Current Pain and Headache Reports (2018) 22:82

https://doi.org/10.1007/s11916-018-0736-y

HOT TOPICS IN PAIN AND HEADACHE (N ROSEN, SECTION EDITOR)

A Short Review of the Treatment of Headaches Using

Osteopathic Manipulative Treatment
John Whalen 1 & Sheldon Yao 1 & Adena Leder 1

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Purpose of Review This review highlights the importance of osteopathic manipulative treatment (OMT) in headache sufferers.
OMT is a viable option for patients who either do not wish to use pharmaceuticals or who have contraindications to pharma-
ceuticals. Patients with headaches that are refractory to other treatment options may also be candidates for OMT. Multiple
headache etiologies are amenable to this non-invasive treatment option and they will be reviewed here. Although there are
advantages to using this treatment method, there are also shortcomings in the literature, which will be discussed.
Recent Findings Roughly 45 million Americans suffer from headaches every year. Many headache sufferers are unable to find
relief through conventional treatment options. OMT is a useful non-invasive treatment option with little to no side effects. There
are multiple headache types. Migraine, tension-type headache, combat-related events, post-traumatic headache, sinusitis, tooth
extraction, concussions, and others have all shown benefit from OMT.
Summary OMT is a non-invasive treatment option for individuals suffering from various types of headaches. This treatment
option is tailored to the individual needs of the patient and is delivered by licensed and experienced osteopathic physicians. This
review of literature also highlights where there is need for further research in the field.

Keywords Headache . Migraine . Osteopathic manipulative treatment

Introduction treatment options are often unsatisfying [4]. Over-the-counter

medications are often advised by physicians without warnings
Headaches are a common ailment and can be extremely dis- of the possible side effects. NSAIDs (non-steroidal anti-
abling. Migraine headaches are the most common type of inflammatory drugs), the leading over-the-counter agent in
headache and possibly the most debilitating. Of the roughly headache treatment are used as an abortive medication [3].
45 million Americans who suffer from headaches, according to Excessive NSAID use has been linked to gastro-intestinal ul-
the American Migraine Foundation, approximately 36 million cers, renal impairment, and cardiovascular complications.
Americans suffer from migraines [1, 2]. It is not uncommon for Excessive acetaminophen use has been linked to liver dysfunc-
treatment options to cause headaches. Medication-overuse tion [3]. Triptans are another widely used medication for head-
headache is also known as rebound headache [3].Though aches. Triptans have some minor side-effects like nausea, dry
headache occurrence is common, conventional medication mouth, dizziness, fatigue, and even headache [3]. Other side-
effects of this medication include tachycardia, and vasocon-
Topical Collection on Hot Topics in Pain and Headache striction of arteries, including coronary arteries and veins [5].
Thus, the use of this class of drug with Prinzmetal’s angina,
* John Whalen cardiovascular disease, or peripheral artery disease is generally
[email protected] contraindicated [5]. Ergots (i.e., dihydroergotamine) are an
abortive migraine treatment option. While ergots can relieve
Sheldon Yao
[email protected] headache symptoms, these medications may also have severe
cardiovascular contraindications [5].
Adena Leder
[email protected]
The use of many of these medications is relatively contra-
indicated in special populations due to potential drug interac-
1
New York Institute of Technology College of Osteopathic Medicine, tions and adverse effects. Children, pregnant women, and the
Glen Head, NY, USA elderly are especially at risk. In the elderly, there is often the
82 Page 2 of 7 Curr Pain Headache Rep (2018) 22:82

issue of polypharmacy, and decreased renal function, which neuromusculoskeletal medicine, family medicine, or sports
limits the ability to prescribe further medications. Children medicine certified. The physician who is providing this treat-
need to be monitored very closely when prescribed triptans. ment is well trained and knowledgeable about the indications
Triptans have been linked to pulmonary disease and cardiac and contraindications of the procedures. These physicians in-
valvular disease [6]. There is variability in prescribing prac- dividualize the treatment to the particular patient’s needs.
tices with regard to triptans in pregnant patients. The risk to
the developing fetus when exposed to a triptan may include
low birth weight, impairment of skeletal ossification, and re- Mechanism of Osteopathic Manipulative Treatment
productive dysfunctions later in life [6]. Dihydroergotamine
as well as other ergot alkaloids are contraindicated in pregnan- OMT improves the symptoms of a headache through multiple
cy. These drugs have potent oxytocic and uterine stimulant different mechanisms. OMT is used to treat headaches by
properties, which can induce labor [4]. Individuals with car- correcting somatic dysfunctions related to the head and neck
diovascular complications should use these medications with region. The term somatic dysfunction is defined as “impaired
caution as it can cause peripheral and coronary artery vaso- or altered function of related components of the somatic (body
constriction [5]. framework) system: skeletal, arthrodial, and myofascial struc-
Finally, excess use of headache medications can lead to tures, and related vascular, lymphatic, and neural elements”
rebound headaches [3]. Rebound headaches are headaches [12]. Through the treatment of these dysfunctions, headaches
that are actually caused by the medications themselves [3]. that are the result of myofascial and structural restrictions in
Overuse of medications or daily medication use for headaches the head and neck can be addressed.
can interfere with the normal functions of the brain, especially OMT can alleviate headaches through manipulation of
the normal inflammatory response of the brain [7]. Excess the fascia surrounding cranial bones. Thus, the manipulation
medication use, greater than 10 to 15 days a month, has been of the fascia can help the function of the surrounding struc-
linked to migraine transformation and accelerating headache tures, which include the cranial bones and nerves. Though
frequency [7].Disruption of inflammatory mediators has been some controversy might exist, evidence has been shown that
linked to sensitization of trigeminovascular neurons, which the sutures of the cranium can move between 2.58° to 1.25°
contributes to the formation of migraines [7]. based on x-ray findings [13••]. One theory that exists is, by
Botulinum toxin injections have been FDA approved manipulating the fascia around cranial bones, restrictions to
since 2010 as a treatment option for headaches, especially the nervous system could be decreased, potentially having a
for patients who have more than 15 headaches per months, positive effect overall on the nervous system. The major
also known as chronic headaches [8].In the PREEMPT 2 cranial nerve of the parasympathetic nervous system is the
trial the results showed a significant decrease in migraines vagus nerve. This nerve may benefit through the manual
as well as a decrease in headache-related disability manipulation of the neighboring tissues and the occipital
[9].However, the drawbacks to utilizing this medication in- bone and cervical spine [14]. Through the manipulation of
clude cost (not always covered by commercial insurance the neighboring tissues, this nerve could have musculoskel-
companies), and it can be a painful treatment (approximate- etal restrictions removed [14]. The removal of these restric-
ly 30 injections per treatment). Additionally, in order for the tions may be able to improve the function of the nervous
medication to be covered by insurance, the patient must tissue and alleviate symptoms.
demonstrate more than 15 migraines per month and failures Recently discovered evidence of the glymphatic system
of at least two daily oral prophylactic medications [8]. shows how the brain has a lymphatic system [15••]. There
According to the American migraine foundation, the FDA are OMT techniques that are specifically designed to remove
recommends dosages of 155 units per treatment to properly restrictions to and promote lymphatic flow. Cranial osteopath-
treat this condition [8]. Some of the possible side effects of ic manipulative treatment has been theorized to also increase
botulinum toxin injections include pain and swelling at the blood flow and fluid drainage from specific areas of the cra-
injection site, ptosis, excessive dryness or tearing, flu like nium, face, and neck [16]. The increase of blood flow could
symptoms, and even headache [10]. More severe (but rarer decrease symptoms and increase oxygen and nutrients to this
symptoms) include dyspnea, muscle weakness, and vision area. Increasing lymph drainage, specifically for the sinuses,
problems [10]. Osteopathic manipulative treatment (OMT) could decrease pressure and relieve symptoms of a headache
can serve as an alternative to ergots, NSAIDS, triptans, and [16]. By manipulating the cranial bones and the structure of
botulinum toxin therapy without the extensive list of side the skull, a physician has the ability to increase drainage of the
effects and with a similar level of efficacy. skull and CNS [14]. Osteopathic manipulative treatment of the
OMT is performed by licensed and trained osteopathic cranium and drainage of the glymphatic system not only has
physicians who have completed medical school [11]. The ma- the ability to help individuals with headaches, it has also been
jority of osteopathic physicians who perform OMT are theorized to help individuals with Alzheimer’s disease [15••].
Curr Pain Headache Rep (2018) 22:82 Page 3 of 7 82

Etiologies and Treatments of Headaches receptors [23]. Thus, by correcting somatic dysfunctions
which normally would lead to the irritation of the trigeminal
OMT has the ability to treat multiple headache types. One ganglion, the osteopathic physician can treat and prevent
cause of headaches is sinus congestion and sinus infections. headaches [23].
The sinuses in the skull can become inflamed and fill with Post-traumatic headache has been reported to cause head-
fluid and mucus from the lymphatic system [17•]. OMT has aches in individuals [24]. Often other forms of treatment have
been shown to decrease the symptoms of individuals with not been successful in providing relief [24]. OMT has been
headaches caused by sinusitis [17•]. Data from the treatment shown to help post-traumatic headaches and those produced
of sinusitis can be found in Table 1. by extreme stress [23].
Increased tension in the muscles of the head and neck are Finally, headaches caused by concussions have shown im-
the most common etiologies of tension headaches. Relieving provement with OMT [25]. Similarly, treating the somatic
the muscle tension through OMT is specifically implemented dysfunctions specific to the patient with extra attention to
to treat this type of headache [18, 21•]. Improving autonomic the suboccipital area, the patient’s headache was improved
tone, blood flow, and lymph drainage will improve the symp- [25]. OMT has also been seen to treat the rarely diagnosed,
toms of these headaches as well. The somatic dysfunctions new daily persistent headache [26].
that are commonly associated with tension headaches can be
diagnosed and treated, often relieving the symptoms of the
headache. Typically, individuals who suffer from tension
Review Article Methods
headaches are treated with pharmacological remedies. Many
of the pharmacological treatments have side effects which the
Journal articles were reviewed by two researchers and ana-
patients are unable to tolerate, or these side effects may be
lyzed for their number of subjects and use of osteopathic ma-
detrimental to the patient’s health [3].
nipulation. Articles were chosen for their use of osteopathic
No standardized treatment was seen in the articles. Rather,
manipulative treatment as well as description of the tech-
the patient who was complaining of a headache was scanned
niques that were used and description of the results. In this
by the physician for somatic dysfunctions, which were then
review article, an effort was made to look for articles
corrected in the manner that was most appropriate from the
explaining how osteopathic manipulative treatment can be
point of view of the physician. Since each patient could have
used to treat headaches of varying etiologies. This review
different dysfunctions, no two treatments were the same. The
demonstrates the broad range of effects that osteopathic ma-
two articles that were reviewed had different treatments based
nipulative treatment could have for headache sufferers. Each
upon the type of osteopathic manipulative treatment that was
article was analyzed for their use of osteopathic manipulative
performed and the amount of time per treatment.
treatment and their connection to the change in symptoms
Migraine headaches are one of the most common forms of
seen in the patient.
headaches and one of the most debilitating for those who have
Articles that used other methods along with osteopathic
them. Two types of migraine headaches were included in this
manipulative treatment were not excluded. Rather, this was
study, typical migraine headaches and high-frequency mi-
done to show how osteopathic manipulative treatment could
graine headaches [19, 20]. Data from both studies can be seen
be used alone or in conjunction with other medical treatments.
in Table 1, which show that OMT was able to decrease symp-
Case studies were also used to demonstrate how osteopathic
toms and decrease frequency of headache occurrences.
manipulative treatment can be used for specialized cases. The
Dental complications are often a reason for headaches in
articles did not have a standard number of patients nor a stan-
individuals and OMT was shown in one study to decrease the
dard population from which patients were drawn. Rather the
headaches accompanied by tooth pain [22•]. Structural dam-
articles reviewed in this paper range from a single patient to 76
age and irritation of the mandible can cause headaches in
patients. The ages range from 15 years old to 65 years old.
individuals. OMT was seen to relieve the symptoms in indi-
viduals with a persistent headache after the removal of a tooth
[22•]. By relieving the dysfunction found in the cranial bones
(specifically the sphenoid bones), the patient may experience Results
relief [22•]. The sphenoid bone has foramina that allow for the
passage of the three components of the trigeminal nerve [22•]. Seven studies were analyzed in the creation of this journal
If the trigeminal nerve is irritated or affected, it will produce article. Osteopathic manipulative treatment was used in all
substances that vasodilate the surrounding blood vessels [23]. seven of these studies and was used for different headache
The surrounding blood vessels lie just beneath the dura mater etiologies. In all of the studies, osteopathic manipulative treat-
which has pain receptors [23]. As the vessels dilate and ment was found to improve the symptoms of the patients.
stretch, they stretch the dura mater and activate the pain Though some of the articles have evidence of other treatments
 82

Table 1 Below is a table of the various articles that are reviewed. Included in the table are the first author or authors, outcome measure, the type of manipulation treatment, length of the procedure and
number of procedures, the population that the treatment was given to, and type of headache that was treated and the outcome results

Author (year) Outcome Intervention type Length of procedure Population Type of Outcome results
measures Headache
Page 4 of 7

Lee-Wong M, et al., Efficacy of Osteopathic manipulation of Each of the 15 patients who 15 patients of unknown age and Sinus headache The average pretreatment score for
2011 [17•] “osteopathic individuals with chronic sinusitis accepted the offer received 1 gender [17•]. [17•]. the 15 participants was 3.07.
manipulative [17•]. osteopathic manipulation Immediately after the
treatment” session, which comprised 6 osteopathic manipulation
protocol to treat maneuvers lasting 3 min each protocol, the average score was
individuals with (for a total of 18 min of 2.33, representing a statistical
chronic sinusitis treatment) [17]. difference of P = .0012. On the
[17•]. scale of improvement in sinus
symptoms, 1 patient reported
complete improvement, 11
reported moderate improvement,
and 3 reported minimal
improvement. Only 4 patients
reported discomfort (classified as
minimal) with the manipulation
procedures [17•].
Mariagrazia D’Ippolito, Efficacy of Four 45-min sessions were Over an 8-week span [18]. The medical records of 11 patients High-frequency The medical records of 11 patients
Psy; Marco Osteopathic provided over 8 weeks. The (6 women; mean [SD] age, 47.5 migraine-type (6 women; mean [SD] age, 47.5
Tramontano, DO Manipulation techniques were focused on [7.8] years) with diagnosis of headaches, [7.8] years) with diagnosis of
(Italy); Maria for individuals correcting the dysfunctions high-frequency migraine were where high-frequency migraine were
Gabriella Buzzi, MD, with found during the first evaluation included in the study [18]. medications included in the study. The T0 and
PhD [18]. high-frequency and were performed using to treat T1 questionnaire scores showed
migraine-type myofascial techniques, balanced migraines statistically significant decreases
headaches [18]. ligamentous tension, and were also in mean scores: STAI X-2 (T0:
osteopathy in the cranial field used [18]. 43.18 [2.47]; T1: 39.45 [2.52];
[18]. P < .05) HIT-6 (T0: 63 [2.20];
T1: 56.27 [2.24]; P < .05) and
HDI (T0: 58.72 [6.75]; T1: 45.09
[7.01]; P < .05) [18].
Hollis H. King, DO, PhD Efficacy of Craniosacral therapy was applied The 20 participants (18 women, 2 Participants aged 18 to 50 years Migraine Results showed significant
University of Osteopathic by 1 of 4 therapists who were men) were randomly assigned to were recruited if they had a headaches lowering of HIT-6 scores
California, San Diego Manipulation trained in CST, which is a 1 of 2 groups, A or B. The HIT-6 diagnosis of migraine and [19]. immediately after CST and then
School of Medicine for individuals technique similar to cranial was filled out 4 times every reported that they had had 2 or at 4 weeks after receipt of CST
[19] migraine type osteopathic manipulative 4 weeks: first, at baseline; more migraine headaches in the (P = .004) [19].
headaches [19] medicine. In this study, the second, after group A received month preceding the study [19].
therapists followed the sequence CST and group B waited; third,
of the so-called 10-step CST, after group B received CST and
which are diaphragm, cranial group A waited; and fourth,
bone, and facial bone “releases 4 weeks later [19].
[19].”
Gemma Victoria Efficacy of The suboccipital musculature was Each subject received four Seventy-six (62 women) patients Tension-type Compared to baseline, the
ESPÍ-LÓPEZ, et al., Osteopathic palpated until contact was made treatment sessions, each lasting aged between 18 and 65 years headaches suboccipital inhibition treatment
Curr Pain Headache Rep (2018) 22:82

2016 [18] Manipulation with the posterior arch of the approximately 20 min, with (age 39.9 ± 10.9) with either [18] group showed a significant
for individuals atlas, and progressive and deep 7-day intervals. Treatments were episodic or chronic TTH [18]. improvement in their overall
with gliding pressure was applied, performed at a specialized center quality of life at the 1-month
tension-type pushing the atlas anteriorly. The for the treatment of headache follow-up and also showed
headaches [18] occiput rested on the hands of the [18]. specific improvement in the
therapist while the atlas was dimensions related to moderate
Table 1 (continued)

Author (year) Outcome Intervention type Length of procedure Population Type of Outcome results
measures Headache

supported by the fingertips. physical activities, and in their

Finger pressure was maintained emotional Role [18].
for 10 min to produce the
proposed therapeutic effect of
inhibiting the suboccipital soft
tissues [18].
Patricia M. Meyer, DO, Osteopathic Osteopathic manipulative treatment OMT was performed once at the A 52-year-old man presented with Headache that is The patient reported substantial
MS Sharon M. Manipulation was performed at the 2-month 2-month follow-up visit and neck pain, headache, and low attributed to a improvement in his symptoms
Curr Pain Headache Rep (2018) 22:82

Gustowski, DO, for individuals follow-up visit. The cranial again 1 week after the first back pain that began 2 weeks tooth on a follow-up visit 1 week after
MPH, 2012 [20] with headaches dysfunction was addressed using treatment [20]. previously. These symptoms extraction and receiving OMT. He had
and neck pain parietal and frontal lifts, as well began after a right upper tooth neck injury resolution of his headaches,
after tooth as the v-spread technique. extraction, as well as after he had [20]. minimal residual pain in his
extractions and Muscle energy, myofascial overstretched his neck and neck, and a decrease in his arm
neck injury [20]. release, counterstrain, and overexerted himself while tenderness. The patient was
articulatory techniques were pushing a car [20]. again treated with OMT at this
applied to the cervical spine. The visit, with complete resolution of
thoracic spine dysfunction was his symptoms [20].
treated using the high-velocity,
low-amplitude technique, and
the rib dysfunction was resolved
using the Still technique. The
patient reported substantial
improvement in his symptoms
on a follow-up visit 1 week after
receiving OMT. He had
resolution of his headaches,
minimal residual pain in his
neck, and a decrease in his arm
tenderness. The patient was
again treated with OMT at this
visit, with complete resolution of
his symptoms [20].
Guido Rolle, MD, DO Efficacy of The OMT that was performed for One course of treatment lasted 21 individuals randomly selected Frequent 40 patients completed the study
(Italy); Lucio Osteopathic the experimental group was 1 month and then a 3-month who have been suffering from Episodic (OMTh, n = 21; control, n = 19).
Tremolizzo, MD, manipulation tailored for the needs of each course of treatment existed [21•]. frequent episodic Tension-type Tension-Type The OMTh group had a
PhD; Francesco for individuals person, no uniform treatment headaches [21•]. Headache significant reduction in headache
Somalvico, MS; Carlo with Frequent was performed [21•]. [21•] frequency over time that
Ferrarese, MD, PhD; Episodic persisted 1 month (approximate
and Livio C. Bressan, Tension-Type reduction, 40%; P < .001) and
MD [21•] Headache [21•] 3 months (approximate
reduction, 50%; P < .001) after
the end of treatment. Moreover,
there was an absolute difference
between the 2 treatment groups
at the end of the study, with a
33% lower frequency of
headache in the OMTh group
Page 5 of 7 82

(P < .001) [21•].

82 Page 6 of 7 Curr Pain Headache Rep (2018) 22:82

that were used with osteopathic manipulative treatment, they the results of different journal articles can be compared in a
were not excluded. uniform fashion. This is very different than a pharmacological
article in which each person in a trial will receive the exact same
drug at the exact same dose and at the exact same time.
Discussion Another limitation of this review article was that each study
that was analyzed had a different system of measuring the
Osteopathic manipulative treatment is capable of improving change in symptoms of their subjects. Some articles had each
headache symptoms in patients that are unable or unwilling to patient subjectively state what their pain level was on a scale of
tolerate other forms of treatment. Though the methods by which 1 to 10; that was then compared to their pain level after the
the patients recorded their change in symptoms was not uni- treatment was completed. Other studies used questionnaires in
form, a pattern of positive findings can be established. order to assess the level of pain the patient was experiencing. A
Consistently, individuals who were suffering from a headache unified standardized method is needed to assess pain, especially
and who received OMT had a reduction of symptoms. It is seen for a symptom like headache which is incredibly subjective.
as an alternative when other more conventional treatments are
not available. OMT may be implemented when conventional Future Research
treatments are not successful, as well as in conjunction with
conventional treatments. More data is needed to determine if Future studies should include more complete descriptions of
OMT increases the efficacy of other conventional headache the techniques, amount of time per technique, and reason for
treatments. In many regards, the pharmacological treatments the treatment in their research. Many of the articles that were
may only be beneficial to the individual by masking the pain cited in this review were case studies. The results of these case
and the symptoms rather than treating the underlying cause. studies will need to be reproduced and tested in larger num-
OMT can potentially correct the underlying cause of the bers to show statistical significance as well as reproducibility.
person’s headache. The results also reveal that, though head- Another suggestion is to collect data as to how the patient is
aches can have various etiologies, OMT can be used to relieve reacting after each and every technique. The reason for this is
any type of headache, regardless of the cause. OMT is not to determine which techniques are having a positive reaction
limited to the musculoskeletal etiology. These procedures and which ones are not. A direct connection between the
can be used to treat headaches that come from neurological, OMT techniques, the physical changes to the neck and head
circulatory, and even psychological etiologies. created by the procedure, and the decrease in symptoms due to
OMT is also able to shed light on the pathophysiology of the physical change needs to be documented. This will show
headaches. By manipulating cranial bones, improving blood that OMT is directly having an impact on the headache rather
flow, increasing lymph drainage, and treating somatic dysfunc- than a psychosomatic or placebo-like effect on the patient.
tions, headache symptoms are capable of being improved. This Based upon that recommendation, future articles could pin-
could suggest that many headaches and headache symptoms point the cause of the headaches and improve our understand-
are caused by structural abnormalities in the neck and skull, ing of them. More studies should be completed containing
rather than just imbalances of chemicals or neurotransmitters. OMT as the only treatment, instead of studies that have both
Though the data is sparse and the methods of reducing the OMT and conventional treatments.
symptoms of headaches are not completely comparable be-
tween studies, evidence has been shown of its effectiveness.
More research and studies will need to be completed in order Conclusion
to show the effectiveness of the treatments. Though a definitive
conclusion about the efficacy of OMT for headaches could not In summary, headaches are a major debilitating condition for
be concluded, the evidence that OMT is beneficial is strong. Americans and many of these individuals only use pharmacolog-
ical agents to treat their symptoms. Through treatment of the
Study Limitations somatic dysfunctions that often cause headaches, relief can be
found for those individuals. The information in this review article
One limitation of the study was the number of available journal helps to support the notion that OMT is beneficial for the treat-
articles to review. The limited number of articles made it chal- ment of headaches, though the number of articles and amount of
lenging to fully assess the impact of OMT for headaches. information is limited. According to the Migraine foundation,
Another constraint of this study is that OMT is by design not a migraines alone cost Americans 36 billion dollars a year annual-
standardized procedure. OMT is designed to treat only the so- ly, and cause 113 million lost work days [27]. This drain on
matic dysfunctions that exist for each individual person. Thus, society and the resources of the healthcare industry need to be
no one person will get the exact same treatment as anyone else. analyzed differently. Perhaps with further research, headaches
A standardization of OMT treatments needs to be created so that and migraines will be analyzed and treated differently. With a
Curr Pain Headache Rep (2018) 22:82 Page 7 of 7 82

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