1.
Abstract
2.
Treatment
3. Background
4. Objectives
5. Criteria for including studies
6.
Search strategy
7. Data collection and evaluation of studies
8.
Description of studies
9.
Methodological quality
10. Results
11. Discussion of findings
12. Conclusions
13. References
14.
Further Resources
1.
Abstract
Headache
is one of the most common medical complaints in the general population.
Tension-type headache and migraine are the most common types of primary
headache (headache that is not due to underlying disease). People with
tension-type headache or migraine can experience considerable pain,
disability and reduced quality of life
Many
people with headache use non-invasive physical therapies, in addition to, or
instead of, pharmacological treatments. There are a diverse range of
physical therapies with various proposed modes of action. Some physical
therapies are administered by health professionals while others are
administered by practitioners of complementary medicine. Many physical
therapies are self-administered.
There is
some evidence from a Cochrane systematic review to suggest that certain
physical therapies may be of some benefit in preventing migraine and
tension-type headache. In particular, spinal manipulation may be of benefit,
though it is not possible to make definitive conclusions.
The
evidence to support various other physical therapies such as pulsating
electromagnetic fields, transcutaneous electrical nerve stimulation (TENS),
therapeutic touch, cranial electrotherapy and massage (or various
combinations of these) is weak.
The
studies in the Cochrane review were generally inadequately powered to
evaluate safety. However, the limited evidence available suggests that
non-invasive physical therapies are associated with little risk of serious
adverse events.
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2.
Treatment
Type of treatment:
Non-invasive
physical treatments for people with chronic or recurrent headache.
Synonyms
and Common names
Treatments
include (but are not limited to) therapeutic heat or cold, traction,
electrical modalities (e.g. TENS, interferential therapy, electromagnetic
therapy, microcurrent, ultrasound, laser), exercise, spinal manipulation or
mobilisation, massage, reflexology, stretching and trigger-point therapy.
Indication Treatment of people with chronic or
recurrent headache.
3.
Background
Headache
is among the most common medical complaints in the general population.
Headaches are categorized as primary if there is no underlying medical
condition to account for the headache, or secondary if the headache is due
to an underlying medical condition.
Tension-type headache is the most common primary headache and accounts for
90% of all headaches. Migraine is the second most frequently occurring
primary headache (Steiner 2002). Tension-type headache and migraine can
cause a significant amount of pain and disability, and can lead to a reduced
quality of life. In addition, they are associated with a significant
socioeconomic burden due to days of work lost. It should be noted that
symptoms of migraine and tension-type headache often overlap and a diagnosis
is sometimes difficult.
There are
various treatment approaches for primary headaches. These commonly involve
pharmacological therapy. Simple analgesics and nonsteroidal
anti-inflammatory drugs (NSAIDs) are widely used to relieve headache pain
while more potent analgesics may sometimes be required. Various classes of
medication are also used in a prophylactic capacity to prevent headaches in
those with chronic or recurrent headache.
Many
people use physical therapies in addition to (or instead of) pharmacological
treatment to treat headache. There are many different types of physical
treatments. Some of these include therapeutic heat or cold, traction,
electrical modalities (e.g. TENS, interferential therapy, electromagnetic
therapy, microcurrent, ultrasound, laser), exercise, spinal manipulation or
mobilization, massage, reflexology, stretching and trigger-point therapy.
Physical treatments are often used with the aim of avoiding the side effects
of pharmacological treatment.
Some of
these physical therapies are administered by health professionals such as
physiotherapists or practitioners of complementary medicine, while others
may be self-administered. For many physical treatments, the precise mode of
action is poorly understood. Nevertheless, theories concerning their effects
often relate to the observation that direct mechanical pressure and effects
mediated by the nervous system may
reduce
muscular and mental tension.
The aim of
this review was to assess the effectiveness of non-invasive physical
therapies in people with chronic or recurrent headache. A secondary
objective was to evaluate the safety of these therapies.
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4.
Objectives
To
assess the potential benefits and harms of non-invasive physical therapies
for people with chronic or recurrent headaches.
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5.
Criteria
for including studies
·
Types of study: published systematic reviews or randomised
controlled trials (RCTs) and quasi-randomised trials of non-invasive
physical treatments
versus placebo, no treatment or any other treatment, in people with chronic
or recurrent headache.
·
Types of participants: persons of any age with chronic or
recurrent headache including (but not limited to) migraine, episodic and
chronic tension-type headache, cluster headache and cervicogenic headache.
·
Types of intervention:
non-invasive physical treatments including (but not limited) to therapeutic
heat or cold, traction, electrical modalities (e.g. TENS, interferential
therapy, electromagnetic therapy, microcurrent, ultrasound, laser),
exercise, spinal manipulation or mobilization, massage, reflexology,
stretching and trigger-point therapy.
·
Types of outcome measure: patient-related outcomes such as
headache pain intensity, headache index, headache frequency, headache
duration, analgesic use, activities of daily living, quality of life,
functional health status or patient satisfaction. Side effects were
reported, if data were available.
·
Exclusions: Studies of acupuncture and psychological interventions as the
primary intervention were excluded.
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6.
Search
strategy
The
following databases were searched in May 2006: AMED, The Cochrane Library,
MEDLINE, EMBASE, CINAHL. The reference lists of publications retrieved by
the search for further relevant studies were checked.
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7.
Data
collection and evaluation of studies
We
used the above search strategy to obtain titles and abstracts of studies
that were potentially relevant to this review. Where studies met the
criteria for inclusion, they were assessed in full text. The quality of each
study was evaluated using the SIGN criteria (http://www.sign.ac.uk/methodology/checklists.html)
for the evaluation of RCTs and systematic reviews. Where primary studies
were included in a good quality systematic review, the systematic review was
included rather than the individual primary studies.
The overall
quality of the body of evidence (considering all the included studies) was
graded according to the CEBM levels of evidence system (www.cebm.net/levels_of_evidence.asp).
Relevant data
were extracted from the studies selected for inclusion.
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8.
Description of studies
Only a single
Cochrane systematic review of randomised and quasi-randomised controlled
trials of non-invasive physical treatments for chronic or recurrent headache
(Bronfort et al. 2004) met the criteria for inclusion. Studies published
since the Cochrane systematic review did not meet the criteria for
inclusion.
Summary
details of the trials included in the systematic review are as follows:
|
Study
|
Participants |
Intervention & Comparison |
Outcomes measured |
Comment |
|
Ahonen
1984
Finland
|
22
people with myogenic headache associated with tension-neck syndrome |
Acupuncture
vs
parafango (warm paraffin and mud) + massage followed by ultrasound
for 3
weeks |
·
Headache pain intensity (VAS) |
Parallel group design
Loss
to follow up not specified
Side
effects not specified |
|
Ammer
1990
Austria |
40
people with cervicogenic-like occipital headache |
Spinal
manipulative therapy + pulsed galvanic current to neck
vs
direct galvanic current to forehead/neck + ultrasound and UV-light
vs
moist herbal pack + massage of neck and shoulders
for 2
weeks |
·
Patient-rated headache improvement
|
Parallel group design
16%
loss to follow up (7/45) |
|
Bitterli 1977
Switzerland |
30
people with cervicogenic-like headache |
Spinal
manipulative therapy for 3 weeks
vs
mobilization for 3 weeks
vs
waiting for 3 weeks followed by spinal manipulative therapy for 3
weeks,
with
post-treatment follow up at 3 months |
·
Headache pain intensity (VAS) |
Parallel group design
23%
(7/30) missing pain ratings at 3 months
Side
effects not specified |
|
Boline
1995
USA |
150
people with tension-type headache |
High
velocity, low amplitude spinal manipulative therapy (preceded by
moist heat and light massage to neck)
vs
amitriptyline therapy
for 6
weeks |
·
Headache pain intensity, headache frequency, and OTC medication use
|
Parallel group design
16%
loss to follow up (24/150)
Side
effects reported |
|
Bove
1998
Denmark |
75
people with tension-type headache |
Soft
tissue therapy (deep friction massage) and high velocity, low
amplitude cervical spinal manipulative therapy
vs
soft tissue therapy + low power (placebo) laser treatment |
·
Headache pain intensity
·
Headache duration
·
Medication use |
Parallel group design
7%
loss to follow up (5/75)
|
|
Carlsson 1990
Sweden |
48
people with tension-type headache |
Relaxation, automassage, cryotherapy, TENS, stretching and education
over 8-12
weeks
vs
classical Chinese acupuncture over 2-8
weeks |
·
Headache pain intensity
·
Headache frequency
|
16%
loss to follow up (10/62)
Side
effects reported |
|
Howe
1993
UK |
27
patients with neck-related, chronic, non-specified headache |
NSAID
+ high velocity, low amplitude cervical spinal manipulative therapy
vs
NSAID alone |
·
Patient-rated degree of headache improvement |
Parallel group design
Dosage
and time not reported
Loss
to follow up not specified
Side
effects not reported |
|
Hoyt
1979 |
22
people with chronic muscle tension headache |
Palpatory examination of cervical spine + high velocity, low
amplitude cervical manipulation + soft tissue procedures
vs
palpatory examination of cervical spine without manipulation
vs
supine rest
for 10
minutes |
·
Headache pain intensity |
Parallel group design
Loss
to follow up not specified
No
information about side effects
Location not specified |
|
Jensen
1990
Denmark |
23
people with post-traumatic headache |
Manual
therapy to cervical and upper thoracic spine often in combination
with muscle energy technique
vs
cold pack to neck and shoulders for 15-20
minutes
for 2
sessions (1 per week) |
·
Headache pain intensity |
Parallel group design
17%
loss to follow up (4/23)
Side
effects not specified |
|
Jull
2002
Australia |
200
people with cervicogenic headache |
Manipulative therapy
vs
therapeutic exercise
vs
manipulative therapy + therapeutic exercise
vs no
physical treatment |
·
Headache pain intensity
·
Headache frequency
·
Headache duration |
2х2
factorial design
3.5%
loss to follow up (7/200)
Some
information relating to side effects |
|
Keller
1986
USA |
60
people with tension headache |
Therapeutic touch with intention to heal + rest and deep breathing
vs
placebo touch without intention to heal + rest and deep breathing
for 1
session |
·
Pain
using 3 subscales from McGill-Melzack Pain Questionnaire assessed 5
minutes and 4 hours after treatment |
Loss
to follow up not specified
Side
effects not specified
|
|
Marcus
1998
USA |
88
people with migraine headache |
Postural correction, cervical range-of-motion exercises, isometric
neck strengthening exercises, self-mobilisation exercises, whole
body stretching and conditioning, and ‘flare up’ management
techniques such as heat, ice and trigger point treatment
vs
progressive muscle relaxation, breathing exercises and thermal
biofeedback training |
·
Headache severity (used to calculated headache index score)
·
Medication use |
22%
loss to follow up (19/88)
Side
effects not specified |
|
Nelson
1998
USA
|
218
people with chronic migraine headache |
High
velocity, low amplitude cervical spine manipulation preceded by
light massage +/- trigger point therapy
vs
amitriptyline therapy |
·
Headache index (calculated using pain intensity)
·
OTC
medication use |
26%
loss to follow up (56/218)
Side
effects reported
|
|
Nilsson 1997
Denmark |
54
people with cervicogenic headache |
High
velocity, low amplitude spinal manipulation
vs
deep friction massage + low level laser
for 6
sessions over 3 weeks |
·
Headache pain intensity
·
Headache duration
·
Medication use |
2%
loss to follow up (1/54)
Side
effects not reported |
|
Parker
1980
Australia |
85
people with migraine headache |
Cervical spine manipulation + other spinal manipulation (all by
chiropractors)
vs
cervical spine manipulation + other manipulation techniques (all by
doctors or physical therapists)
Up to
2 sessions per week for 2 months |
·
Headache intensity
·
Headache frequency
·
Headache duration
·
Headache disability |
4%
loss to follow up (3/85)
Side
effects not specified |
|
Reich
1989
USA |
703
people with vascular/migraine headache or muscle contraction
headache |
Relaxation
vs
electrical modalities
vs
biofeedback
vs
combination of two of the above |
·
Headache pain intensity
·
Headache duration |
Loss
to follow up not specified |
|
Sherman 1998
USA |
12
people with migraine |
Pulsating electromagnetic field (PEMF) applied to medial thigh
vs
placebo (inactive PEMF)
for 10
sessions (1 hour per day, 5 days per week) |
·
Number
of headaches per week |
Double-blind crossover design
Data
are presented for patients who received either treatment first as
5/6 patients declined to cross over |
|
Sherman 1999 |
48
people with migraine |
Pulsating electromagnetic field (PEMF) applied to medial thigh
vs
placebo (inactive PEMF)
for 10
sessions (1 hour per day, 5 days per week) |
·
Headache activity index (calculated from headache frequency,
duration, intensity and medication use) |
Parallel group design
Location not specified
13%
loss to follow up (6/48)
Side
effects not specified |
|
Solomon 1985
USA |
62
people with migraine headache, muscle-contraction headache or both |
Cranial electrotherapy-perceived stimulus
vs
cranial electrotherapy-subliminal stimulus
for
one 15 minute session |
·
Pain
severity
·
Headache pain intensity improvement |
6%
loss to follow up (4/62)
No
information about side effects |
|
Solomon 1989
USA |
112
people with muscle contraction headache |
Cranial electrotherapy (CE)
vs
placebo CE |
·
Headache pain intensity
·
% of
patients rating CE effective |
Parallel group design
Placebo-controlled
11%
loss to follow up (12/112) because of lack of headaches that could
be evaluated
Side
effects reported |
|
Tuchin
2000
Australia |
127
people with migraine headache |
High
velocity, low amplitude spinal manipulative therapy (up to 16
treatments)
vs
detuned interferential therapy |
·
Headache pain intensity
·
Headache duration
·
Headache frequency
·
Medication use |
Parallel group design
Number
of sessions of interferential therapy not specified
3%
loss to follow up (4/127)
Side
effects reported |
|
Whittingham 1997
Australia |
105
people with cervicogenic headache |
Spinal
manipulative therapy
vs
placebo,
for 3
sessions per week for 3 weeks |
·
Headache pain intensity
·
Headache disability from Neck Disability Index
·
Number
of headache locations |
3%
loss to follow up (3/105)
Unexplained inconsistency between main outcomes and diary data
Effectiveness of blinding not adequately evaluated |
9.
Methodological quality
The
Cochrane review (Bronfort et al. 2004) was of good quality. However,
clinical heterogeneity of the trials in terms of headache type, patient
characteristics, interventions, comparison therapies and outcome measures,
prevented the pooling of results for meta-analysis. In addition, of the 22
studies with a total of 2628 patients (age 12 to 78 years) that met the
inclusion criteria, 12 studies had questionable methodological quality.
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10.
Results
Migraine
headache
Spinal
manipulation therapy
The systematic review identified three trials that evaluated spinal
manipulation therapy in people with migraine (Nelson 1998; Parker 1980;
Tuchin 2000). These trials were too dissimilar for their results to be
pooled. There is evidence from a good quality study that spinal manipulation
therapy is similar to amitriptyline (Nelson 1998). There is some evidence
(without a high degree of reliability) that spinal manipulation therapy is
superior to mobilization in people with migraine (Parker 1980).
Pulsating
electromagnetic fields
The systematic review identified two trials that evaluated the effect of
pulsating electromagnetic fields in people with migraine (Sherman 1998;
Sherman 1999). These two trials were too dissimilar for their results to be
pooled. There is some evidence (without a high degree of reliability) that
treatment with pulsating electromagnetic fields is superior to placebo in
people with migraine headache.
Physical
treatment combinations
The systematic review identified two trials that evaluated physical
treatment combinations in people with migraine (Marcus 1998; Reich 1989).
The two trials were too dissimilar for their results to be pooled. There is
limited evidence that a combination of home exercise, stretching, and
heat/ice is inferior to biofeedback/relaxation (Marcus 1998). There is some
evidence (without a high degree of reliability) that a combination of TENS
and electrical neurotransmitter modulation is inferior to biofeedback and
superior to relaxation (Reich 1989).
Tension-type
headache
Spinal
manipulation therapy
The systematic review identified two trials that evaluated spinal
manipulation therapy in people with tension-type headache (Boline 1995; Hoyt
1979). The two studies were too dissimilar for their results to be pooled.
There was moderate evidence that spinal manipulation therapy is generally
inferior to amitriptyline during treatment but may be superior to
amitriptyline post-treatment (Boline 1995). There is limited evidence to
suggest that spinal manipulation therapy is superior to no treatment (Hoyt
1979).
Cranial
electrotherapy
One trial evaluated cranial electrotherapy in people with tension-type
headache (Solomon 1989). This trial found that cranial electrotherapy was
superior to placebo. However, reliability was compromised due to uncertainly
over the impact that group differences in important baseline characteristics
had on the final outcomes.
Therapeutic
touch
The systematic review identified one trial that evaluated therapeutic touch
in people with tension-type headache (Keller 1986). Large and statistically
significant lower pain ratings were observed post-treatment in people
receiving therapeutic touch compared with placebo.
Physical
treatment combination
The systematic review identified four trials that evaluated physical
treatment combinations in people with tension-type headache (Ahonen 1984;
Bove 1998; Carlsson 1990; Reich 1989). The four studies were too dissimilar
for their results to be pooled. There was some evidence (without a high
degree of reliability) that a regimen of massage, ultrasound and hot packs
was similar to acupuncture (Ahonen 1984). There was moderate evidence to
show that spinal manipulation therapy plus massage was no more effective
than massage alone (Bove 1998). There is limited evidence that a regimen of
auto-massage, TENS and stretching is at least as effective as acupuncture (Carlsson
1990). There was some evidence (without a high degree of reliability) that a
combination of TENS and electrical neurotransmitter modulation may be
similar to biofeedback and to relaxation after 4 weeks of treatment (Reich
1989).
Cervicogenic
headache
Spinal manipulation therapy
Five studies evaluated spinal manipulation therapy in people with
cervicogenic headache (Bitterli 1977; Howe 1983; Jull 2002; Nilsson 1997;
Whittingham 1997). The five studies were too dissimilar for their results to
be pooled.
There is some evidence (without a high degree of
reliability) that spinal manipulation therapy is at least as effective as
mobilisation and to a wait-list control for pain reduction (Bitterli 1977).
There is some evidence (without a high degree of reliability) that spinal
manipulation therapy plus NSAIDs is at least as effective as NSAIDs alone
(Howe 1983). There is moderate evidence that spinal manipulation therapy is
superior to no treatment in reducing headache pain and frequency, but
similar to no treatment for headache duration (Jull 2002). There is some
evidence (without a high degree of reliability) that spinal manipulation
therapy is similar to exercise for headache pain and frequency (Jull 2002).
There is moderate evidence showing that spinal manipulation therapy is at
least as effective as massage plus placebo laser treatment (Nilsson 1997).
There is moderate evidence that spinal manipulation therapy is superior to
placebo for pain, disability and number of headache sites (Whittingham
1997).
Massage
One trial evaluated the effect of massage in people with cervicogenic
headache (Nilsson 1997). This trial found that massage plus placebo laser
was inferior to spinal manipulation therapy for pain and headache hours.
Exercise therapy
One trial evaluated the effect of exercise therapy in people with
cervicogenic headache (Jull 2002). This trial found that exercise was
superior to no treatment in reducing headache pain and frequency at 1 week
and 1 year after 6 weeks of treatment. Exercise was also at least as
effective as manipulation.
Mobilisation
One trial evaluated mobilisation in people with cervicogenic headache (Bitterli
1977). This showed some evidence (without a high degree of reliability) that
mobilisation is inferior to spinal manipulation after 3 weeks of treatment
and similar to manipulation at 3 months.
Physical treatment combinations
Two trials evaluated physical treatment combinations (Ammer 1990; Jull
2002). The two studies were too dissimilar for their results to be pooled.
There is some evidence (without a high degree of reliability) that spinal
mobilisation therapy plus galvanic current is superior to a combination of
galvanic current, ultrasound and UV light, and to a combination of massage
and moist herbal packs, for headache improvement after 2 weeks (Ammer 1990).
There is moderate evidence that spinal manipulation therapy plus exercise is
superior to no treatment (Jull 2002). There is some evidence (without a high
degree of reliability) that spinal manipulation therapy plus exercise is
generally similar to exercise alone for reducing headache pain and frequency
(Jull 2002). There is some evidence (without a high degree of reliability)
that spinal manipulation therapy plus exercise is similar to spinal
manipulation therapy alone (Jull 2002).
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11.
Discussion of findings
The
evidence for different non-invasive physical therapies for the various types
of headache rests on separate, generally small, individual trials. The
clinical heterogeneity of the trials prevented statistical pooling of
results for meta-analysis. Furthermore, complete-blinding for some of the
treatments is inherently impossible or very difficult to achieve.
As such, while
there is some evidence to suggest that certain types of physical therapy may
be of benefit in some types of headache, it is impossible to make definitive
conclusions. The best available evidence relates to the use of spinal
manipulation therapy in people with migraine. In a good quality RCT in
people with migraine, spinal manipulation therapy was an effective treatment
option, with a short-term effect similar to that of amitriptyline, a
commonly used, effective drug. Weaker evidence suggests that various other
physical treatments may also be effective, but results from these trials are
not reliable enough to make firm conclusions.
There was no
consistent evidence in these studies of any serious adverse events
associated with non-invasive physical therapies, but the trials were
probably underpowered to adequately assess adverse events.
The
relative cost-effectiveness of these physical therapies is not known.
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12.
Conclusion
There is
level 3 evidence from
a Cochrane review that some physical therapies may be effective in people
with certain types of chronic or recurrent headache. The best evidence
relates to the use of spinal manipulation therapy in people with migraine,
although weaker evidence suggests that various other physical treatments may
also be of benefit to people with a range of headache types. Overall,
physical treatments for people with chronic or recurrent headache do not
appear to be associated with serious adverse events. More trials are needed
to establish a firmer basis for considering physical treatments as viable
options to pharmacological therapy.
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13.
References
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