Research Review By Dr. Michael Haneline©


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Date Posted:

December 2020

Study Title:

Effectiveness of manual therapy in patients with tension-type headache. A systematic review and meta-analysis


Kamonseki D, Lopes E, van der Meer H, Calixtre L

Author's Affiliations:

Laboratory of Analysis and Intervention of the Shoulder Complex, Universidade Federal de São Carlos (UFSCar), São Carlos, SP, Brazil.

Publication Information:

Disability and Rehabilitation 2020 Sep 12; 1-10. DOI:10.1080/09638288.2020.1813817

Background Information:

Tension type headache (TTH) is the most common type of primary headache, affecting 46% of adults at some point during their lifetime (1). Symptoms of TTH include bilateral head pain that is non-pulsating, has a pressing or tightening quality, and is of mild to moderate intensity. The pain is not typically aggravated by physical activity (in fact, it is often relieved by exercise), nor is it associated with nausea and vomiting.

The cause of TTH is currently undetermined, although it is thought to be multifactorial. Following are some of the likely contributing factors of TTH (2-4):
  • Activation of hyperexcitable peripheral afferent neurons from the muscles of the head and neck.
  • Muscle tension and tenderness due to psychological stress are associated with TTH symptoms and may aggravate the condition when present.
  • Abnormalities in central pain processing and generalized increased pain sensitivity are common in patients with chronic TTH.
  • Genetic factors may increase a person’s susceptibility for developing TTH.
Non-pharmacologic treatments for patients with TTH have been recommended, including acupuncture and dry needling, cognitive-behavioral therapy, biofeedback training, relaxation training, manual therapy and physical modalities.

The effectiveness of manual therapy interventions for the treatment of TTH have previously been investigated in systematic reviews, although the findings of these reviews are somewhat conflicting. Fernández-de-las-Peñas et al. (5) concluded that there is no rigorous evidence to support the use of spinal manipulation or soft tissue interventions for TTH. On the other hand, Mesa-Jimenez et al. (6) reported that manual therapy may be more effective than pharmacological treatment in the short term but equally effective long term. Lozano Lopez et al. (7) included studies that reported manual therapy showed more favorable outcomes than standard treatments or placebo.

The current authors thought there was a need to conduct another systematic review because of limitations with the previous reviews. Mainly, studies were included in the previous systematic reviews in which manual therapy interventions were combined with other interventions. When interventions are combined in a study, the ability to identify the effectiveness of individual manual therapy methods is limited. Another reason for conducting another review is that more studies have been published on this topic since the last review was conducted.

Therefore, the purpose of this review was to summarize and analyze the current evidence regarding the use of manual therapy interventions alone (i.e., not including other modalities) to improve pain intensity, headache frequency and impact of headache in individuals with TTH.

Pertinent Results:

The literature search yielded 671 studies, and after the selection process, 15 RCTs were included in the review. The resulting pooled sample included 1131 subjects, with 780 (68.9%) of them being female.

Tension-type headache was diagnosed in twelve of the studies using the International Classification of Headache Disorders (ICHD) diagnostic criteria. Five of the studies included only subjects with chronic TTH, 1 study included subjects with episodic TTH and the other nine studies included subjects with both types of TTH.

The types of interventions that were utilized in the studies included:
  • high velocity and low amplitude manipulation (HVLA), mainly applied to the cervical region;
  • soft tissue therapy (myofascial release, massage, soft tissue compression, neural mobilization, positional release, craniosacral therapy, and muscle energy); and
  • dry needling, which was only used in one study.
Reported adverse effects were associated with amitriptyline intake, HVLA thrust techniques and dry needling, but all adverse effects were mild and temporary.

Effects of manual therapy on pain intensity:
  • A pooled estimate from 8 studies which included 560 participants showed that manual therapy was not superior to no treatment for pain intensity. However, a sensitivity analysis involving six of the studies having high methodological quality resulted in an overall effect that favored manual therapy.
  • A subgroup analysis showed that HVLA thrust techniques were not superior to no treatment for pain intensity based on low quality of evidence. However, soft tissue interventions and dry needling were found to be superior to no treatment on pain intensity based on low and moderate quality of evidence, respectively.
  • Soft tissue interventions were compared to other treatments in 4 very low quality studies that included a total of 236 participants, which showed that soft tissue interventions were not superior to other treatments for pain intensity.
Effects of manual therapy on pain frequency:
  • Manual therapy was found to be superior to no treatment on pain frequency in 6 studies, with a pooled sample of 477 participants. Only soft tissue interventions were compared to other types of treatment for the frequency of pain, and were not found to be superior.
  • Subgroup analysis showed that HVLA thrust techniques were not superior to no treatment, whereas soft tissue interventions and dry needling were superior to no treatment for the frequency of pain.
Effects of manual therapy on the impact of the headache:
  • Soft tissue interventions were found to be not superior to control groups on the impact of headache in 4 studies with a pooled sample of 297 participants.
  • No studies investigated HVLA thrust techniques and dry needling regarding the impact of headache.

Clinical Application & Conclusions:

Based on the evidence presented in this review, there is support for the use of soft tissue interventions and dry needling to improve pain intensity and frequency in patients with TTH.

The evidence did not support the use of HVLA techniques for improving pain intensity or frequency in patients with TTH. Finally, manual therapy in general was not effective for improving the impact of headache in patients with TTH (remember this was not based on any studies looking at HVLA SMT).

Reviewer’s Comment:
In defense of several letters to the editor regarding the 1998 study by Bove and Nilsson (8) that was included in this review, headache diagnosis was portrayed as being fraught with pitfalls. In particular, TTH and cervicogenic headache presentations often overlap and many field practitioners are generally not aware of the distinctions between these specific diagnostic categories. Bove and Nilsson suggested that if manipulation helped a patient with TTH, it probably was a misdiagnosed cervicogenic headache. They further suggested that practitioners should learn to differentiate cervicogenic headache and TTH since they clearly demand different treatments, and the 2 types together amount to about 80% of all headache cases.

Editor’s Comment:
The TTH literature is a bit of a mess for a number of reasons. As these authors identified, many studies included in prior systematic reviews combined interventions, which complicates interpretation. TTH is known to be a multifactorial condition, so it is unlikely there is a one-trick cure. In my experience, manual therapy (including SMT) can be really helpful for some with TTH, and not have much of an impact on others. Also remember, the literature regarding SMT as a treatment for cervicogenic headache is a little stronger, which makes sense.

Study Methods:

This was a systematic review that followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

A literature search was conducted via 4 biomedical search engines and included publications up to June 2020. Also, the included articles were screened to identify relevant studies from the articles’ reference lists.

The retrieved articles were screened for inclusion by 2 independent reviewers who first analyzed titles and abstracts, excluding those that were not related to the topic of the review. After the initial screening, the full texts of potentially relevant articles were selected for final evaluation. Any disagreements were resolved by consensus.

Eligibility/inclusion criteria for selecting studies to be included in the review were as follows:
  • Studies had to be randomized controlled trials (RCTs) that compared manual therapy techniques alone (i.e., not associated with other types of treatment) to no treatment, placebo/sham intervention, or other types of treatment.
  • Participants could be of either sex, had to be aged 18 years or older, and diagnosed with episodic or chronic TTH.
  • Interventions included all types of manual therapy techniques, including joint mobilization, HVLA thrust techniques, soft tissue interventions, myofascial trigger points release, craniosacral therapy, massage, and dry needling. The manual therapy techniques could have been delivered in combination with other manual therapy techniques.
  • The primary outcome measures had to include pain intensity, pain frequency and/or the impact of headache.
The study’s exclusion criteria were as follows.
  • Studies in which manual therapy was also used in the control group.
  • Studies that included individuals with headache caused by injury to the head and/or neck and other head/neck related diagnoses besides TTH.
The Physiotherapy Evidence-Based Database (PEDro) scale was used to assess the included studies’ risk of bias by two reviewers, with any inconsistencies being solved by a third reviewer.

The GRADE system of evaluating the quality of evidence was utilized in this study. GRADE classifies evidence as being of:
  • High quality: meaning one can be very confident that the true effect lies close to that of the estimate of the effect;
  • Moderate quality: moderately confident in the effect estimate and the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different;
  • Low quality: low confidence in the effect estimate and the true effect may be substantially different from the estimate of the effect; and
  • Very low quality: little confidence in the effect estimate and the true effect is likely to be substantially different from the estimate of effect.
The quality of evidence was classified based on: 1) the study’s risk of bias (i.e. methodological limitations); 2) inconsistency of studies (i.e. heterogeneity); 3) indirectness which occurs when participants, interventions, or outcome measures from the included studies are different; 4) imprecision due to a small pooled sample (< 400 participants in the comparison group) and/or wide confidence intervals; and 5) publication bias.

Study Strengths / Weaknesses

This was a well-done systematic review and meta-analysis that followed PRISMA, Cochrane and GRADE guidelines. The clinical practice recommendations for treatment of patients with TTH that were provided are therefore appropriate.

This review did not include RCTs where manual therapy was used along with other types of interventions, which resulted in a review that provided information about the effectiveness of manual therapy interventions alone.

The authors listed several study limitations, including:
  • TTH is inherently difficult to diagnose and some of the included studies did not describe which TTH diagnostic criteria were followed. This may have resulted in participants being included that did not actually have TTH.
  • Only studies published in English, Spanish and Portuguese were considered, so studies in other languages would have been missed.
  • The sham manual therapies used in the included studies typically simulated the active intervention, but without the thrust (HVLA) or skin penetration (dry needling). However, when a sham procedure is used in a control group, there are potential physiological effects that could confound a study’s findings.
  • Few studies were included in this review. These studies used diverse methods, generally were of limited quality, and had small sample sizes which did not permit making more definitive conclusions.

Additional References:

  1. Stovner L, Hagen K, Jensen R, et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 2007; 27(3): 193–210.
  2. Loder E, Rizzoli P. Tension-type headache. BMJ 2008; 336(7635): 88–92.
  3. Nijs J, Van Houdenhove B, Oostendorp RAB. Recognition of central sensitization in patients with musculoskeletal pain: application of pain neurophysiology in manual therapy practice. Man Ther 2010; 15(2): 135–141.
  4. Fernández-de-las-Peñas C, Cuadrado M, Arendt-Nielsen L, et al. Myofascial trigger points and sensitization: an updated pain model for tension-type headache. Cephalalgia 2007; 27(5): 383–393.
  5. Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, et al. Are manual therapies effective in reducing pain from tension-type headache?: a systematic review Clin J Pain 2006; 22(3): 278–285.
  6. Mesa-Jimenez JA, Lozano-Lopez C, Angulo-Dıaz-Parreno S, et al. Multimodal manual therapy vs. pharmacological care for management of tension type headache: A meta-analysis of randomized trials. Cephalalgia 2015; 35(14): 1323–1332.
  7. Lozano Lopez C, Mesa Jimenez J, de la Hoz Aizpurua JL, et al. Efficacy of manual therapy in the treatment of tension-type headache. A systematic review from 2000 to 2013. Neurology 2016; 31(6): 357–369.
  8. Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache: a randomized controlled trial. JAMA 1998; 280: 1576-1579.