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.