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Evidence summary
Small studies offer mixed evidence of benefit
Seven RCTs using manual therapies to treat chronic tension headaches have reported the change in headache frequency (TABLE1-7). Most, but not all, manual therapies significantly improved headache frequency.
Participants ranged in age from 18 to 65 years, with mean age ranges of 33 to 42 years in each study. At baseline, patients had 10 or more tension-type headaches per month. The manual therapies varied in techniques, duration, and the training of the person performing the intervention:
- Twice-weekly chiropractic spinal manipulation for 6 weeks1
- Soft-tissue therapy plus spinal manipulation (8 treatments over 4 weeks)2
- Chiropractic spinal manipulation with or without amitriptyline for 14 weeks3
- Corrective osteopathic manipulation treatment (OMT) techniques tailored for each patient for 1 month4
- High-velocity low-amplitude manipulation (HVLA) plus exercise or myofascial release plus exercise twice weekly for 8 weeks5
- Manual therapy treatment consisting of a combination of mobilizations of the cervical and thoracic spine, exercises, and postural correction for up to 9 sessions of 30 minutes each6
- One hour of direct or indirect myofascial release treatment twice weekly for 12 weeks.7
Three studies involved chiropractic providers.1-3 One study (n = 19) found a positive effect, in which chiropractic manipulation augmented with amitriptyline performed better than chiropractic manipulation alone.3 Another chiropractic study did not find an immediate posttreatment benefit but did report significant headache reduction at the 4-week follow-up interval.1 The third chiropractic study did not show additional benefit from HVLA manipulation.2
One small study involving osteopathic physicians using OMT found reduced headache frequency after 12 weeks but not at 4 weeks.4 Another study, comparing HVLA or myofascial release with exercise to exercise alone, found benefit for the HVLA group but not for myofascial release; interventions in this study were performed by a physician with at least 6 years of unspecified manual therapy experience.5 A small study of manual therapists found improvement at the end of manual therapy but not at 18 months.6 Another small study using providers with 10 months’ experience with myofascial release found reduced headache frequency 4 weeks after a course of direct and indirect myofascial release (compared with sham release).7
Editor’s takeaway
It isn’t hard to imagine why muscle tension headaches might respond to certain forms of manual therapy. However, all available studies of these modalities have been small (< 100 patients) or lacked blinding, introducing the potential for significant bias. Nevertheless, for now it appears reasonable to refer interested patients with tension headache to an osteopathic physician for OMT or myofascial release to reduce headache frequency.
1. Boline PD, Kassak K, Bronfort G, et al. Spinal manipulation vs amitriptyline for the treatment of chronic tension-type headaches—a randomized clinical-trial. J Manipulative Physiol Ther. 1995;18:148-254.
2. Bove G. Spinal manipulation in the treatment of episodic tension-type headache: a randomized controlled trial. JAMA. 1998;280:1576-1579.
3. Vernon H, Jansz G, Goldsmith CH, et al. A randomized, placebo-controlled clinical trial of chiropractic and medical prophylactic treatment of adults with tension-type headache: results from a stopped trial. J Manipulative Physiol Ther. 2009;32:344-351.
4. Rolle G, Tremolizzo L, Somalvico F, et al. Pilot trial of osteopathic manipulative therapy for patients with frequent episodic tension-type headache. J Am Osteopath Assoc. 2014;114:678-685. doi: 10.7556/jaoa.2014.136
5. Corum M, Aydin T, Ceylan CM, et al. The comparative effects of spinal manipulation, myofascial release and exercise in tension-type headache patients with neck pain: a randomized controlled trial. Complement Ther Clin Pract. 2021;43:101319. doi: 0.1016/j.ctcp.2021.101319
6. Castien RF, van der Windt DAWM, Grooten A, et al. Effectiveness of manual therapy compared to usual care by the general practitioner for chronic tension-type headache: a pragmatic, randomised, clinical trial. Cephalalgia. 2009;31:133-143.
7. Ajimsha MS. Effectiveness of direct vs indirect technique myofascial release in the management of tension-type headache. J Bodyw Mov Ther. 2011;15:431-435. doi: 10.1016/j.jbmt.2011.01.021
Evidence summary
Small studies offer mixed evidence of benefit
Seven RCTs using manual therapies to treat chronic tension headaches have reported the change in headache frequency (TABLE1-7). Most, but not all, manual therapies significantly improved headache frequency.
Participants ranged in age from 18 to 65 years, with mean age ranges of 33 to 42 years in each study. At baseline, patients had 10 or more tension-type headaches per month. The manual therapies varied in techniques, duration, and the training of the person performing the intervention:
- Twice-weekly chiropractic spinal manipulation for 6 weeks1
- Soft-tissue therapy plus spinal manipulation (8 treatments over 4 weeks)2
- Chiropractic spinal manipulation with or without amitriptyline for 14 weeks3
- Corrective osteopathic manipulation treatment (OMT) techniques tailored for each patient for 1 month4
- High-velocity low-amplitude manipulation (HVLA) plus exercise or myofascial release plus exercise twice weekly for 8 weeks5
- Manual therapy treatment consisting of a combination of mobilizations of the cervical and thoracic spine, exercises, and postural correction for up to 9 sessions of 30 minutes each6
- One hour of direct or indirect myofascial release treatment twice weekly for 12 weeks.7
Three studies involved chiropractic providers.1-3 One study (n = 19) found a positive effect, in which chiropractic manipulation augmented with amitriptyline performed better than chiropractic manipulation alone.3 Another chiropractic study did not find an immediate posttreatment benefit but did report significant headache reduction at the 4-week follow-up interval.1 The third chiropractic study did not show additional benefit from HVLA manipulation.2
One small study involving osteopathic physicians using OMT found reduced headache frequency after 12 weeks but not at 4 weeks.4 Another study, comparing HVLA or myofascial release with exercise to exercise alone, found benefit for the HVLA group but not for myofascial release; interventions in this study were performed by a physician with at least 6 years of unspecified manual therapy experience.5 A small study of manual therapists found improvement at the end of manual therapy but not at 18 months.6 Another small study using providers with 10 months’ experience with myofascial release found reduced headache frequency 4 weeks after a course of direct and indirect myofascial release (compared with sham release).7
Editor’s takeaway
It isn’t hard to imagine why muscle tension headaches might respond to certain forms of manual therapy. However, all available studies of these modalities have been small (< 100 patients) or lacked blinding, introducing the potential for significant bias. Nevertheless, for now it appears reasonable to refer interested patients with tension headache to an osteopathic physician for OMT or myofascial release to reduce headache frequency.
Evidence summary
Small studies offer mixed evidence of benefit
Seven RCTs using manual therapies to treat chronic tension headaches have reported the change in headache frequency (TABLE1-7). Most, but not all, manual therapies significantly improved headache frequency.
Participants ranged in age from 18 to 65 years, with mean age ranges of 33 to 42 years in each study. At baseline, patients had 10 or more tension-type headaches per month. The manual therapies varied in techniques, duration, and the training of the person performing the intervention:
- Twice-weekly chiropractic spinal manipulation for 6 weeks1
- Soft-tissue therapy plus spinal manipulation (8 treatments over 4 weeks)2
- Chiropractic spinal manipulation with or without amitriptyline for 14 weeks3
- Corrective osteopathic manipulation treatment (OMT) techniques tailored for each patient for 1 month4
- High-velocity low-amplitude manipulation (HVLA) plus exercise or myofascial release plus exercise twice weekly for 8 weeks5
- Manual therapy treatment consisting of a combination of mobilizations of the cervical and thoracic spine, exercises, and postural correction for up to 9 sessions of 30 minutes each6
- One hour of direct or indirect myofascial release treatment twice weekly for 12 weeks.7
Three studies involved chiropractic providers.1-3 One study (n = 19) found a positive effect, in which chiropractic manipulation augmented with amitriptyline performed better than chiropractic manipulation alone.3 Another chiropractic study did not find an immediate posttreatment benefit but did report significant headache reduction at the 4-week follow-up interval.1 The third chiropractic study did not show additional benefit from HVLA manipulation.2
One small study involving osteopathic physicians using OMT found reduced headache frequency after 12 weeks but not at 4 weeks.4 Another study, comparing HVLA or myofascial release with exercise to exercise alone, found benefit for the HVLA group but not for myofascial release; interventions in this study were performed by a physician with at least 6 years of unspecified manual therapy experience.5 A small study of manual therapists found improvement at the end of manual therapy but not at 18 months.6 Another small study using providers with 10 months’ experience with myofascial release found reduced headache frequency 4 weeks after a course of direct and indirect myofascial release (compared with sham release).7
Editor’s takeaway
It isn’t hard to imagine why muscle tension headaches might respond to certain forms of manual therapy. However, all available studies of these modalities have been small (< 100 patients) or lacked blinding, introducing the potential for significant bias. Nevertheless, for now it appears reasonable to refer interested patients with tension headache to an osteopathic physician for OMT or myofascial release to reduce headache frequency.
1. Boline PD, Kassak K, Bronfort G, et al. Spinal manipulation vs amitriptyline for the treatment of chronic tension-type headaches—a randomized clinical-trial. J Manipulative Physiol Ther. 1995;18:148-254.
2. Bove G. Spinal manipulation in the treatment of episodic tension-type headache: a randomized controlled trial. JAMA. 1998;280:1576-1579.
3. Vernon H, Jansz G, Goldsmith CH, et al. A randomized, placebo-controlled clinical trial of chiropractic and medical prophylactic treatment of adults with tension-type headache: results from a stopped trial. J Manipulative Physiol Ther. 2009;32:344-351.
4. Rolle G, Tremolizzo L, Somalvico F, et al. Pilot trial of osteopathic manipulative therapy for patients with frequent episodic tension-type headache. J Am Osteopath Assoc. 2014;114:678-685. doi: 10.7556/jaoa.2014.136
5. Corum M, Aydin T, Ceylan CM, et al. The comparative effects of spinal manipulation, myofascial release and exercise in tension-type headache patients with neck pain: a randomized controlled trial. Complement Ther Clin Pract. 2021;43:101319. doi: 0.1016/j.ctcp.2021.101319
6. Castien RF, van der Windt DAWM, Grooten A, et al. Effectiveness of manual therapy compared to usual care by the general practitioner for chronic tension-type headache: a pragmatic, randomised, clinical trial. Cephalalgia. 2009;31:133-143.
7. Ajimsha MS. Effectiveness of direct vs indirect technique myofascial release in the management of tension-type headache. J Bodyw Mov Ther. 2011;15:431-435. doi: 10.1016/j.jbmt.2011.01.021
1. Boline PD, Kassak K, Bronfort G, et al. Spinal manipulation vs amitriptyline for the treatment of chronic tension-type headaches—a randomized clinical-trial. J Manipulative Physiol Ther. 1995;18:148-254.
2. Bove G. Spinal manipulation in the treatment of episodic tension-type headache: a randomized controlled trial. JAMA. 1998;280:1576-1579.
3. Vernon H, Jansz G, Goldsmith CH, et al. A randomized, placebo-controlled clinical trial of chiropractic and medical prophylactic treatment of adults with tension-type headache: results from a stopped trial. J Manipulative Physiol Ther. 2009;32:344-351.
4. Rolle G, Tremolizzo L, Somalvico F, et al. Pilot trial of osteopathic manipulative therapy for patients with frequent episodic tension-type headache. J Am Osteopath Assoc. 2014;114:678-685. doi: 10.7556/jaoa.2014.136
5. Corum M, Aydin T, Ceylan CM, et al. The comparative effects of spinal manipulation, myofascial release and exercise in tension-type headache patients with neck pain: a randomized controlled trial. Complement Ther Clin Pract. 2021;43:101319. doi: 0.1016/j.ctcp.2021.101319
6. Castien RF, van der Windt DAWM, Grooten A, et al. Effectiveness of manual therapy compared to usual care by the general practitioner for chronic tension-type headache: a pragmatic, randomised, clinical trial. Cephalalgia. 2009;31:133-143.
7. Ajimsha MS. Effectiveness of direct vs indirect technique myofascial release in the management of tension-type headache. J Bodyw Mov Ther. 2011;15:431-435. doi: 10.1016/j.jbmt.2011.01.021
EVIDENCE-BASED ANSWER:
MAYBE. Among patients with chronic tension headaches, manual therapies may reduce headache frequency more than sham manual therapy, usual care, or exercise treatments—by 1.5 to 4.2 headaches or days with headache per week (strength of recommendation, B; preponderance of evidence from primarily small, heterogeneous randomized controlled trials [RCTs]).
