTs, but most of these scales have not been adequately developed and have not been adequately tested for validity and reliability. A valid and reliable scale for the assessment of the methodological quality of physical therapy trials needs to be developed.

Management of functional somatic syndromes

Although functional somatic syndromes (FSS) show substantial overlap, treatment research is mostly confined to single syndromes, with a lack of valid and generally accepted diagnostic criteria across medical specialties. Here, we review management for the full variety of FSS, drawn from systematic reviews and meta-analyses since 2001, and give recommendations for a stepped care approach that differentiates between uncomplicated and complicated FSS. Non-pharmacological treatments involving active participation of patients, such as exercise and psychotherapy, seem to be more effective than those that involve passive physical measures, including injections and operations. Pharmacological agents with CNS action seem to be more consistently effective than drugs aiming at restoration of peripheral physiological dysfunction. A balance between biomedical, organ-oriented, and cognitive interpersonal approaches is most appropriate at this truly psychosomatic interface. In view of the iatrogenic component in the maintenance of FSS, doctor-centred interventions and close observation of the doctor-patient relationship are of particular importance.

Combination of low-dose mirtazapine and ibuprofen for prophylaxis of chronic tension-type headache

Chronic headaches are difficult to treat and represent the biggest challenge in headache centres. Mirtazapine has a prophylactic and ibuprofen an acute effect in tension-type headache. Combination therapy may increase efficacy and lower side effects. We aimed to evaluate the prophylactic effect of a combination of low-dose mirtazapine and ibuprofen in chronic tension-type headache. Ninety-three patients were included in the double-blind, placebo-controlled, parallel trial. Following a 4-week run-in period they were randomized to four groups for treatment with a combination of mirtazapine 4.5 mg and ibuprofen 400 mg, placebo, mirtazapine 4.5 mg or ibuprofen 400 mg daily for 8 weeks. Eighty-four patients completed the study. The primary efficacy parameter, change in area under the headache curve from run-in to the last 4 weeks of treatment, did not differ between combination therapy (190) and placebo (219), P = 0.85. Explanatory analyses revealed worsening of headache already in the third week of treatment with ibuprofen alone. In conclusion, the combination of low-dose mirtazapine and ibuprofen is not effective for the treatment of chronic tension-type headache. Moreover, the study suggests that daily intake of ibuprofen worsens headache already after few weeks in chronic tension-type headache.

Tension-type headache: the most common, but also the most neglected, headache disorder

PURPOSE OF REVIEW

Tension-type headache is the most common type of headache and, in its chronic form, one of the most neglected and difficult types of headache to treat. Recently published data will be reviewed.

RECENT FINDINGS

The prevalence of frequent tension-type headache increased significantly from 1989 to 2001, and several risk factors have been identified. The incidence decreases markedly with age. The prognosis is fairly favorable for the episodic forms. Chronic tension-type headache, coexisting migraine, sleep problems and not being married were identified as risk factors for a poor outcome. Previous reports of sensitization of the central nervous system in patients with chronic tension-type headache were confirmed by the findings of generalized pain hypersensitivity both in skin and in muscles, and of a decrease in the volume of gray matter in brain structures. A promising new animal model of tension-type headache has been developed. In addition, the efficacy of a prophylactic drug, mirtazapine, with fewer side-effects than the tricyclic antidepressants has been demonstrated.

SUMMARY

The new data on the prevalence, incidence and prognosis of tension-type headache are valuable for health care planning and in daily clinical practice. The increased knowledge with regard to abnormal central pain modulation, together with the development of an animal model, hold promise for much-needed improvements in the understanding of pathophysiological mechanisms and treatment.

Characteristics and Treatment of Headache After Traumatic Brain Injury

Headache is one of the most common complaints in patients with traumatic brain injury. By definition, headache that develops within 1 wk after head trauma (or within 1 wk after regaining consciousness) is referred to as posttraumatic headache (PTH). Although most PTH resolves within 6-12 mos after injury, approximately 18-33% of PTH persists beyond 1 yr. We performed a systematic literature review on this topic and found that many patients with PTH had clinical presentations very similar to tension-type headache (37% of all PTH) and migraine (29% of all PTH). Although there is no universally accepted protocol for treating PTH, many clinicians treat PTH as if they were managing primary headache. As a result of the heterogeneity in the terminology and paucity in prospective, well-controlled studies in this field, there is a definite need for conducting double-blind, placebo-controlled treatment trials in patients with PTH.

A systematic review of systematic reviews of spinal manipulation

OBJECTIVES

To systematically collate and evaluate the evidence from recent systematic reviews of clinical trials of spinal manipulation.

DESIGN

Literature searches were carried out in four electronic databases for all systematic reviews of the effectiveness of spinal manipulation in any indication, published between 2000 and May 2005. Reviews were defined as systematic if they included an explicit and repeatable inclusion and exclusion criteria for studies.

RESULTS

Sixteen papers were included relating to the following conditions: back pain (n=3), neck pain (n=2), lower back pain and neck pain (n=1), headache (n=3), non-spinal pain (n=1), primary and secondary dysmenorrhoea (n=1), infantile colic (n=1), asthma (n=1), allergy (n=1), cervicogenic dizziness (n=1), and any medical problem (n=1). The conclusions of these reviews were largely negative, except for back pain where spinal manipulation was considered superior to sham manipulation but not better than conventional treatments.

CONCLUSIONS

Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.

Traumatic Brain Injury and Pain

The co-occurrence of traumatic brain injury (TBI) and pain is quite frequent and presents a number of challenges to the medical practitioner. The distinct nature and extent of these challenges calls for considering the co-existence of TBI and pain a unique medical entity. Clearly, from a research standpoint, the area is in its infancy. The clinician is often left with adapting standard techniques effective for evaluating and treating pain in patients without TBI. Such adaptations require a readiness to recognize how pain affects the presence and course of TBI-related symptoms and, in turn, how TBI symptoms affect the presence and course of pain. Given the myriad factors that can affect outcome, effective evaluation and treatment of this co-occurring problem need to rely on a biopsychosocial model, which encourages consideration of a broad perspective of possible causes and care approaches as well as use of multiple disciplines.