SCIENTIFIC RESEARCH ARTICLE (ORIGINAL ARTICLE)

Effectiveness of Physical Therapy in Patients with

Tension-type Headache: Literature Review

Gemma Victoria Espí-López1, Anna Arnal-Gómez1, Teresa Arbós-Berenguer2,

Ángel Arturo López González2 and Teófila Vicente-Herrero3

1)
Physiotherapy Department, University of Valencia C/Gascó Oliag, 5. PC: 46010 Valencia, Spain.
2)
Nursing and Physiotherapy Department, University of Illes Balears Carretera de Valldemossa, km 7,5. PC: 07122 Palma de Mallorca,
Islas Baleares, Spain
3)
Occupational Health Service, Correos Group of Valencia Pza. Ayuntamiento, 24. PC: 46002 Valencia, Spain.

ABSTRACT. Background: Tension-type headache (TTH) is a disease with a great incidence on quality
of life and with a significant socioeconomic impact. Objectives: The aim of this review is to determine
the effectiveness of physical therapy by using manual therapy (MT) for the relief of TTH. Data sources:
A review was done identifying randomized controlled trials through searches in MEDLINE, PEDro, Co-
chrane and CINAHL (January 2002 - April 2012). Study selection: English-language studies, with adult
patients and number of subjects not under 11, diagnosed with episodic tension-type headache (ETTH)
and chronic tension-type headache (CTTH) were included. Data extraction: Initial search was under-
taken with the words Effectiveness, Tension-type headache, and Manual therapy (39 studies). In addi-
tion, a search which included terms related to treatments such as physiotherapy, physical therapy, spinal
manipulation was performed (25 studies). Results: From the two searches 9 studies met the inclusion
criteria and were analysed finding statistically significant results: 1) myofascial release, cervical traction,
neck muscles trigger points in cervical thoracic muscles and stretching; 2) Superficial heat and massage,
connective tissue manipulation and vertebral Cyriax mobilization; 3) cervical or thoracic spinal manipu-
lation and cervical chin-occipital manual traction; 4) massage, progressive relaxation and gentle stretch-
ing, program of active exercises of shoulder, neck and pericranial muscles; 5) massage, passive rhythmic
mobilization techniques, cervical, thoracic and lumbopelvic postural correction and cranio-cervical ex-
ercises; 6) progressive muscular relaxation combined with joint mobilization, functional, muscle energy,
and strain/counterstrain techniques, and cranial osteopathic treatment; 7) massage focused on relieving
myofascial trigger point activity; 8) pressure release and muscle energy in suboccipital muscles; 9) com-
bination of mobilizations of the cervical and thoracic spine, exercises and postural correction. All studies
used a combination of different techniques and none analyzed treatments separately, also all the studies
have assessed aspects related to TTH beyond frequency and intensity of pain. Conclusions: The findings
from these studies showed evidence that physiotherapy with articulatory MT, combined with cervical
muscle stretching and massage are effective for this disease in different aspects related with TTH. No evi-
dence was found of the effectiveness of the techniques applied separately.
Key words: Physical therapy, Manual therapy, Tension-type headache, Effectiveness
(J Jpn Phys Ther Assoc 17: 31–38, 2014)

The types and characteristics of tension-type headaches national Headache Society (IHS) in 20041). The most com-
(TTH) were included in primary headaches by the Inter- mon tension type headaches are episodic tension headaches
(ETTH), which frequency is less than 15 days per month,
Received: December 13, 2013
and chronic tension-type headaches (CTTH), which fre-
Accepted: June 23, 2014
Advance Publication by J-STAGE: August 13, 2014 quency is more than 15 days per month. This last type also
Correspondence to: Gemma Victoria Espí-López, Physiotherapy Depart- is characterised for its episodes of pain ranging from 30
ment, University of Valencia, Gascó Oliag, 5 PC. 46010 Valencia, Spain. minutes to 7 days. To be considered chronic, the headache
e-mail: [email protected]
32 Espí-López, et al.

should meet 2 or more of the following characteristics: bi- Manual therapy is considered one of the main treat-
lateral location, non-pulsatile pressure, mild or moderate ments for TTH. It is based on the treatment of neuro-mus-
pain and does not increase with physical activity. culoskeletal dysfunction through muscle and joint ana-
TTH also constitute an important area of primary care lytical manipulations based on their biomechanical study.
visits. Due to the effectiveness obtained from symptomatic There is a wide range of manual therapy treatments used in
medication, both migraines and tension headaches are of- physiotherapy11). The characteristics of the headache have
ten self-treated by patients who suffer from them2). Both to be studied to achieve an accurate diagnosis before apply-
frequency and intensity of pain can produce serious distur- ing any of these manual treatments12).
bances on the patient. Moreover, when it becomes chronic, The reviews we have found so far show either the
it turns into an important problem for both the doctor and non-effectiveness of treatments4), or always include spinal
the patient. Diagnosis of this disease is exclusively done on manipulation13,14). However, there are recent studies that in-
the clinical data and there are no other complementary di- clude manual therapy techniques which were not studied
agnostic tests to confirm TTH, so it is often done by exclu- in previous reviews. Therefore, it is necessary to collect
sion of other diseases. Prevalence rates range from 22.65% recent studies in order to focus on those treatments with
to 30% of the population, and it has repercussions on work, scientific quality, and incorporate and compare studies that
social fields, daily living activities and quality of life3). include both manipulative and articulatory therapy.
Both human and socio-economic impact are considerable The novelty of this systematic review in relation to
due to lost workdays or days with reduced work efficiency other reviews, is that we want to find the effectiveness
TTH may as well affect quality of life, impairing relation- of treatments applied in patients with TTH, not only spi-
ships with family, friends and colleagues. It can even result nal manipulation but also other treatments which include
in the cancellation of family and social activities4). In re- manual therapy. Moreover, in our study we review which
cent studies conducted in Spain, it was shown that 31% of other aspects related to TTH have been assessed beyond
people who suffered headaches were disabling during the frequency and intensity of pain which are the most com-
episode, whereas 53% reduced the efficiency of their daily mon aspects.
life activities. For Lenssink et al., 2004, from all types of
headaches, TTH is the most common form, constituting a Objective
major health problem with great socioeconomic impact4). The aim of this review is to determine the effective-
Primary headaches have a high incidence and preva- ness of physical therapy by using manual therapy (MT),
lence in general population. Migraine and TTH are the manipulative or not, in TTH treatment, as well as the as-
leading types of primary headaches. Not only have social sessed aspects.
and health transcendence but also have an important reper-
cussion in the public health system. Due to them, a high av- Methods
erage of appointments are made to different health profes-
sionals and lead to a large number of medical prescriptions From February to April 2012 systematic searches of
which cause high costs5). scientific literature were undertaken on MEDLINE, PE-
Additionally, muscle disorders play an important role Dro, Cochrane and CINAHL, for randomized controlled
in headaches. Even ETTH could become chronic because studies published from January 2002 to April 2012. For
of these disorders. In fact, it has been proved that neck and this review the initial search terms were obtained from the
head trigger points in TTH patients score higher in pain MeSH and were: effectiveness, tension-type headache, and
intensity and frequency than in healthy people6). Buchgreitz manual therapy. An additional search was done using the
et al., 20087), believe that central sensitivity caused by long following keywords also obtained from MeSH: treatment,
periods of suffering pain can make the process chronic. physiotherapy, physical therapy, physiological and spinal
Fernández et al., 2006, evaluated pericranial and neck manipulation.
muscles trigger points (TrP) both in patients with CTTH
and in healthy subjects. They studied bilateral TrP in tra- Study selection
pezium, sternocleidomastoid and temporalis muscles. Sub- Studies were included if they: 1) were in English lan-
jects with TTH with active points showed a greater intensi- guage, 2) included adult patients, 3) the sample size was
ty and duration of headache compared with those who had never below 10, 4) subjects were diagnosed with ETTH and
latent points (P < 0.05)8,9). CTTH according to the IHS criteria1) 5) included manual
Serrano et al., 200710), published a study in which therapy techniques applied more than one session per treat-
they showed that pericranial muscle contracture and stress ment , 6) studies from 2002 until 2012 and 7) at least one
played an important role in headache’s physiopathology, of the following parameters were measured: pain intensity,
which justifies the presence of pericranial pain hypersensi- pain frequency y , other evaluations concerning headache.
tivity and decreased pain threshold. The title, abstract and keywords of each article were
 PHYSICAL THERAPY FOR TENSION-TYPE HEADACHE 33

Fig. 1. Flow diagram of study selection procedure

assessed to determine if it fulfilled the inclusion criteria well as one study which examined both headache and ver-
outlined above. Studies which met inclusion criteria were tigo. Also repeated studies were excluded. The 9 remaining
included for full-text review. studies met the inclusion criteria and were analyzed. Fig. 1
shows the procedure used in study selection.
Data extraction
The selection of studies and data extraction was car- Interventions
ried by two reviewers. Initial search was undertaken on The treatments that each of the 9 studies included for
randomized controlled trials with adult patients diagnosed TTH were: 1) massage, myofascial release, traction, trig-
with TTH (IHS criteria), using the words effectiveness, ten- ger point therapy, stretching and relaxation15); 2) superficial
sion-type headache, and manual therapy. This way 39 stud- heat, massage, connective tissue manipulation and spinal
ies were obtained and reviewed. Reviews were excluded mobilization16); 3) chiropractic manipulation17); 4) initial
for not being the subject of study, but they were considered gentle massage, progressive relaxation and gentle stretch-
for the discussion. ing, adding a daily home program of active exercises for
Additionally, the following MeSH terms were added shoulder, neck and pericranial muscles18); 5) friction mas-
in the search: treatment, physiotherapy, physical therapy, sage, rhythmic passive mobilization techniques based on
physiological and spinal manipulation. Therefore, 25 more the Maitland method and cervical, thoracic and lumbopel-
studies were obtained and reviewed. One of them was ex- vic postural correction, as well as cranio-cervical exer-
cluded since it included headache with symptoms of ver- cises19); 6) progressive muscular relaxation, joint mobili-
tigo. Finally, the studies meeting the inclusion criteria were zation, functional, muscle energy, and strain/counterstrain
reviewed and analyzed. techniques, and cranial osteopathic treatment20); 7) massage
focusing on myofascial trigger point activity21); 8) pressure
Results release and muscle energy in suboccipital muscles22); 9)
cervical and thoracic spine mobilization and postural cor-
Study selection rection23).
From the search strategy, 64 potentially relevant stud-
ies were found, from which 7 reviews were excluded, as
34 Espí-López, et al.

Description of included studies therapy treatment.

The characteristics, results and main conclusions of the 2. Demirturk et al., 200216) conducted a comparative
9 analyzed studies are as follows and are presented sum- study on the efficacy of two different manual treatment
marized in Table 1. methods in patients with TTH. The study included 35
1. Quinn and Chandler, 200215) performed a headache patients with a mean age of 38.27 years old, who were
treatment recruiting 25 patients between 18 and 55 years randomly allocated into two groups. Only 30 patients
old. The treatment was done for 4 weeks, 2 times per completed the treatment programs. Superficial heat and
week, 30 minutes each session with the following 6 massage were applied to both groups, as well as connec-
phase sequence: 3 minutes of preparatory tissue warm- tive tissue manipulation to group 1 (n = 15) and vertebral
up, 5 minutes of myofascial release, 2 minutes of cervical Cyriax mobilization to group 2 (n = 15). The treatment
traction, 5 minutes of TrP in trapezius, sternocleidomas- program consisted of 20 sessions over 4 weeks plus 1
toid, suboccipital, splenius capitis and elevator scapulae month of follow-up. For comparing the effectiveness of
muscles, 5 minutes of stretching and 3 to 5 minutes of the methods the following parameters were evaluated be-
relaxation. After 4 weeks relevant outcomes were ex- fore and after treatment and in a month follow-up: head-
tracted for frequency (P = 0.009), duration of pain (P = ache pain intensity, cervical active movement range, and
0.58), and pain intensity (P = 0.19). Therefore there was pain threshold to pressure. The study results indicated
an improvement of the three measures after the manual that all parameters had significant improvements in both

Table 1. Characteristics of studies with MT and their efficacy (1)

Author n Treatment Type of Treatment Effect
duration study
Quinn and Chandler 25 4 weeks Trial without Massage, myofascial inhibition, Frequency P=0.00
200213) control traction, trigger point therapy, Pain Duration P=0.58
group stretching and relaxation Intensity P=0.19
Demirturk et al., 200214) 35 4 weeks Comparative G1: Superficial heat and Pain index, intensiy and
trial massage + connective tissue movement range P>0.05 in both
manipulation groups.
G2: Superficial heat and
massage + spinal Cyriax
mobilization
Donkin et al. 200215) 30 4 weeks Comparative G1: Thoracic spinal Perception of pain, disability,
pilot study manipulation CROM, frequency, intensity
G2: chiropractic manipulation and duration p<0.05 in , both
and cervical occipital manual groups, but better results for
traction manipulation without traction
Torelli et al., 200416) 50 G1: 8 weeks Comparative G1: Treatment (gentle massage, G1 and G2: Frequency reduced
treatment trial progressive relaxation gentle P<0.001 Compared G1 and G2
+ 12 weks stretching, and active exercises) results in the CTTH compared
observación + observation with ETTH P<0.002
G2: 8 weeks G2: Observation+ Treatment as Intensity, duration, and
observación G1 consumption of medication no
+ 8 weeks significatn results in any group
treatment + 12 no results
obsevación
van Ettekoven and Lucas, 81 6 weeks Randomized G1: friction massage, passive G1: Frequency P=0.0001;
200617) controlled rhythmic mobilization Intensity P=0.001;
trial techniques based on Maitland Duration P=0.01;
method, cervical, thoracic and Quality of life P <0.001
lumbopelvic postural correction G2: All parameters p>0.05
and cranio-cervical exercises
G2: Control group treatment
was the same except that
cranio-cervical exercises were
not applied
 PHYSICAL THERAPY FOR TENSION-TYPE HEADACHE 35

Table 1. Characteristics of studies with MT and their efficacy (2)

Author n Treatment Type of Treatment Effect
duration study
Anderson and Seniscal, 26 3 weeks Randomized G1: progressive muscular G1: Frequency P=0.016
200618) controlled relaxation + treatment (3 session Intensity, degree of pain no
trial with + joint mobilization, results positive; degree of pain
muscle energy and strain/ improved on 57,5%.
counterstrain techniques, G2: Degree of pain only
osteopathy). imporved on 15,6%.
G2: progressive muscular
relaxation
Moraska and Chandler, 18 6 weeks Pilot study Massage focused on relieving Frequency P<0.001
200819) one group myofascial trigger point activity Intensity P<0.01
Duration P<0.05
Disability P<0.001
Toro-Velasco et al., 11 2 sessions Pilot study G1: Pressure release and muscle G1: Index of HRV P=0.01
200920) energy in suboccipital muscles Anxiety P=0.03
G2: placebo treatment with Hostility, anger P=0.04
ultrasound therapy Intensity P<0.05
G2: Parameters p>0.05
Castien et al., 201121) 82 8 weeks Randomized G1: Mobilization of cervical G1: Impact P<0.001
controlled and thoracic spine, postural Disability P=0.001
trial correction exercises. Movement P=0.023
G2: usual care by general Algometry P=0.001
practitioner Strength P=0.011
G2: Parameters p>0.05

groups (P > 0.05). Thus, both treatments improved the was treated with initial gentle massage, progressive re-
measures. laxation and gentle stretching, adding daily home pro-
3. Donkin et al., 200217) performed a study with 30 pa- gram of active exercises of shoulder, neck and pericra-
tients between 20 and 62 years old divided into two nial muscles, plus 12 weeks of follow-up. Group 2 had
groups with 15 subjects each. The treatment was un- 8 weeks of observation, then 8 weeks of identical phys-
dertaken in 9 sessions over 4 weeks. The first group re- iotherapy treatment as Group 1, followed by 12 weeks
ceived cervical or thoracic spinal manipulation and the of follow-up. Comparing headache frequency before and
second received chiropractic manipulation and cervical after the treatment a significant and equal decrease was
chin-occipital manual traction 20 times (10 seconds of shown in both groups (P < 0.001). These results were
traction followed by 10 seconds of pause). Perception of significant for CTTH compared with ETTH (P < 0.002).
pain was assessed by the McGill questionnaire, disability The intensity, duration and medication, did not change
by the Neck Disability Index, intensity by the Numerical throughout the study and showed no variations between
Pain Rating Scale 101, and also cervical range of motion chronic tension headache or between episodic tension-
(CROM) and a daily register of pain frequency, intensity type headache. The study was limited by the lack of
and duration were evaluated. The first group improved as double-blind design.
well in all parameters of daily pain. Moreover, compared 5. van Ettekoven and Lucas, 200619) conducted a multi-
with the second group the first group improved in pain center, randomized controlled trial with a treatment pe-
intensity (P = 0.042), pain perception (P = 0.082) and riod of 6 weeks, immediate evaluation after them and a
its daily pain improved in intensity (P = 0.005) and in 6 months follow-up. The objective was to determine the
frequency (P = 0.018), while the rest of parameters re- effectiveness of a cranio-cervical exercise program com-
mained unchanged. The study concludes that manipula- bined with other physiotherapy treatments in patients
tion without traction is the most effective technique. with TTH. The study recruited 81 participants with TTH
4. Torelli et al., 200418) evaluated results of physiother- and a mean age of 48.3 years (SD 18.39) who were ran-
apy for TTH in 50 patients, aged between 18 and 70: domly allocated into two groups. One group was treated
26 diagnosed with ETTH and 24 with CTTH. Patients with friction massage, passive rhythmic mobilization
received physiotherapy treatment for 8 weeks: group 1 techniques based on Maitland method, cervical, thoracic
36 Espí-López, et al.

and lumbopelvic postural correction and cranio-cervical (HRV), mood states and pressure pain thresholds (PPT)
exercises with a latex band (150 cm). The control group in patients with CTTH. The sample had 11 patients with
treatment was the same except that cranio-cervical exer- a mean age of 51 years (SD 15). Group 1 received the
cises were not applied. Frequency, intensity and duration experimental treatment (pressure release and muscle en-
of pain, were evaluated, as well as quality of life with the ergy in suboccipital muscles for 40 minutes) and group
SF-36, and the multidimensional aspect with the Mul- 2 had placebo treatment with ultrasound therapy. Evalu-
tidimensional Health Locus of Control scale (MHLC). ation was performed by holter, electrocardiogram, and
The cranio-cervical exercise group showed significant PPT on temporalis, suboccipital, upper trapezius, sple-
reduction in most of the parameters. This trial showed nius capitis, sternocleidomastoid, levator scapulae, and
that cranio-cervical physiotherapy including an exercise semispinalis capitis. The mood profile was evaluated
program is effective for a long period of time in TTH. with the Profile of Mood States questionnaire (POMS).
6. Anderson and Seniscal, 200620) conducted a study to The data were obtained before intervention, immediately
compare the effects of a treatment based only on pro- after it and 24 hours later. Paired comparisons after the
gressive muscle relaxation, with a treatment based on intervention showed that the group treated with MT had
progressive muscular relaxation combined with joint an increased rate of HRV (P = 0.01), whereas no chang-
mobilization, functional, muscle energy, and strain/coun- es were found after intervention in placebo group (P =
terstrain techniques, and cranial osteopathic treatment. It 0.7). There were also differences for tension-anxiety (F
was a single-blind, randomized, clinical trial undertaken = 5.3, P = 0.03), and for hostility and anger (F = 4.6, P
with 26 patients with TTH (12 in the control group and = 0.04). Paired comparisons showed that pain intensity
14 in the experimental group). Both groups practiced re- was reduced 24 hours after the MT (P <0.05) but not
laxation exercises for 20 minutes at home, while the ex- after placebo intervention (P = 0.9). Therefore, the appli-
perimental group also received 3 osteopathic treatments cation of a single session of MT produces an immediate
(1 per week) that focused on the pelvis, cranium, cervical increase in heart rate variability index and a decrease in
and upper thoracic spine, clavicles, and upper ribs. Pain tension, in anger state and perceived pain in patients with
frequency was registered and it decreased significantly CTTH.
in the experimental group (P = 0.016), but the level of 9. The study performed by Castien et al., 201123) evaluat-
improvement in pain and headache intensity was not sta- ed the effectiveness of MT in the CTTH with 82 subjects
tistically significant. The pain rate also improved 57.5% that were randomly allocated: 41 received MT treatment
in the experimental group, while in the control group it and 41 received usual care by general practitioner. The
improved 15.6%. Therefore, progressive muscle relax- MT treatment consisted of a combination of mobiliza-
ation combined with osteopathic treatment was more ef- tions of the cervical and thoracic spine, exercises and
fective than only progressive muscle relaxation. postural correction for 8 weeks, with a maximum of 9
7. Moraska and Chandler, 200821) performed a study to sessions of 30 minutes each. Evaluation included pain
evaluate the short-term changes in patients with TTH. frequency, use of medication, headache severity, impact
The physiotherapy program was based on massage fo- and disability produced by headache evaluated with the
cused on relieving myofascial trigger point activity. The Headache Impact Test-6 (HIT-6), algometry, strength of
study recruited 18 participants with a mean age of 43.8 cervical flexors and cervical range of motion. Evaluation
years, who received the treatment 2 times per week, in was done at the end of the 8 week treatment and had
45 minute massage sessions, which began after a three a follow-up of 26 weeks. Significant differences were
week base-line period. Disability evaluation was done found for the MT group in frequency (-6.4 days, 95% CI
using the Headache Disability Inventory (HDI) and with -8.3 to -4.6), duration of headache (-5.3 hours, 95%, CI
a record of frequency, intensity and duration of pain. -9.5 to -1.2) and headache intensity (-1.8, 95% CI -3.1 to
The headaches were registered during base-line period, -0.7). After 8 weeks pain frequency was reduced to 50%
6 week treatment period and 3 week follow-up. Pain fre- in 87.5% of participants in MT group and in 27.5% in the
quency decreased from 4.7 (SD 0.7) episodes per week usual care group (Table 1). At 26 weeks follow-up the
to 3.7 (SD 0.9) during treatment period and to 3.2 (SD differences between groups were statistically significant
1.0) during the follow-up. The headache intensity was in headache frequency (-4.9 days, 95% CI -6.95 to -2.98)
reduced by 30% and headache duration decreased from pain intensity (-1.4, 95% CI -2.7 to -0.2) and impact of
4.0 (SD 1.3) to 2.8 (SD 0.5) hours. Disability index also pain (P = 0.012) in favour of the MT group. Therefore,
showed significant improvement. This results show that MT was proved to be more effective than usual care.
massage combined with myofascial trigger point treat- All the analyzed studies combine different techniques
ment is effective. and no study applies manual therapy separately and evalu-
8. Toro-Velasco et al., 200922) studied the immediate ef- ates its effectiveness, making it difficult to know which of
fects of head and neck massage on heart rate variability the techniques is most effective. 4 of them include massage,
 PHYSICAL THERAPY FOR TENSION-TYPE HEADACHE 37

Table 2. Summary of other systematic reviews of effectiveness of MT in CTTH

Author Type of treatment n Results

11)
Espí and Gómez, 2010 Drugs, manual therapy 15 studies Joint therapy, functional techniques, with
muscle relaxation have good results.
Astin and Ernst, 200222) Vertebral manipultaion 8 studies Only 3 treated TTH and do not show
conclusive results referring to effectiveness.
Fernández et al., 200623) Vertebral manipulation, 6 studies Studies using spinal manipulation showed
massage, vertebral evidence of effectiveness (level 4), while soft
mobilization, manual tissue techniques showed limited evidence
traction, cranium therapy (level 3).
Lenssinck et al., 20044) Physiotherapy and spinal 8 studies Insufficient evidence to support or refute
manipulation the efficacy of physiotherapy and spinal
manipulation in patients with TTH

2 include suboccipital inhibition and 2 spinal manipulation for reducing pain in TTH based on the methodology scale
in a different region. of PEDro. Only 6 studies had used manual therapy. Accord-
Common techniques to most of the studies are postural ing to PEDro scale evidence changed from 2 to 8 (mean 5.8
correction exercises or similar and myofascial techniques. SD = 2.1). Quality and results analysis of all trials did not
The 3 higher methodological quality studies are RCTs, provide evidence that manual therapy had a positive effect
but they combine a greater number of manual therapy tech- in reducing TTH: spinal manipulation showed evidence of
niques and none of them focuses on the treatment of suboc- effectiveness (level 4), while soft tissue techniques showed
cipital or craniocervical region. limited evidence (level 3).
Lenssinck et al., 20044) performed a systematic review
Discussion of randomized controlled trials (RCTs) to determine the ef-
fectiveness of physiotherapy and spinal manipulation in pa-
This review found that manual therapy can be an alter- tients with TTH. A total of 8 RCTs that used physiotherapy
native for treatments and therapies used for TTH which do or spinal manipulation in the treatment of TTH in adults
not have complete effectiveness. were selected. These studies showed a variety of interven-
The studies found in this review show that massage tions such as spinal chiropractic manipulation, connective
combined with: cervical exercises, myofascial techniques, tissue manipulation or physiotherapy. Only two studies
postural techniques, cervical relaxation exercises, cervical were considered of high quality, but showed opposite re-
mobilization, gentle and progressive stretching or TrP treat- sults. Due to clinical heterogeneity and low methodologi-
ment are effective in reducing pain frequency, intensity and cal quality of many of the studies, it did not seem possible
duration, as well as increasing range of motion. Relaxation to show valid conclusions. Therefore, there is insufficient
exercises combined with cervical exercises were only ef- evidence to support or refute the efficacy of physiotherapy
fective in reducing pain frequency in CTTH, and were not and spinal manipulation in patients with TTH according to
in ETTH. The reviewed studies that apply only manipula- this review. Table 2 shows different reviews that study the
tion showed positive results, however, they did not have effectiveness of MT in TTH.
control group or their methodological quality was low and As shown in this review, massage combined with other
systematic reviews show no conclusive results of its ef- physiotherapy techniques is usually effective, but we still
fectiveness. However this therapy appears to be effective do not know if other physiotherapy techniques are effec-
when it is combined with massage. tive separately. Likewise, so are MT techniques. However,
Other authors13) conducted a review which evaluated few studies have implemented specific physiotherapy tech-
the effectiveness of manipulation in headache. It included niques based on MT for the treatment of headache, prob-
8 randomized studies and the Jadad scale was used for as- ably this is due to the effectiveness for relieving pain of
sessing the validity of the scientific article. 6 trials were in- pharmacological measures11). Therefore, greater number
cluded in the study and only 3 treated TTH. No conclusive of evidence-based studies is needed to determine the ef-
results referring to the effectiveness of spinal manipulation fectiveness of physiotherapy for patients with TTH. In ad-
were obtained since the studies were limited for not having dition, due to the application of treatments that combine
control group or only single-blind control. several techniques, it is not possible to distinguish whether
Along the same lines, Fernández de las Peñas et al.14) the same results would be shown for each treatment on its
performed a review of the effectiveness of manual therapy own.
38 Espí-López, et al.

The highlight of this review was to determine other Brain. 2008, 131(12): 3232–3238.
physiotherapy techniques which include manipulative man- 8) Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML,
ual therapy or not and the assessments which are important Gerwin RD and Pareja JA: Myofascial trigger points and
in different spheres such as quality of life, disability, impact their relationship to headache clinical parameters in chronic
of pain and pain perception, and not just pain frequency tension-type headache. Headache. 2006, 46: 1264–1272.
9) Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML,
and intensity of pain during crisis which decreases in most
Gerwin RD and Pareja JA: Trigger points in the suboccipital
of the treatments. The main limitation of this study is that
muscles and forward head posture in tension-type headache.
the results are not taken into account the risk of bias and
Headache. 2006, 46: 454–460.
reporting bias. 10) Serrano C, Andrés MT and Sánchez-Palomo MJ: Cefalea de
tensión. Medicine. 2007, 9(70): 4473–4479.
Conclusion 11) Espí GV and Gómez A: Eficacia del tratamiento en la cefalea
tensional. Revisión sistemática. Fisioterapia. 2010, 32(1):
Cervical exercises, relaxation, massage, postural exer- 33–40.
cises, cranio-cervical techniques, thermotherapy, vertebral 12) Niere KR: Pain descriptors used by headache patients pre-
mobilization and stretching are effective in reducing TTH senting for physiotherapy. Physioteherapy. 2002, 88(7): 409–
symptoms such as pain frequency and intensity. In the stud- 416.
ies that have applied joint mobilization, cervical range of 13) Astin JA and Ernst E: The effectiveness of spinal manipu-
lation for the treatment of headache disorders: a systematic
motion has improved. Other parameters such as quality of
review of randomized clinical trials. Cephalalgia. 2002, 22:
life, impact and pain disability and psychological aspects
617–623.
have improved with MT. Therefore it would be advisable
14) Fernández de las-Peñas C, Alonso-Blanco C, Cuadrado ML,
to use it both to improve the quality of life of patients and Miangolarra JC, Barriga FJ and Pareja JA: Are manual thera-
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