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

Exercise and Manual Therapy for the Treatment of Primary Headache: An Umbrella and Mapping Review

OBJECTIVE

The main aim of this study was to assess through systematic review the efficacy of exercise and manual therapy (MT) interventions in individuals with primary headache.

METHODS

In this umbrella review, 2 authors reviewed systematic reviews by searching the Cochrane Database of Systematic Reviews, MEDLINE, PEDro, Web of Science, and Google Scholar. Systematic reviews that evaluated the effectiveness of MT. Exercise-based interventions, or both in patients with primary headaches were included. Methodological quality was analyzed using the ROBIS scale, and the strength of evidence was established according to the Grading Criteria of the Physical Activity Guidelines Advisory Committee.

RESULTS

Thirty-one systematic reviews containing 79 trials and involving 9103 patients were included. The 7 exercise-related systematic reviews reported beneficial effects on primary headache based on unclear to moderate evidence. Of the 23 MT-related systematic reviews, 11 reported enhanced effectiveness compared with usual care; however, overall heterogeneity and risk of bias were high. Systematic reviews that evaluated the effectiveness of MT, exercise-based interventions, or both in patients with primary headaches were included.

CONCLUSION

Results show that exercise could be an effective therapy for the treatment of primary headache, with moderate to limited quality of evidence regarding the positive effects in terms of pain intensity and frequency and duration of headache. Moderate quality of evidence was found regarding the ability of MT to reduce pain intensity in patients with tension-type headaches, but quality of evidence was limited in terms of frequency of headache and disability and pain reduction in patients with migraine.

IMPACT

Exercise could be an effective treatment in patients with primary headache. Manual therapy showed limited evidence to reduce pain intensity in patients with tension-type headache. It is not possible to establish a preferential exercise protocol or MT program, so psychosocial and behavioral variables need to be considered in future studies.

Manual therapy in adults with tension-type headache: A systematic review

INTRODUCTION

Tension-type headache is the most common primary headache, with a high prevalence and a considerable socioeconomic impact. Manual physical therapy techniques are widely used in the clinical field to treat the symptoms associated with tension-type headache. This systematic review aims to determine the effectiveness of manual and non-invasive therapies in the treatment of patients with tension-type headache.

DEVELOPMENT

We conducted a systematic review of randomised controlled trials in the following databases: Brain, PubMed, Web of Science, PEDro, Scopus, CINAHL, and Science Direct. Ten randomised controlled trials were included for analysis. According to these studies, manual therapy improves symptoms, increasing patients' well-being and improving the outcome measures analysed.

CONCLUSIONS

Manual therapy has positive effects on pain intensity, pain frequency, disability, overall impact, quality of life, and craniocervical range of motion in adults with tension-type headache. None of the techniques was found to be superior to the others; combining different techniques seems to be the most effective approach.

Advances in the Understanding of Pathophysiology of TTH and its Management

Background

Tension-type headache (TTH) is the most common form of primary headache.

Objective

The aim of this study was to document and summarize the advances in the understanding of TTH in terms of pathogenesis and management.

Material and Methods

We reviewed the available literature on the pathogenesis and management of TTH by searches of PubMed between 1969 and October 2020, and references from relevant articles. The search terms "tension-type headache", "episodic tension-type headache", chronic tension-type headache, "pathophysiology", and "treatment" were used.

Results

TTH occurs in two forms: episodic TTH (ETTH) and chronic TTH (CTTH). Unlike chronic migraine, CTTH has been less thoroughly studied and is a more difficult headache to treat. Frequent ETTH and CTTH are associated with significant disability. The pathogenesis of TTH is multifactorial and varies between the subtypes. Peripheral mechanism (myofascial nociception) and environmental factors are possibly more important in ETTH, whereas genetic and central factors (sensitization and inadequate endogenous pain control) may play a significant role in the chronic variety. The treatment of TTH consists of pharmacologic and non-pharmacologic approaches. Simple analgesics like NSAIDs are the mainstays for acute management of ETTH. CTTH requires a multimodal approach. Preventive drugs like amitriptyline or mirtazapine and non-pharmacologic measures like relaxation and stress management techniques and physical therapies are often combined. Despite these measures, the outcome remains unsatisfactory in many patients.

Conclusion

There is clearly an urgent need to understand the pathophysiology and improve the management of TTH patients, especially the chronic form.

Clinical Reasoning Behind Non-Pharmacological Interventions for the Management of Headaches: A Narrative Literature Review

Headache is the clinical syndrome most commonly observed by neurologists in daily practice. Pharmacological and non-pharmacological treatments are commonly used for the management of headaches; however, the clinical reasoning behind these interventions is not properly applied. We conducted a narrative literature review using as data sources for academic PubMed, MEDLINE, EMBASE, AMED, CINAHL, EBSCO, PEDro, Cochrane Database of Systematic Reviews, Cochrane Collaboration Trials Register, and SCOPUS. This narrative literature review mainly considered systematic reviews, meta-analyses, randomised clinical trials, and expert opinions published after the year 2000 discussing clinical reasoning for application of non-pharmacological interventions in individuals with tension-type, migraine, and cervicogenic headaches. After the data extraction, we organized the literature thematically as follows: (1) mapping of theoretical aspects of non-pharmacological interventions; (2) summarizing most updated literature about effectiveness of non-pharmacological interventions grouped by targeted tissue and headache; (3) identifying research gaps in the existing literature and proposing hypotheses for better understanding of current clinical reasoning. We found that there are many non-pharmacological treatment strategies used for headaches, including beyond the tissue-based impairment treatments (bottom-up) and strategies targeting the central nervous system (top down). Bottom-up strategies include joint-biased, soft-tissue biased, or needling interventions, whereas top-down strategies include exercise and cognitive interventions. Evidence shows that the effectiveness of these interventions depends on the application of proper clinical reasoning, since not all strategies are effective for all headaches. For instance, evidence of non-pharmacological interventions is more controversial for migraines than for tension-type or cervicogenic headaches, since migraine pathogenesis involves activation of sub-cortical structures and the trigemino- vascular system, whereas pathogenesis of tension-type or cervicogenic headaches is most associated to musculoskeletal impairments of the cervical spine. We conclude that current literature suggests that not all non-pharmacological interventions are effective for all headaches, and that multimodal, not isolated, approaches seem to be more effective for patients with headaches. Most published studies have reported small clinical effects in the short term. This narrative literature review provides some hypotheses for discrepancies in the available literature and future research. Clinical reasoning should be applied to better understand the effects of non-pharmacological interventions.

Manual Therapy and Quality of Life in People with Headache: Systematic Review and Meta-analysis of Randomized Controlled Trials

PURPOSE OF REVIEW

People with headache usually experienced significantly lower health-related quality of life (HRQoL) than the healthy subjects. The goal of this systematic review was to evaluate the effectiveness of manual therapy on HRQoL in patients with tension-type headache (TTH), migraine (MH) or cervicogenic headache (CGH).

RECENT FINDINGS

We searched randomized controlled trials (RCTs) on MEDLINE, COCHRANE and PEDro databases. Treatment was manual therapy compared to usual care or placebo. The outcome was the HRQoL that could be measured by Headache Impact Test (HIT-6), Headache Disability Inventory (HDI), Migraine Disability Assessment Questionnaire (MIDAS) and Short Form Health Survey 12/36 (SF-12/36). For the RCT internal validity, we used the Cochrane risk of bias (RoB) tool. For the level of evidence, we used the Grading of Recommendations, Assessment, Development and Evaluation approach (GRADE). We identified a total of 10 RCTs, 7 of which were included into the meta-analysis. For HIT-6 scale, meta-analysis showed statistically significant differences in favour to manual therapy both after treatment (mean difference (MD) - 3.67; 95% CI from - 5.71 to - 1.63) and at follow-up (MD - 2.47; 95% CI from - 3.27 to - 1.68). For HDI scale, meta-analysis showed statistically significant differences in favour to manual therapy both after treatment (MD - 4.01; 95% CI from - 5.82 to - 2.20) and at follow-up (MD - 5.62; 95% CI from - 10.69 to - 0.54). Other scales provided inconclusive results. Manual therapy should be considered as an effective approach in improving the quality of life in patients with TTH and MH, while in patients with CGH, the results were inconsistent. Those positive results should be considered with caution due to the very low level of evidence. Researchers should in future design primary studies using valid and reliable disease-specific outcome measures.

Effectiveness of Trigger Point Manual Treatment on the Frequency, Intensity, and Duration of Attacks in Primary Headaches: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

A variety of interventions has been proposed for symptomatology relief in primary headaches. Among these, manual trigger points (TrPs) treatment gains popularity, but its effects have not been investigated yet.

Objective

The aim was to establish the effectiveness of manual TrP compared to minimal active or no active interventions in terms of frequency, intensity, and duration of attacks in adult people with primary headaches.

Methods

We searched MEDLINE, COCHRANE, Web Of Science, and PEDro databases up to November 2017 for randomized controlled trials (RCTs). Two independent reviewers appraised the risk-of-bias (RoB) and the grading of recommendations, assessment, development, and evaluation (GRADE) to evaluate the overall quality of evidence.

Results

Seven RCTs that compared manual treatment vs minimal active intervention were included: 5 focused on tension-type headache (TTH) and 2 on Migraine (MH); 3 out of 7 RCTs had high RoB. Combined TTH and MH results show statistically significant reduction for all outcomes after treatment compared to controls, but the level of evidence was very low. Subgroup analysis showed a statistically significant reduction in attack frequency (no. of attacks per month) after treatment in TTH (MD −3.50; 95% CI from −4.91 to −2.09; 4 RCTs) and in MH (MD −1.92; 95% CI from −3.03 to −0.80; 2 RCTs). Pain intensity (0–100 scale) was reduced in TTH (MD −12.83; 95% CI from −19.49 to −6.17; 4 RCTs) and in MH (MD −13.60; 95% CI from −19.54 to −7.66; 2RCTs). Duration of attacks (hours) was reduced in TTH (MD −0.51; 95% CI from −0.97 to −0.04; 2 RCTs) and in MH (MD −10.68; 95% CI from −14.41 to −6.95; 1 RCT).

Conclusion

Manual TrPs treatment of head and neck muscles may reduce frequency, intensity, and duration of attacks in TTH and MH, but the quality of evidence according to GRADE approach was very low for the presence of few studies, high RoB, and imprecision of results.

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.

The risk associated with spinal manipulation: an overview of reviews

BACKGROUND

Spinal manipulative therapy (SMT) is a widely used manual treatment, but many reviews exist with conflicting conclusions about the safety of SMT. We performed an overview of reviews to elucidate and quantify the risk of serious adverse events (SAEs) associated with SMT.

METHODS

We searched five electronic databases from inception to December 8, 2015. We included reviews on any type of studies, patients, and SMT technique. Our primary outcome was SAEs. Quality of the included reviews was assessed using a measurement tool to assess systematic reviews (AMSTAR). Since there were insufficient data for calculating incidence rates of SAEs, we used an alternative approach; the conclusions regarding safety of SMT were extracted for each review, and the communicated opinion were judged by two reviewers independently as safe, harmful, or neutral/unclear. Risk ratios (RRs) of a review communicating that SMT is safe and meeting the requirements for each AMSTAR item, were calculated.

RESULTS

We identified 283 eligible reviews, but only 118 provided data for synthesis. The most frequently described adverse events (AEs) were stroke, headache, and vertebral artery dissection. Fifty-four reviews (46%) expressed that SMT is safe, 15 (13%) expressed that SMT is harmful, and 49 reviews (42%) were neutral or unclear. Thirteen reviews reported incidence estimates for SAEs, roughly ranging from 1 in 20,000 to 1 in 250,000,000 manipulations. Low methodological quality was present, with a median of 4 of 11 AMSTAR items met (interquartile range, 3 to 6). Reviews meeting the requirements for each of the AMSTAR items (i.e. good internal validity) had a higher chance of expressing that SMT is safe.

CONCLUSIONS

It is currently not possible to provide an overall conclusion about the safety of SMT; however, the types of SAEs reported can indeed be significant, sustaining that some risk is present. High quality research and consistent reporting of AEs and SAEs are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015030068 .

Combined transcranial and trans-spinal direct current stimulation in chronic headache: A feasibility and safety trial for a novel intervention

Background:

Chronic primary headache disorders are associated with frequent, severe pain and significant functional impairment, with treatment remaining challenging.

Objective:

We examined the feasibility and safety of a novel brain [transcranial direct current stimulation (tDCS)] and spinal cord stimulation [trans-spinal cord direct current stimulation (tsDCS)] treatment in chronic headache.

Methods:

Nine participants (3 males; aged, 40 ± 15 years) suffering from chronic daily headache, chronic tension-type headache, or chronic migraine received the combined brain and spinal cord intervention for 5 consecutive days. Stimulation was applied for a total of 40 minutes (20 minutes of tDCS followed by 20 minutes of tsDCS) at 1 mA. Pain sensitivity and headache symptoms (frequency, severity, duration, and medications recorded via a headache diary, 4 weeks before and after treatment) were assessed.

Results:

The treatment was safe, feasible, and well tolerated. Headache frequency was reduced following the treatment (p = 0.026) in chronic tension-type headache and chronic migraine, but not in chronic daily headache. Headache severity was reduced immediately post-treatment in 67% of sessions. A trend towards a reduction in medication use was observed (p = 0.075). No changes in headache severity (p = 0.16) or duration (p = 0.34) were present.

Conclusion:

These data suggest that combined tDCS and tsDCS intervention is safe and feasible, and may improve headache frequency in patients with chronic primary headache disorders.

THE EFFECT OF BODY AWARENESS THERAPY AND AEROBIC EXERCISES ON PAIN AND QUALITY OF LIFE IN THE PATIENTS WITH TENSION TYPE HEADACHE

BACKGROUND

This study is to investigate the effect of Body Awareness Therapy (BAT) and Aerobic Exercises on pain and quality of life in patients with Tension-Type Headache (TTH).

MATERIALS AND METHOD

Sixty individuals with TTH diagnosis who referred Neurologist were incorporated into study. The individuals were randomly grouped into 3 as BAT (n=20), aerobic exercise (n=20) and control group (n=20). Pain severity of the individuals was evaluated by Visual Analog Scale (VAS) and pain diary, disability with ache; by Pain Disability Index (PDI) and Headache Impact Tests (HIT) and quality of life was evaluated by SF-36. Subsequent to first assessments, 3 sessions of 60 minutes per week throughout 6 weeks totally.

RESULTS

When the groups were compared at the end of the study, a significant decrease was observed in VAS, PDI and HIT values in the individuals in the BAT and aerobic exercise groups. With the individuals in group BAT and aerobic exercise all parameters of quality of life were observed to be increased significantly.

CONCLUSION

BAT and aerobic exercise programs to be applied on TTH patients were concluded to be important in decreasing the pain, in increasing the quality of life and in reducing pain-related daily constraints of the individuals.

The Possible Role of Meditation in Myofascial Pain Syndrome: A New Hypothesis

BACKGROUND OF HYPOTHESIS

Myofascial pain syndrome (MPS) is the most common musculoskeletal pain disorder of the head and neck area. In the past, several theories were put forth to explain its origin and nature, but none proved complete. Myofascial pain responds to changing psychological states and stress, anxiety, lack of sleep, anger, depression and chronic pain are direct contributional factors. Myofascial pain syndrome may be considered as a psychosomatic disorder. There are numerous accepted palliative approaches, but of all, relaxation techniques stand out and initiate healing at the base level. In this article, the connection between mental factors, MPS and meditation are highlighted. Recent literature has shed light on the fundamental role of free radicals in the emergence of myofascial pain. The accumulating free radicals disrupt mitochondrial integrity and function, leading to sustenance and progression of MPS. Meditation on the other hand was shown to reduce free radical load and can result in clinical improvement. 'Mindfulness' is the working principle behind the effect of all meditations, and I emphasize that it can serve as a potential tool to reverse the neuro-architectural, neurobiological and cellular changes that occur in MPS.

CONCLUSIONS

The findings described in this paper were drawn from studies on myofascial pain, fibromyalgia, similar chronic pain models and most importantly from self experience (experimentation). Till date, no hypothesis is available connecting MPS and meditation. Mechanisms linking MPS and meditation were identified, and this paper can ignite novel research in this direction.

Physical therapy for headaches

Background Headache is the medical problem most commonly observed by neurologists. Non-pharmacological treatments are commonly demanded by individuals with headaches, but their evidence of effectiveness is conflicting. Aim The current review provides an updated discussion on what is supported by current scientific evidence about physical therapies for tension-type headache (TTH), migraine, and cervicogenic headache (CeH), and which gaps there still may be in our understanding of the interventions. Methods PubMed, MEDLINE, EMBASE, AMED, CINAHL, EBSCO, Cochrane Database of Systematic Reviews, Cochrane Collaboration Trials Register, PEDro, and SCOPUS were searched from their inception through March 2015. Results/Discussion Several physical therapies including spinal joint manipulation/mobilization, soft tissue interventions, therapeutic exercises and needling therapies are proposed to be effective for the management of headaches. Current evidence has shown that the effectiveness of these interventions will depend on proper clinical reasoning since not all interventions are equally effective for all headache pain conditions. For instance, evidence of physical therapy in migraine is more controversial than in TTH, since migraine pathogenesis involves activation of sub-cortical structures and the trigemino-vascular system, whereas pathogenesis of TTH is more associated with musculoskeletal disorders, e.g. muscle pain. It seems that multimodal approaches including different interventions are more effective for patients with TTH, migraine and CeH.

Efficacy of Physiotherapy Including a Craniocervical Training Programme for Tension-Type Headache; A Randomized Clinical Trial

We conducted a multicentre, randomized controlled trial with blinded outcome assessment. The treatment period was 6 weeks with follow-up assessment immediately thereafter and after 6 months. The objective was to determine the effectiveness of a craniocervical training programme combined with physiotherapy for tension-type headache. Eighty-one participants meeting the diagnostic criteria for tension-type headache were randomly assigned to an exercise group (physiotherapy and an additional craniocervical training programme) and a control group (physiotherapy alone). The primary outcome measure was headache frequency. Secondary outcomes included headache intensity and duration, Quality of Life (SF-36) and the Multidimensional Headache Locus of Control scale (MHLC). At 6 months' follow-up, the craniocervical training group showed significantly reduced headache frequency, intensity and duration ( P < 0.001 for all). Effect sizes were large and clinically relevant. Loss to follow-up amounted to 3.7±. Physiotherapy including craniocervical training reduces symptoms of tension-type headache significantly over a prolonged time frame.

Spinal rehabilitative exercise or manual treatment for the prevention of tension-type headache in adults

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the short- and long-term effects of manual treatment and spinal rehabilitative exercise for the prevention of tension-type headache in adults.

Effectiveness of Physical Therapy in Patients with Tension-type Headache: Literature Review

BACKGROUND

Tension-type headache (TTH) is a disease with a great incidence on quality of life and with a significant socioeconomic impact.

OBJECTIVES

The aim of this review is to determine the effectiveness of physical therapy by using manual therapy (MT) for the relief of TTH.

DATA SOURCES

A review was done identifying randomized controlled trials through searches in MEDLINE, PEDro, Cochrane and CINAHL (January 2002 - April 2012).

STUDY SELECTION

English-language studies, with adult patients and number of subjects not under 11, diagnosed with episodic tension-type headache (ETTH) and chronic tension-type headache (CTTH) were included.

DATA EXTRACTION

Initial search was undertaken with the words Effectiveness, Tension-type headache, and Manual therapy (39 studies). In addition, a search which included terms related to treatments such as physiotherapy, physical therapy, spinal manipulation was performed (25 studies).

RESULTS

From the two searches 9 studies met the inclusion criteria and were analysed finding statistically significant results: 1) myofascial release, cervical traction, neck muscles trigger points in cervical thoracic muscles and stretching; 2) Superficial heat and massage, connective tissue manipulation and vertebral Cyriax mobilization; 3) cervical or thoracic spinal manipulation and cervical chin-occipital manual traction; 4) massage, progressive relaxation and gentle stretching, program of active exercises of shoulder, neck and pericranial muscles; 5) massage, passive rhythmic mobilization techniques, cervical, thoracic and lumbopelvic postural correction and cranio-cervical exercises; 6) progressive muscular relaxation combined with joint mobilization, functional, muscle energy, and strain/counterstrain techniques, and cranial osteopathic treatment; 7) massage focused on relieving myofascial trigger point activity; 8) pressure release and muscle energy in suboccipital muscles; 9) combination of mobilizations of the cervical and thoracic spine, exercises and postural correction. All studies used a combination of different techniques and none analyzed treatments separately, also all the studies have assessed aspects related to TTH beyond frequency and intensity of pain.

CONCLUSIONS

The findings from these studies showed evidence that physiotherapy with articulatory MT, combined with cervical muscle stretching and massage are effective for this disease in different aspects related with TTH. No evidence was found of the effectiveness of the techniques applied separately.

Multimodal manual therapy vs. pharmacological care for management of tension type headache: A meta-analysis of randomized trials

BACKGROUND

Manual therapies are generally requested by patients with tension type headache.

OBJECTIVE

To compare the efficacy of multimodal manual therapy vs. pharmacological care for the management of tension type headache pain by conducting a meta-analysis of randomized controlled trials.

METHODS

PubMed, MEDLINE, EMBASE, AMED, CINAHL, EBSCO, Cochrane Database of Systematic Reviews, Cochrane Collaboration Trials Register, PEDro and SCOPUS were searched from their inception until June 2014. All randomized controlled trials comparing any manual therapy vs. medication care for treating tension type headache adults were included. Data were extracted and methodological quality assessed independently by two reviewers. We pooled headache frequency as the main outcome and also intensity and duration. The weighted mean difference between manual therapy and pharmacological care was used to determine effect sizes.

RESULTS

Five randomized controlled trials met our inclusion criteria and were included in the meta-analysis. Pooled analyses found that manual therapies were more effective than pharmacological care in reducing frequency (weighted mean difference -0.8036, 95% confidence interval -1.66 to -0.44; three trials), intensity (weighted mean difference -0.5974, 95% confidence interval -0.8875 to -0.3073; five trials) and duration (weighted mean difference -0.5558, 95% confidence interval -0.9124 to -0.1992; three trials) of the headache immediately after treatment. No differences were found at longer follow-up for headache intensity (weighted mean difference -0.3498, 95% confidence interval -1.106 to 0.407; three trials).

CONCLUSION

Manual therapies were associated with moderate effectiveness at short term, but similar effectiveness at longer follow-up for reducing headache frequency, intensity and duration in tension type headache than pharmacological medical drug care. However, due to the heterogeneity of the interventions, these results should be considered with caution at this stage.

Part II--Management of pediatric post-traumatic headaches

BACKGROUND

Post-traumatic headache is one of the most common symptoms occurring after mild traumatic brain injury in children.

METHODS

This is an expert opinion-based two-part review on pediatric post-traumatic headaches. In part II, we focus on the medical management of post-traumatic headaches. There are no randomized controlled trials evaluating the efficacy of therapies specifically for pediatric post-traumatic headaches. Thus, the algorithm we propose has been extrapolated from the primary headache literature and small noncontrolled trials of post-traumatic headache.

RESULTS

Most post-traumatic headaches are migraine or tension type, and standard medications for these headache types are used. A multifaceted approach is needed to address all the possible causes of headache and any comorbid conditions that may delay recovery or alter treatment choices. For acute treatment, nonsteroidal anti-inflammatories can be used. If the headaches have migrainous features and nonsteroidal anti-inflammatories are not effective, triptans may be beneficial. Opioids are not indicated. Medication overuse should be avoided. For preventive treatments, some reports indicate that amitriptyline, gabapentin, or topiramate may be beneficial. Amitriptyline is a good choice because it can be used to treat both migraine and tension-type headaches. Nerve blocks, nutraceuticals (e.g. melatonin), and behavioral therapies may also be useful, and lifestyle factors, especially adequate sleep hygiene and strategies to cope with anxiety, should be emphasized.

CONCLUSIONS

Improved treatment of acute post-traumatic headache may reduce the likelihood of developing chronic headaches, which can be especially problematic to effectively manage and can be functionally debilitating.

Tension-Type Headache in Children: The Cinderella of Headache Disorders!

Tension-type headache (TTH) may be as common a headache disorder as migraine in children and adolescents. TTH has a neurobiological basis with genetic and environmental factors making variable contributions to the different sub-types. The diagnostic criteria for TTH in the second edition of the “International Classification of Headache Disorders” appear to be applicable to children. Anxiety and mood disorders may be co-morbid with frequent episodic and chronic TTH. Psychosocial stressors play an important role in precipitating and maintaining TTH. Hence, a biopsychosocial approach should be adopted for care. Standardized histories and examinations together with prospective headache diaries are the foundations for good management; attention to ‘red flags’ will help identify secondary causes that present with headache similar to TT. There are no randomized controlled drug trials for the treatment of TTH. Relaxation and cognitive behavioral therapies are effective. TTH in children and adolescents warrants greater recognition from the clinician and scientist. Studies focusing on TTH are overdue.

Manual therapies for primary chronic headaches: a systematic review of randomized controlled trials

This is to our knowledge the first systematic review regarding the efficacy of manual therapy randomized clinical trials (RCT) for primary chronic headaches. A comprehensive English literature search on CINHAL, Cochrane, Medline, Ovid and PubMed identified 6 RCTs all investigating chronic tension-type headache (CTTH). One study applied massage therapy and five studies applied physiotherapy. Four studies were considered to be of good methodological quality by the PEDro scale. All studies were pragmatic or used no treatment as a control group, and only two studies avoided co-intervention, which may lead to possible bias and makes interpretation of the results more difficult. The RCTs suggest that massage and physiotherapy are effective treatment options in the management of CTTH. One of the RCTs showed that physiotherapy reduced headache frequency and intensity statistical significant better than usual care by the general practitioner. The efficacy of physiotherapy at post-treatment and at 6 months follow-up equals the efficacy of tricyclic antidepressants. Effect size of physiotherapy was up to 0.62. Future manual therapy RCTs are requested addressing the efficacy in chronic migraine with and without medication overuse. Future RCTs on headache should adhere to the International Headache Society’s guidelines for clinical trials, i.e. frequency as primary end-point, while duration and intensity should be secondary end-point, avoid co-intervention, includes sufficient sample size and follow-up period for at least 6 months.

Pilot Trial of Osteopathic Manipulative Therapy for Patients With Frequent Episodic Tension-Type Headache

Context: Osteopathic manipulative therapy (OMTh; manipulative care provided by foreign-trained osteopaths) may be used for managing headache pain and related disability, but there is a need for high-quality randomized controlled trials to assess the effectiveness of this intervention.

Objective: To explore the efficacy of OMTh for pain management in frequent episodic tension-type headache (TTH).

Design: Single-blind randomized placebo-controlled pilot study.

Setting: Patients were recruited from 5 primary care settings.

Patients: Forty-four patients who were affected by frequent episodic TTH and not taking any drugs for prophylactic management of episodic TTH were recruited.

Interventions: Patients were randomly allocated to an experimental or control group. The experimental group received corrective OMTh techniques, tailored for each patient; the control group received assessment of the cranial rhythmic impulse (sham therapy). The study included a 1-month baseline period, a 1-month treatment period, and a 3-month follow-up period.

Main Outcome Measures: The primary outcome was the change in patient-reported headache frequency, and secondary outcomes included changes in headache pain intensity (discrete score, 1 [lowest perceived pain] to 5 [worst perceived pain]), over-the-counter medication use, and Headache Disability Inventory score.

Results: Forty patients completed the study (OMTh, n=21; control, n=19). The OMTh group had a significant reduction in headache frequency over time that persisted 1 month (approximate reduction, 40%; P<.001) and 3 months (approximate reduction, 50%; P<.001) after the end of treatment. Moreover, there was an absolute difference between the 2 treatment groups at the end of the study, with a 33% lower frequency of headache in the OMTh group (P<.001).

Conclusion: This feasibility study demonstrated the efficacy of OMTh in the management of frequent episodic TTH, compared with sham therapy in a control group. Osteopathic manipulative therapy may be preferred over other treatment modalities and may benefit patients who have adverse effects to medications or who have difficulty complying with pharmacologic regimens. This protocol may serve as a model for future studies.

Efficacy of manual therapy in the treatment of tension-type headache. A systematic review from 2000-2013

OBJECTIVES

To study the efficacy of manual therapy in the treatment of tension-type headache (TTH) by assessing the quality of randomized control trials (RCTs) published from the year 2000 to April 2013.

METHODS

A search was performed in the following databases: MEDLINE, EBSCO, CINAHL, SCOPUS, PEDRO and OVID. An analysis was made of RCT including patients with TTH receiving any manual therapy, and assessing outcome measures including the intensity, and frequency or duration of the headache. Two independent referees reviewed the methodological quality of RCTs using the Jadad scale. Data from the studies were extracted by two different reviewers.

RESULTS

A total of fourteen RCTs were selected. Twelve studies showed acceptable quality (Jadad scale ≥3), and the remaining 2 had low quality (Jadad=2). The studies showed positive results, including reduction in headache intensity and/or frequency, reduction of medication consumption, and improvement in quality of life.

CONCLUSIONS

The effectiveness of manual therapy for TTH cannot be completely assessed due to the heterogeneity in study design, outcome measures, and different treatments. Nevertheless, the results suggest patients with TTH receiving manual therapies showed better progress than those receiving conventional treatment or placebo. Further studies of high quality using manual therapy protocols, and also including standardized outcome measures, are now needed to clarify the efficacy of manual therapy in the management of TTH.

Efficacy of manual and manipulative therapy in the perception of pain and cervical motion in patients with tension-type headache: a randomized, controlled clinical trial

OBJECTIVE

The purpose of this study was to evaluate the efficacy of manipulative and manual therapy treatments with regard to pain perception and neck mobility in patients with tension-type headache.

METHODS

A randomized clinical trial was conducted on 84 adults diagnosed with tension-type headache. Eighty-four subjects were enrolled in this study: 68 women and 16 men. Mean age was 39.76 years, ranging from 18 to 65 years. A total of 57.1% were diagnosed with chronic tension-type headache and 42.9% with tension-type headache. Participants were divided into 3 treatment groups (manual therapy, manipulative therapy, a combination of manual and manipulative therapy) and a control group. Four treatment sessions were administered during 4 weeks, with posttreatment assessment and follow-up at 1 month. Cervical ranges of motion pain perception, and frequency and intensity of headaches were assessed.

RESULTS

All 3 treatment groups showed significant improvements in the different dimensions of pain perception. Manual therapy and manipulative treatment improved some cervical ranges of motion. Headache frequency was reduced with manipulative treatment (P < .008). Combined treatment reported improvement after the treatment (P < .000) and at follow-up (P < .002). Pain intensity improved after the treatment and at follow-up with manipulative therapy (P < .01) and combined treatment (P < .01).

CONCLUSIONS

Both treatments, administered both separately and combined together, showed efficacy for patients with tension-type headache with regard to pain perception. As for cervical ranges of motion, treatments produced greater effect when separately administered.

Evidence for the use of dry needling and physiotherapy in the management of cervicogenic or tension-type headache: A systematic review

Background:

There is good evidence in the literature supporting physiotherapy in the management of some forms of headache. Dry needling of myofascial trigger points is becoming an increasingly common approach despite a paucity of research evidence supporting its use. The purpose of this review was to determine the evidence supporting the use of dry needling in addition to conventional physiotherapy in the management of tension-type and cervicogenic headache.

Methods:

Ten databases were searched for evidence of the effect of dry needling on the severity and frequency of tension and cervicogenic headache based ICHD classifications.

Results:

Three relevant studies were identified and all three showed statistically significant improvements following dry needling, but no significant differences between groups. Only one study reported on headache frequency or intensity, reporting a 45 mm improvement in VAS score following the addition of dry needling to conventional physiotherapy. Two studies showed significant improvements with dry needling over 4–5 weeks of treatment. No adverse events were reported.

Conclusions:

The literature suggests that while there is insufficient evidence to strongly advocate for the use of dry needling, it may be a useful addition to conventional physiotherapy in headache management. Further research with a stronger methodological design is required.

Therapeutic options for cervicogenic headache

The term cervicogenic headache (CeH) describes a syndrome originating from the cervical spine. There are a variety of therapeutic approaches used for the management of CeH, but scientific evidence of their effectiveness is scarce. No medication drug has proven to be effective. The evidence for greater occipital nerve blocks, cervical nerve blockades, facet joint injections and surgical procedures is limited. Several physical therapy interventions are proposed for CeH, with spinal manipulation and soft tissue interventions being the most commonly used. However, the lack of solid evidence of positive effects and risks of serious complications for spinal manipulation should be considered in favor of other physical therapy interventions associated with less risk. The inconsistent results in the literature can be related to the fact that maybe not all therapeutic interventions are appropriate for all patients with CeH or maybe not all patients with CeH will benefit from particular interventions.

The working mechanism of manual therapy in participants with chronic tension-type headache

STUDY DESIGN

Prospective longitudinal study.

OBJECTIVE

To explore the working mechanism of manual therapy, we investigated whether 3 cervical spine variables were mediators of the effect of manual therapy on headache frequency. Background Manual therapy has been shown to reduce headache frequency in participants with chronic tension-type headache (CTTH). To what extent specific elements of treatment contribute to the effectiveness of manual therapy in CTTH is unknown.

METHODS

One hundred eighty-two participants with CTTH participated in a prospective longitudinal study: 142 underwent manual therapy and 40 participants received usual care by their general practitioner. Regression analysis was performed according to the steps described by Baron and Kenny, and the proportion of mediated effect was estimated for 3 potential mediators: (1) cervical range of motion, (2) neck flexor endurance, and (3) forward head posture. Outcome was defined as a 50% or greater reduction in headache days.

RESULTS

Neck flexor endurance mediated 24.5% of the effect of manual therapy. Cervical range of motion and forward head posture showed no mediated effect.

CONCLUSIONS

Increased neck flexor endurance appears to be a working mechanism of manual therapy. This finding supports isometric training of neck flexors in participants with CTTH. Trial registered with Netherlands Trial Register (TR 1074).

Italian guidelines for primary headaches: 2012 revised version

The first edition of the Italian diagnostic and therapeutic guidelines for primary headaches in adults was published in J Headache Pain 2(Suppl. 1):105-190 (2001). Ten years later, the guideline committee of the Italian Society for the Study of Headaches (SISC) decided it was time to update therapeutic guidelines. A literature search was carried out on Medline database, and all articles on primary headache treatments in English, German, French and Italian published from February 2001 to December 2011 were taken into account. Only randomized controlled trials (RCT) and meta-analyses were analysed for each drug. If RCT were lacking, open studies and case series were also examined. According to the previous edition, four levels of recommendation were defined on the basis of levels of evidence, scientific strength of evidence and clinical effectiveness. Recommendations for symptomatic and prophylactic treatment of migraine and cluster headache were therefore revised with respect to previous 2001 guidelines and a section was dedicated to non-pharmacological treatment. This article reports a summary of the revised version published in extenso in an Italian version.

Evidence-based guidelines for the chiropractic treatment of adults with headache

OBJECTIVE

The purpose of this manuscript is to provide evidence-informed practice recommendations for the chiropractic treatment of headache in adults.

METHODS

Systematic literature searches of controlled clinical trials published through August 2009 relevant to chiropractic practice were conducted using the databases MEDLINE; EMBASE; Allied and Complementary Medicine; the Cumulative Index to Nursing and Allied Health Literature; Manual, Alternative, and Natural Therapy Index System; Alt HealthWatch; Index to Chiropractic Literature; and the Cochrane Library. The number, quality, and consistency of findings were considered to assign an overall strength of evidence (strong, moderate, limited, or conflicting) and to formulate practice recommendations.

RESULTS

Twenty-one articles met inclusion criteria and were used to develop recommendations. Evidence did not exceed a moderate level. For migraine, spinal manipulation and multimodal multidisciplinary interventions including massage are recommended for management of patients with episodic or chronic migraine. For tension-type headache, spinal manipulation cannot be recommended for the management of episodic tension-type headache. A recommendation cannot be made for or against the use of spinal manipulation for patients with chronic tension-type headache. Low-load craniocervical mobilization may be beneficial for longer term management of patients with episodic or chronic tension-type headaches. For cervicogenic headache, spinal manipulation is recommended. Joint mobilization or deep neck flexor exercises may improve symptoms. There is no consistently additive benefit of combining joint mobilization and deep neck flexor exercises for patients with cervicogenic headache. Adverse events were not addressed in most clinical trials; and if they were, there were none or they were minor.

CONCLUSIONS

Evidence suggests that chiropractic care, including spinal manipulation, improves migraine and cervicogenic headaches. The type, frequency, dosage, and duration of treatment(s) should be based on guideline recommendations, clinical experience, and findings. Evidence for the use of spinal manipulation as an isolated intervention for patients with tension-type headache remains equivocal.

Drug and Nondrug Treatment in Tension-type Headache

Tension-type headache (TTH) is a common primary headache with tremendous socioeconomic impact. Establishment of an accurate diagnosis is important before initiation of any treatment. Nondrug management is crucial. Information, reassurance and identification of trigger factors may be rewarding. Psychological treatments with scientific evidence for efficacy include relaxation training, EMG biofeedback and cognitive-behavioural therapy. Physical therapy and acupuncture are widely used, but the scientific evidence for efficacy is sparse. Simple analgesics are the mainstays for treatment of episodic TTH. Combination analgesics, triptans, muscle relaxants and opioids should not be used, and it is crucial to avoid frequent and excessive use of simple analgesics to prevent the development of medication-overuse headache. The tricyclic antidepressant amitriptyline is drug of first choice for the prophylactic treatment of chronic TTH. The efficacy is modest and treatment is often hampered by side effects. Thus, treatment of frequent TTH is often difficult and multidisciplinary treatment strategies can be useful. The development of specific nonpharmacological and pharmacological managements for TTH with higher efficacy and fewer side effects is urgently needed. Future studies should also examine the relative efficacy of the various treatment modalities; for example, psychological, physical and pharmacological treatments, and clarify how treatment programs should be optimized to best suit the individual patient.