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Table 3

Results of manual therapy randomized controlled trials (RCTs) of chronic tension-type headache (CTTH)

CountryStudy populationMethodInterventionResults
Spain 2009 [20]
11 participants (3 M, 8 F)
RCT of 8 days duration conducted by a physiotherapist i.e.
All interventions received two treatments over 8 days lasting for 40 min
Headache intensity decreased statistical significant 24 hours after massage (p < 0.05), whereas detuned ultrasound had no statistical significant effect
Age 41-60 yrs
2 treatments with one week interval, each followed by 24-hours post-treatment assessment
Head and neck massage
Mean headache intensity was reduced 24% after massage, and 3% after detuned ultrasound
Mean 51 ± 15 yrs
Comparison of pre-and post-treatment at the treatment laboratory
Detuned ultrasound at head and neck area (control group)
Effect size 0.32
Headache diagnosed by neurologist
Drop outs (n = 0)
USA 1989 [21]
55 participants (15 M, 40 F)
RCT of 9 months duration conducted by a physiotherapist i.e. 3 months treatment 3, 6 months follow-up
All interventions received detoxification (when necessary) and amitriptyline (in some cases)
The efficacy parameter was the mean headache index defined as weekly frequency x intensity on a 0-10 numeric rating. Mean headache index at baseline was 30
Age 23-62 yrs
Comparison of weekly treatments and follow-up
Biofeedback treatment (n = 9; 4 M and 5 F)
Biofeedback reduced the headache index defined as frequency x intensity by 83% and 76% post-treatment and 3 months follow-up, while physiotherapy combined with TENS reduced it by 97% and 93% and TENS by 94% and 92% respectively
Mean age 36.9 yrs
Headache diary recordings
Physiotherapy including heat pack, soft tissue work and ultrasound with home exercises and home transcutaneus electrical nerve stimulation (TENS) treatment, average 12.8 sessions over 3 months (n = 28; 4 M and 24 F)
The improvement was sustained at 6 months in physiotherapy combined with TENS and TENS group, i.e. 95% and 97% reduction of the headache index
Mean headache duration 8.4 yrs
TENS treatment by physiotherapist, 12 sessions followed by additional home TENS treatment twice a day for another month (n = 18; 7 M and 11 F)
Retrospect headache diagnosis
Drop outs of 6 months follow-up (n = 18; 7 M and 11 F)
Effect size not applicable
12 participants had co-occurrence of menstrual migraine
Turkey 2002 [22]
35 female participants
RCT of 10 weeks duration conducted by a physiotherapist i.e. 2 weeks baseline, 4 weeks treatment, 4 weeks follow-up
All interventions received superficial heat and classic massage to the neck and upper back prior to intervention
Efficacy parameter was headache index defined as headache frequency x intensity
Age 19-59 yrs
Comparison of baseline, post-treatment and follow-up
Spinal connective tissue manipulation by a physiotherapist daily (n = 15)
Both the spinal connective tissue manipulation and cervical mobilization groups had statistical significant improvement, i.e. 38% vs. 54% post-treatment and 48% vs. 86% at 3 months follow-up
Mean age 37.9 yrs
Headache diary recordings
Cervical mobilization according to Cyriax principle by a physiotherapist three times per week (n = 15)
No statistical significant differences between the two groups
Mean headache duration 9.8 yrs
Drop outs (n = 5)
Effect size 0.21 before to after treatment, 0.30 after treatment to follow-up, and 0.37 before treatment to follow-up
Headache diagnosed by neurologist
Denmark 2004 [23]
CTTH (n = 24) (10 M, 14 F)
RCT of 6 months duration conducted by a physiotherapist i.e. 1 month baseline, 2 months treatment, 3 months follow-up
Standardised physiotherapy including massage, relaxation and stretching twice a week for 4 weeks followed by twice a week physical group exercise for 4 weeks (n = 18)
Headache days were statistical significantly reduced in the physiotherapy group post-treatment and at follow-up as compared to the observation group (p < 0.001)
Age 24-63
Comparison of baseline, post-treatment and follow-up
Observation period, kept diary for 8 weeks followed by the same intervention (n = 19)
54% of participants responded with >50% reduction of headache days
Mean age 44.9 yrs
Headache diary recordings
Drop outs (n = 11) (5 M, 6 F)
Headache duration and intensity were unchanged in both groups
Duration of headache 23.1 yrs
Women responded statistical significantly better than men (p = 0.01)
Mean headache frequency 15.8 days per month
Effect size not applicable
Headache diagnosed by a neurologist
Netherland 2006 [24]
TTH (n = 42) and episodic tension-type headache (n = 39)
RCT of 7½ months duration conducted by twenty physiotherapist’s i.e. Initial baseline 6 weeks treatment, 6 months follow-up, Comparison of pre- and post-treatment and follow-up
Craniocervical training program by a physiotherapist including low-load endurance exercises for cervicoscapular and craniocervical region with twice daily home exercise combined with postural correction exercises (n = 39)
Both groups had statically significant post-treatment improvement of headache frequency, duration and intensity
Mean age 45.9 yrs
Headache diary recordings
Physiotherapy including massage, oscillation techniques described by Maitland and postural correction (n = 40)
In the craniocervical training group 82% and 85% had ≥50% reduction in headache frequency post-treatment and at follow-up, as compared to 52% and 35% in the physiotherapy group.
Mean headache frequency 20.7 days per month
Drop outs (n = 2)
The effect was a statistical significant better in those with CTTH as compared to those with episodic tension-type headache (p < 0.0001).
Headache diagnosed by physician
No individual data are presented for CTTH
Effect size not applicable
Netherland 2011 [25]
82 participants (18 M, 64 F)
RCT of 8½ months duration conducted by four physiotherapist’s i.e. 2 weeks baseline, 2 months treatment, 6 months follow-up
Usual care by general practitioner which consisted of information, re-assurance, advise, lifestyle changes and prescription of analytics and NSAIDs if necessary 2-3 visits (n = 37)
The manual therapy group had statistical significant improvement of headache frequency, duration and intensity post-treatment and at follow-up as compared to usual care group (p < 0.001, p = 0.003, and p = 0.013). This effect was maintained at follow-up (p < 0.001 and p = 0.027), except for duration.
Age 20-63 yrs
Comparison of baseline, post-treatment and follow-up
Manual therapy by a physiotherapist consisting of mobilization of cervical and thoracic column, exercises and postural correction for max 9 sessions of 30 min (n = 38)
At post-treatment and follow-up the headache frequency was reduced 77% and 77% in the manual therapy group as compared to 23% and 35% in usual care group.
Mean age 40.4 yrs
Headache diary recordings
Drop outs (n = 7)
At post-treatment and at follow-up 88% and 82% of the manual therapy group had >50% reduction in headache frequency, and 28% and 41% of the usual care group.
Mean headache duration 12.8 yrs
At post-treatment and follow-up duration was reduced 46% and 55% in the manual therapy group as compared to 5% and 27% in the usual care group.
Mean headache frequency 24 days per month
At post-treatment and follow-up intensity was reduced 43% and 49% in the manual therapy group as compared to 16% and 30% in the usual care group.
Headache diagnosed by physician
Frequency, duration and intensity effect size was 0.62, 0.27 and 0.44 at post-treatment and 0.50, 0.19 and 0.26 at follow-up
 21 participants had co-occurrence of migraine