Research Review By Dr. Demetry Assimakopoulos©


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Date Posted:

June 2017

Study Title:

A Critical Review of Manual Therapy Use for Headache Disorders: Prevalence, Profiles, Motivations, Communication and Self-Reported Effectiveness


Moore CS, Sibbritt DW & Adams J

Author's Affiliations:

Faculty of Health, University of Technology Sydney, Australia

Publication Information:

BMC Neurology 2017; 17: 61. DOI 10.1186/s12883-017-0835-0

Background Information:

Migraine and tension headaches are common and can also co-occur for some patients. Both types of headache carry considerable individual and societal burden. While ablative or preventive pharmacological treatments are often successful for a portion of headache sufferers, these disorders are still reported in the literature as under-diagnosed and under-treated in medical settings (1). Manual therapies (MT), such as spinal manipulation, joint mobilization and massage are widely-used therapeutic interventions, which have demonstrated beneficial results in headache sufferers (2-6). The authors of this review sought to critically review the prevalence of MT use for the treatment of chronic recurrent headaches, and review the patient-related factors associated with the use of MT.

Pertinent Results:

Key findings from the 35 included studies were grouped and analyzed utilizing a critical review approach, which was adapted from previous research. Prevalence findings were reported within one of two possible categories: either as migraine for papers reporting on the populations predominantly or entirely made-up on migraine patients (10 studies), or as headache for studies where the included population was predominantly comprised of other headache types (i.e. tension-type, cluster or cervicogenic headaches – 18 studies). Three studies reported findings on both categories.

Prevalence of Manual Therapy (MT) Use:

  • The prevalence of chiropractic use for those in the general population with migraine ranged from 1-36.2% (average 14.4%), and from 8.9-27.1% (average 18%) in headache patient populations.
  • The prevalence of chiropractic use for those in the general population reporting headaches ranged from 4-28% (average 12.9%). Utilization within the headache-pain clinic population ranged from 12-22% (average 18.6%).
  • Interestingly, headache prevalence ranged from 1.9-45.5% (average 9.8%) in chiropractic populations.
  • The prevalence of physiotherapy use for those in the general population suffering from migraine ranged from 9-57% (average 24.7%). Utilization within headache-pain clinic populations ranged from 4.9-18.7% (average 11.8%).
  • The prevalence of physiotherapy use in the general population with headaches ranged from 12.2-52.0% (average 32.1%). MT utilization prevalence ranged from 27.8-35% within headache-pain clinic populations.
Massage therapy:
  • Massage use for those with migraine ranged from 2-29.7% (average 15.6%) within the general population, and from 10.1-56.4% (average 33.9%) within the headache-pain clinic population.
  • Massage/acupressure use in those reporting headache within headache-pain clinic populations ranged from 12.0-54.0% (average 32.5%).
  • Osteopathy use in those in the general population suffering from migraine was approximately 1%. Utilization was 2.7% within a headache-pain clinic population. Migraines occupied approximately 1.7% of an osteopathy patient population.
  • For headache sufferers, the prevalence of osteopathy use was 9% within a headache-pain clinic population. Headaches occupied 2.7-10% (average 6.4%) of the osteopathy patient populations.
Across all MT professions
  • Prevalence of MT use across all professions in those with migraine ranged from 1-57% (average 15.9%) within the general population. MT utilization ranged from 2.7-56.4% (average 18.4%) within headache-pain clinic patient populations. The prevalence of migraine in MT populations was 1.7%.
  • The combined prevalence of MT use across all MT professions for those individuals in the general population reporting headaches ranged from 4.0-52% (average 17.7%). Utilization of MT in headache sufferers ranged from 9-54% (average 32.3%) within headache-pain clinic patient populations. Headaches occupied a range of 1.9-45.5% (average 9.25%) of MT patient populations.
Profile and Motivation for Manual Therapy (MT) Use:

Patients seeking MT for headache were more often older, female, had a higher rate of comorbidity and exhibited higher rates of medical visits in comparison to non-MT-users. Additionally, MT users generally reported a higher level of headache chronicity and/or disability, compared to non-users. Findings varied for level of income and education.

Headache patients were often motivated to seek MT for headache pain relief (45-84% of responses), due to concerns regarding the safety of standard medical treatment and dissatisfaction with standard medical care.

Several studies reported on concomitant CAM therapy and medical treatment. In these studies, MT was the most frequently used CAM therapy (range 57-86.4%; average 62.8%). Concomitant use of medical and MT care in headache populations ranged from 29.5-79% (average 60%). Interestingly, between 25.5-72.0% (average 52.6%) of headache sufferers did not disclose their use of MT to their medical doctor. The reasons for non-disclosure varied, but included responses like: ‘the doctor never asked’, ‘it was not important for the doctor to know’, ‘none of the doctors’ business’, and ‘the doctor would not understand/discourage use of CAM therapies’..

Internationally, primary care providers and neurologists are typically the first and second line providers for migraine treatment. The only exception was Australia, where those with chronic migraines selected chiropractors at equal frequency to neurologists. Interestingly, Australian episodic migraine sufferers selected chiropractors at a greater frequency than neurologists. Chiropractors were selected as typical providers for those with chronic migraines by 10% of individuals in USA and Canada, 1% in Germany and 0% in UK and France. For those with episodic migraine, chiropractors were selected as the typical provider for 7% of sufferers in USA, 6% in Germany, 4% in Canada and 1% in the UK and France.

Self-Reported Effectiveness of Manual Therapy (MT) Treatment Outcomes
  • Chiropractic users endorsing partial or fully effective headache pain relief ranged from 27-82% (average 45%). One general population study demonstrated 25.6% and 38% self-reported effectiveness for those suffering from primary chronic headaches and secondary chronic headaches, respectively.
  • Massage therapy users endorsing partially or fully effective headache pain relief ranged from 33-64.5% (average 45.2%).
  • Acupressure users endorsing partially or fully effective headache pain relief ranged from 34.4-50% (average 44.5%).
  • Osteopathy and physiotherapy users reported effectiveness of 17% and 36%, respectively. One study assessed the self-reported effectiveness of physiotherapy and demonstrated a 25.5% effectiveness for those with primary chronic headache, and 38% effectiveness for those with secondary chronic headache.
  • The combined results across all MT professions for users endorsing partially or fully effective headache pain relief ranged from 17-82% (average 42.5%).

Clinical Application & Conclusions:

This was the first study to critically review the prevalence and key factors associated with use of manual therapy treatment (MT) for headache within the peer-reviewed literature. The review demonstrated that MT use was higher within medical headache-pain clinic populations in comparison to the general population. The use of individual MT is variable around the world, likely due to regional differences in public access, healthcare funding and MT provider availability. However, overall, the use of MT for headaches and migraines appears to be substantial, and is likely the most common physical modality used for treatment in many countries. Still, the needs of those suffering from headaches can be complex, and may require a multi-disciplinary approach to care. Given its relatively high utilization and efficacy, clinicians should remain cognizant of, and open to discussing MT as a possible adjunct treatment.

Study Methods:

Several databases were accessed to search for relevant material. A hand search of prominent peer-reviewed journals was also performed. Articles selected for review were mostly manuscripts within the epidemiological and health economics fields. Due to the focus of this review, RCTs (and similar clinical research designs), letters, correspondence, editorials, case reports and commentaries were excluded. (Writer’s note: the authors were not specific about why they excluded “RCTs and similar research designs.” The authors purposefully included studies mostly within the realms of epidemiology and health economics. One can only surmise that other study designs were excluded because they cannot make inferences about incidence and prevalence of manual therapy use. The fact that the authors failed to explicitly outline an exclusion criteria is an inherent weakness of this study). Study quality appraisal was conducted using a quality scoring system, developed for the critical appraisal of health literature used for prevalence and incidence of health problems. This system was applicable to 29/35 studies, but not applicable to the remainder of included material.

Study Strengths / Weaknesses:

The authors should be commended for taking a unique look at the literature pertaining to the use of manual therapies for headaches, as well as the additional patient-related factors they reported. The good news is that the patient-reported efficacy of manual therapies was mostly favourable. Having said that, there were several weaknesses in this study. Firstly, as the authors rightfully reported, methodological limitations inherent to the included studies prevent the formulation of a strong conclusion. Additionally, since the degree of utilization was so variable, it remains difficult to truly understand this concept epidemiologically. Finally, as mentioned above, there was no explicit exclusion criteria outlined.

Additional References:

  1. Diamond S, Bigal ME, Silberstein et al. Patterns of diagnosis and acute and preventive treatment for migraine in the united states: results from the American migraine prevalence and prevention study. Headache 2007; 47: 355–63.
  2. Marcus D, Scharff L, Mercer S, Turk D. Nonpharmacological treatment for cmigraine: incremental utility of physical therapycwith relaxation and thermalcbiofeedback. Cephalalgia 1998; 18: 266–72.
  3. Lawler SP, Cameron LD. A randomized, controlled trial of massage therapycas a treatment for migraine. Ann Behav Med 2006; 32: 50–9.
  4. Tuchin PJ, Pollard H, Bonello R. A randomized controlled trial of chiropracticcspinal manipulative therapy for migraine. J Manipulative Physiol Ther 2000; 23: 91–5.
  5. Hoyt W, Shaffer F, Bard D, Benesler J, Blankenhorn G, Gray J, Hartman W, Hughes L. Osteopathic manipulation in the treatment of muscle-contraction headache. J Am Osteopath Assoc 1979; 78: 322–5.
  6. Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002; 27: 1835–43.