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Are Manual Therapies Effective in Reducing Pain From Tension-Type Headache?: A Systematic Review

Fernández-de-las-Peñas, César PT*; Alonso-Blanco, Cristina PT*; Cuadrado, Maria Luz MD, PhD; Miangolarra, Juan Carlos MD, PhD*; Barriga, Francisco J. MD, PhD; Pareja, Juan A. MD, PhD

doi: 10.1097/01.ajp.0000173017.64741.86
Original Articles

Objectives A systematic review was performed to establish whether manual therapies have specific efficacy in reducing pain from tension-type headache (TTH).

Methods Computerized literature searches were performed in MEDLINE, EMBASE, AMED, MANTIS, CINAHL, PEDro, and Cochrane databases. Papers were included if they described clinical (open noncontrolled studies) or randomized controlled trials in which any form of manual therapy was used for TTH, and if they were published after 1994 in the English language. The methodologic quality of the trials was assessed using the PEDro scale. Levels of scientific evidence, based on the quality and the outcomes of the studies, were established for each manual therapy: strong, moderate, limited, and inconclusive evidence.

Results Only six studies met the inclusion criteria. These trials evaluated different manual therapy modalities: spinal manipulation (three trials), classic massage (one trial), connective tissue manipulation (two trials), soft tissue massage (one trial), Dr. Cyriax's vertebral mobilization (one trial), manual traction (one trial), and CV-4 craniosacral technique (one trial). Methodologic PEDro quality scores ranged from 2 to 8 points out of a theoretical maximum of 10 points (mean=5.8±2.1). Analysis of the quality and the outcomes of all trials did not provide rigorous evidence that manual therapies have a positive effect in reducing pain from TTH: spinal manipulative therapy showed inconclusive evidence of effectiveness (level 4), whereas soft tissue techniques showed limited evidence (level 3).

Conclusions The authors found no rigorous evidence that manual therapies have a positive effect in the evolution of TTH. The most urgent need for further research is to establish the efficacy beyond placebo of the different manual therapies currently applied in patients with TTH.

*Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos (URJC), Alcorcón, Madrid, Spain

Departments of Neurology of Fundación Hospital Alcorcón and Medicine of the Universidad Rey Juan Carlos (URJC), Alcorcón, Madrid, Spain

Reprints: César Fernández de las Peñas, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, Alcorcón, Madrid, 28922 Spain (e-mail: or

Received for publication June 9, 2004; first revision January 30, 2005; second revision May 13, 2005; accepted May 21, 2005

© 2006 Lippincott Williams & Wilkins, Inc.