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Abstract

Aim

We aimed to conduct a systematic review evaluating the effectiveness of interventions used by physiotherapists on the intensity, frequency and duration of migraine, tension-type (TTH) and cervicogenic headache (CGH).

Methods

We performed a systematic search of electronic databases and a hand search for controlled trials. A risk of bias analysis was conducted using the Cochrane risk of bias tool (RoB). Meta-analyses present the combined mean effects; sensitivity analyses evaluate the influence of methodological quality.

Results

Of 77 eligible trials, 26 were included in the RoB assessment. Twenty trials were included in meta-analyses. Nineteen out of 26 trials had a high RoB in >1 domain. Meta-analyses of all trials indicated a reduction of TTH (p < 0.0001; mean reduction −1.11 on a 0–10 visual analog scale (VAS); 95% CI −1.64 to −0.57) and CGH (p = 0.0002; mean reduction −2.52 on a 0–10 VAS; 95% CI −3.86 to −1.19) pain intensity, CGH frequency (p < 0.00001; mean reduction −1.34 days per month; 95% CI −1.40 to −1.28), and migraine (p = 0.0001; mean reduction −22.39 hours without relief; 95% CI −33.90 to −10.88) and CGH (p < 0.00001; mean reduction −1.68 hours per day; 95% CI −2.09 to −1.26) duration. Excluding high RoB trials increased the effect sizes and reached additional statistical significance for migraine pain intensity (p < 0.00001; mean reduction −1.94 on a 0–10 VAS; 95% CI −2.61 to −1.27) and frequency (p < 0.00001; mean reduction −9.07 days per month; 95% CI −9.52 to −8.62).

Discussion

Results suggest a statistically significant reduction in the intensity, frequency and duration of migraine, TTH and CGH. Pain reduction and reduction in CGH frequency do not reach clinically relevant effect sizes. Small sample sizes, inadequate use of headache classification, and other methodological shortcomings reduce the confidence in these results. Methodologically sound, randomized controlled trials with adequate sample sizes are required to provide information on whether and which physiotherapy approach is effective. According to Grading of Recommendations Assessment, Development and Evaluation (GRADE), the current level of evidence is low.

Keywords

Headache migraine physical therapy manual therapy exercise

Introduction

A reported lifetime prevalence of more than 90% indicates the global relevance of headache (1). The most common primary headache types are migraine and tension-type headache (TTH) (1), which are often referred to physiotherapy to support pharmacological treatment (2). A frequently reported secondary headache type seen in physiotherapy clinics is cervicogenic headache (CGH) (3,4).

National and international (5,6) guidelines focus primarily on pharmacological management. Supporting non-pharmacological approaches such as biofeedback, acupuncture, relaxation and physical therapy are also recommended but guidelines criticize the low level of evidence.

Existing systematic reviews evaluating the evidence for physiotherapy interventions are either outdated (7,8) or approach the topic from a pre-defined focus on specific interventions. The most recent publication focused on manual therapy for primary headache (9). It reported an effective reduction of symptoms in all six included trials. The authors stated that no trials on migraine or cluster populations were found, hence results included TTH only. A meta-analysis was not conducted. The same authors also conducted a systematic review on cervicogenic headache with similar results (3). Other reviews indicating the potentially beneficial effect of physiotherapy interventions did not use a systematic approach. Evidence-based conclusions cannot be drawn from these publications (10 –12).

Hence, the purpose of this review is to provide an overview of the current evidence on the topic by using a systematic search strategy, evaluating the risk of bias of included trials, systematically extracting data from included trials and combining these in meta-analyses for mean treatment effects to inform clinical practice and guide future research.

Methods

This literature review was conducted and reported following the guidelines published by the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (13,14).

Eligibility criteria for trial inclusion

Types of studies

All randomized controlled trials (RCTs) comparing a physiotherapy intervention with a control group or an active intervention were considered for inclusion in the review. For cross-over trials only the first phase of the trial prior to crossing to the second intervention was included in meta-analyses. Case studies or uncontrolled trials were excluded. Trials had to be published in the English or German language.

Types of participants

Trial participants were adults with migraine, TTH and CGH. In the attempt to include all relevant trials, publications were also included if participants were described as having “mixed headache” or if populations were not classified but according to the clinical description likely to represent these headache types. Excluded were other primary headache types (e.g. cluster headache, short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT)) or secondary headache due to a pathology not located in the cervical spine. Further excluded were headache types of traumatic history such as whiplash-associated disorder because of the heterogeneity of pathologies (15). Trials on children and animal studies were also excluded.

Types of interventions

Trials were eligible for inclusion if the intervention was led by a physiotherapist and was a standard physiotherapy approach such as exercise, manual therapy, soft-tissue techniques, or strength and endurance training. Trials evaluating an intervention applied by a chiropractor, masseur, osteopath, psychologist, alternative healer, yoga teacher or acupuncturists were excluded.

Types of comparisons

Acceptable comparator interventions were any type of placebo intervention or any other active intervention as well as waiting list or standard care.

Types of outcome measures

Based on the results of a scoping search and in order to facilitate the combination of results in meta-analyses, trials were included that evaluated the effect of physiotherapy interventions on at least one of the following outcome measures:

–Intensity of headache measured on a visual analog scale (VAS) or numerical rating scale for pain.

–Frequency of headache episodes measured as number of episodes or number of headache days within a defined period of time (e.g. within one month).

–Duration of headache episodes measured in hours or days without relief.

Search methods for identification of studies

Information sources

Two researchers independently conducted a systematic search of electronic databases relevant to the medical and allied health professions literature. The cut-off date for the literature search was August 20, 2014. PubMed was used to search Medline, OVID to additionally search EMBASE and PsychINFO. Additional database searches were performed in the Cochrane Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Physiotherapy Evidence Database (PeDRO).

Hand-searching included reference lists of previously identified reviews and of the newly acquired trial publications. The contents of all journals in which included trials were published (BMC Musculoskeletal Disorders; Cephalalgia; Clinical Journal of Sports Medicine; Clinical Rehabilitation; Headache; International Journal of Sports Medicine; Journal of Back and Musculoskeletal Rehabilitation; Journal of Exercise and Rehabilitation; Journal of Manipulative and Physiological Therapeutics; Journal of Orthopedic and Sports Physical Therapy; Journal of Pain and Symptom Management; Journal of Rehabilitation Medicine; NeuroRehabilitation; Pain; PloS One; Pain Medicine; Scandinavian Journal of Work, Environment and Health; Spine) as well as other key journals for physiotherapy (Manual Therapy, Physical Therapy) were searched.

Literature search

Medical subject heading (MeSH) terms and natural language terms were combined in the search strategy. The search strategy included terms referring to the population studied, the intervention this review was focused on, the control intervention and the outcome studied. The following search terms were combined:

Population

adult AND (headache OR migraine)

Intervention

physiotherapy OR physical therapy OR exercises OR training OR manual therapy OR mobilization

Comparison

sham OR placebo OR control

Outcome

pain intensity OR frequency OR duration

Search filter or limitations were set to “humans” and “clinical trials.” The search strategy in PubMed (Medline) is shown in Table 1.

Table 1.

Search strategy for PubMed (Medline).

Search	Add to builder	Query	Items found
#5	Add	Search ((((exercise OR training OR mobilization))) AND ((physiotherapy OR physical therapy[Title/Abstract]))) AND ((headache OR migraine[Title/Abstract])) Filters: Clinical Trial	50
#4	Add	Search ((((exercise OR training OR mobilization))) AND ((physiotherapy OR physical therapy[Title/Abstract]))) AND ((headache OR migraine[Title/Abstract]))	236
#3	Add	Search (exercise OR training OR mobilization)	6,033,273
#2	Add	Search (physiotherapy OR physical therapy[Title/Abstract])	144,951
#1	Add	Search (headache OR migraine[Title/Abstract])	77,318

Study selection

Articles identified were selected independently by two reviewers (16) to minimize bias. In the first stage of study selection, the eligibility criteria were applied to the title and abstract of identified articles. In the second stage, the full text publications of potentially eligible articles were obtained and criteria reapplied. Strength of inter-reviewer agreement regarding study eligibility was expressed using Cohen’s kappa coefficient (17). In case of a disagreement between the two reviewers that was not resolved by discussion, a third reviewer was approached who subsequently decided whether the article should be included (16).

Data extraction and management

Data from included trials were collected and entered into a table with pre-specified headings (16) designed to meet the research objectives. The data extraction table contained the following data items:

Author, date and country of the trial study population;

Type of headache investigated and diagnostic criteria;

Type, duration, frequency of intervention(s) including numbers of participants in intervention group;

Type of control intervention(s) and numbers of participants in control group;

Outcome measure(s);

Time point(s) of measurement(s).

Assessment of risk of bias in included studies

Included trials were critically appraised for potential risk of bias by two independent researchers using the Cochrane risk of bias (RoB) assessment tool (18). Strength of inter-rater agreement was expressed using Cohen’s kappa coefficient (17). If blinding of the patient or therapist was impossible for technical reasons, it was rated as “not applicable.” The domain “incomplete outcome data” was considered to induce a risk of bias if data were statistically analyzed per-protocol and losses to follow-up were 20% or higher (19).

Synthesis of results

All trials were included in the descriptive analysis. Meta-analyses were conducted for the outcome measures pain intensity, frequency and duration for each headache type individually using a random-effects model allowing for population and intervention parameters to vary between trials (20). For comparability reasons, only trials that compared physiotherapy interventions with a control group or usual care were entered into the meta-analyses. For these trials mean values and standard deviations (SDs) post-intervention were entered into the meta-analyses. If these were not reported, mean values were calculated from change over time, and SDs from confidence intervals (CIs) or standard errors. Trials that compared two active interventions were reported descriptively.

Including trials with high risk of bias domains in meta-analyses can lead to invalid conclusions (18). To explore the influence of methodological quality on meta-analysis results, sensitivity analyses were conducted that excluded trials with a high risk of bias rating in a minimum of one domain.

In order to define the most effective type of physiotherapy intervention for each headache type, sub-analyses were conducted for each headache type, each outcome and each type of physiotherapy intervention. Interventions were grouped into strength training, manual therapy (plus exercises), trigger point treatment, combined physical and psychological interventions (e.g. exercises combined with relaxation) and aerobic exercises.

The software used for the meta-analyses was Review Manager, version 5.0, Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2008.

Overall level of evidence

The overall level of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation (GRADE) (21). The GRADE approach is used to formulate an overall conclusion on the level of evidence based on the methodological quality of included trials (21). Evidence based on RCTs with a low risk of bias is regarded as high while evidence from observational studies is regarded as low (22). Following specific criteria (e.g. imprecision of results indicated by wide CIs), the level of evidence from RCTs can be downgraded by one or two levels. Accordingly, the level of evidence from observational studies can be upgraded when specific criteria are fulfilled (22).

Results

Study selection

A total of 77 studies were identified during the electronic and hand-search processes. After title/abstract screening, 50 studies were retrieved as full text articles (Figure 1). Full text screening excluded 23 studies that did not include a control group (12,23 –31), did not use headache-related outcome measures (32 –36), did not conduct a physiotherapy intervention (37 –44) and one study (45) because it seemed to investigate the same study population as Mongini et al. (46), resulting in a total number of 26 included trials. Five of these could not be included in the meta-analyses since they compared two active interventions (35,47 –50). One could not be included since results were reported as median and interquartile range and could not be converted (51). The inter-rater agreement of studies to be included in the systematic review during title/abstract and full text screening was very high, with kappa 0.83 (95% CI 0.67 to 0.99).

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for trial inclusion.

Risk of bias

The risk of bias assessment resulted in a considerable number of “unclear” ratings (Table 2). Most ratings of “unclear” were due to the unavailability of a study protocol and hence unclear selective outcome reporting as a source of bias. Further reasons for unclear risk of bias domains included inadequate reporting regarding, for example, the allocation concealment method and assessor blinding. Only seven out of 26 trials were not evaluated as “high” risk of bias in one or more domains. The risk of bias domain that most frequently received the rating “high” was “other sources of bias” and referred to not evaluated patient preference either in trials that compared two active interventions (35,47,50 –52) or in trials comparing an active intervention with no intervention (53 –57). Not evaluating patient preference when, for example, comparing mobilization and massage, was rated as a risk factor for biased results. Accordingly, when comparing an active intervention with usual care, disappointment about not being randomized to the active treatment could influence the results and was also rated as a risk of bias. Further sources of bias included a historical control group (57) and statistically significant baseline differences (51). Small sample sizes additionally impaired the external validity in five trials (54,55,58 –60). The inter-rater agreement for the risk of bias assessment before discussion was moderate, with kappa 0.42 (95% CI 0.28 to 0.56). Results after discussion are presented in Table 2.

Table 2.

Risk of bias evaluation.

Author, year, country	1	2	3	4	5	6	7	8	Additional comments
Andersen et al. 2011; Denmark (61)	+	?	NA	+	?	+	?	−	Exercises not supervised; how often were exercises really performed?
Bodes-Pardo et al. 2013; Spain (62)	+	?	?	NA	+	+	?	+	Participant blinding not evaluated, can patients detect sham condition?
Carlsson et al. 1990; Sweden (47)	+	?	NA	NA	?	−	?	−	Patient preference: acupuncture or physiotherapy?
Castien et al. 2011; The Netherlands (53)	+	+	NA	NA	+	?	?	−	Patient preference: MT versus usual care
Darabaneanu et al. 2011; Germany (58)	?	?	NA	NA	?	−	?	+	Eight patients per group, groups not randomized
de Hertogh et al. 2009; The Netherlands (59)	+	+	NA	NA	+	−	?	−	Small sample size and losses to follow up
Demirturk et al. 2002; Turkey (63)	+	?	NA	NA	?	−	?	−	Five out of 35 lost to follow-up
Dittrich et al. 2008; Austria (54)	+	?	NA	NA	?	?	?	−	Small sample size; patient preference?
Foster et al. 2004; US (60)	+	?	NA	NA	?	+	?	−	Calculated sample size not reached
Ghanbari et al. 2012; Iran (55)	+	?	NA	NA	?	?	?	−	Patient preference? Small sample size
Gunreben-Stempfle et al. 2009; Germany (57)	−	−	NA	NA	?	+	?	−	Historical control group; patient preference?
Hall et al. 2007; Australia (64)	+	+	+	NA	+	+	?	+
Jull et al. 2002; Australia (65)	+	?	NA	NA	+	+	?	+
Lemstra et al. 2002; Canada (56)	+	?	NA	NA	+	+	?	+	Patient preference?
Mongini et al. 2008; Italy (67)	+	?	NA	?	?	−	?	−	Reliability of diary-based data?
Mongini et al. 2012; Italy (46)	+	?	NA	?	?	?	?	−	Reliability of diary-based data?
Narin et al. 2003; Turkey (66)	−	−	NA	NA	?	−	?	+
Shin and Lee 2014; Korea (68)	+	?	?	NA	?	?	?	−	Reliability of placebo SNAG?
Sjögren et al. 2005; Finland (69)	+	?	NA	NA	?	?	?	+
Söderberg et al. 2011; Sweden (35)	+	+	NA	NA	?	+	?	−	Patient preference?
Torelli et al. 2004; Italy (70)	+	?	NA	NA	−	−	?	+	Cross-over trial; n = 13 lost to follow-up
van Ettekoven and Lucas 2006; The Netherlands (48)	+	?	?	NA	+	+	?	+	Patient preference?
Varkey et al. 2009; Sweden (52)	+	+	NA	NA	+	+	?	−	Patient preference? Baseline differences (pain intensity)
von Piekartz and Lüdtke 2011; The Netherlands (49)	+	+	NA	NA	+	+	?	+	Patient preference?
Ylinen et al. 2010; Finland (51)	+	?	?	NA	+	+	?	−	Patient preference? Baseline differences (pain intensity)
Yousseff and Shanb 2013; Egypt (50)	+	+	?	NA	+	?	?	−	Patient preference?

1: Sequence generation; 2: allocation concealment; 3: participant blinding; 4: therapist blinding; 5: assessor blinding; 6: incomplete outcome data; 7: selective reporting; 8: other risks of bias; +: low risk of bias, –: high risk of bias;?: unclear risk of bias; MT: manual therapy; NA: not applicable; SNAG: sustained natural apophyseal glides; US: United States.

Data extraction

Of the 26 included trials, seven investigated the effect of interventions used by physiotherapists for TTH, seven for CGH, six for mixed headache populations and five for migraine (Table 3). One study investigated TTH and migraine and separated the two headache types during the data analysis (57).

Table 3.

Trial characteristics.

Author, year, country	Headache type	Classification criteria	Intervention	Control intervention	Outcome measures	Measurement time points
Andersen et al. 2011; Denmark (61)	TTH migraine	Self-reported headache type	10 weeks; 2 min/day resistance training (Theraband) (n = 64) OR 12 min/day resistance training (Theraband) (n = 64)	1×/week information (n = 64)	Intensity Duration Frequency	After 10 weeks of training
Bodes-Pardo et al. 2013; Spain (62)	CGH with active trigger points in the SCM	Sjaastad and Fredriksen (70)	One week; 3 × trigger point therapy (n = 10)	3 × simulated trigger point therapy (n = 10)	Intensity	After three treatments
Carlsson et al. 1990; Sweden (47)	TTH	Ad hoc committee of the US National Institute of Health (71)	Two to three months; 1–2/week physiotherapy: TENS, relaxation, education and exercises to reduce tension, tape (n = 29)	Four to eight weeks; eight to 10 sessions Acupuncture (n = 23)	Intensity	After final treatment
Castien et al. 2011; The Netherlands (53)	TTH	IHS	9 × manual therapy: mobilization and exercises (n = 41)	Usual care according to Dutch general practice guidelines (n = 41)	Intensity Duration Frequency	After eight weeks of treatment, follow-up after 26 weeks
Darabaneanu et al. 2011; Germany (58)	Migraine	IHS	10 weeks; three workouts/week (50 min) Aerobic training (n = 8)	No training (n = 8)	Intensity Duration Frequency	After 10 weeks of training, follow-up after eight weeks
de Hertogh et al. 2009; The Netherlands (59)	TTH CGH Migraine	IHS for migraine and TTH; Cervicogenic Headache International Study Group for CGH (71)	Six weeks; 2×/week manual therapy: mobilization, stabilization exercises (n = 18)	Usual care according to Dutch guidelines (n = 19)	Intensity Frequency	After six weeks manual therapy; follow-up after 12 and 24 weeks
Demirturk et al. 2002; Turkey (63)	TTH	IHS	One month 20 sessions connective tissue manipulation (n = 15) OR 3×/week mobilization (n = 15)		Intensity	After four weeks’ intervention; follow-up after one month
Dittrich et al. 2008; Austria (54)	Migraine	IHS	Six weeks; 2×/week aerobic exercise (n = 15)	Information about potential effects of exercise (n = 15)	Intensity Frequency	After six weeks’ training
Foster et al. 2004; US (60)	Migraine Cluster TTH	Diagnosed by physician	Six weeks, 1×/week manual therapy (Trager): mobilization, soft tissue techniques, relaxation, exercises (n = 11)	Six weeks; 1×/week Medical doctor visit (n = 6) No medical doctor visits (n = 12)	Intensity Duration Frequency	After six weeks’ intervention
Ghanbari et al. 2012; Iran (55)	TTH	IHS	5 × trigger point therapy (n = 15)	Usual care (medication) (n = 15)	Intensity Duration Frequency	After final treatment; follow-up after two weeks
Gunreben-Stempfle et al. 2009; Germany (57)	TTH Migraine	IHS	96 hours (eight weeks) multidisciplinary program (n = 42)	20 hours multidisciplinary program (n = 46) OR usual care (n = 80)	Intensity Duration Frequency	After 22 weeks
Hall et al. 2007; Australia (64)	CGH	IHS and positive flexion-rotation test (18)	Mobilization and home exercises (one session)	Sham treatment	Intensity	After treatment session and after four, 12 and 24 weeks
Jull et al. 2002; Australia (65)	CGH	Sjaastad und Fredriksen (70)	Six weeks; eight to 12 sessions Manual therapy (n = 51) OR Exercises (n = 52) OR Manual therapy and exercises (n = 49)	Waiting list (n = 48)	Intensity Duration Frequency	After intervention period; Follow-up after three, six and 12 months
Lemstra et al. 2002; Canada (56)	Migraine	IHS	Six weeks; 18 group sessions aerobic training, strength training and psychological interventions (relaxation and behavioral therapy) (n = 41)	Waiting list (n = 36)	Intensity Duration Frequency	After the intervention; follow-up after three months
Mongini et al. 2008; Italy (67)	Migraine TTH	IHS IASP	Eight months Relaxation, posture correction, exercises (n = 169)	Headache diary (n = 175)	Frequency	After the intervention
Mongini et al. 2012; Italy (46)	Migraine TTH	IHS IASP	Six months Relaxation, posture correction, exercises, education for muscle tension release (n = 909)	Headache diary (n = 972)	Frequency	After six months’ intervention
Narin et al. 2003; Turkey (66)	Migraine	IHS	Eight weeks; 3×/week Aerobic training (n = 20)	No intervention (n = 20)	Intensity Duration Frequency	After eight weeks’ training
Shin and Lee 2014; Korea (68)	CGH	Not reported	Four weeks, 3×/week SNAGs (n = 20)	Four weeks; 3×/week placebo SNAGs (n = 20)	Intensity Duration	After four weeks’ intervention
Sjögren et al. 2005; Finland (69)	Headaches not defined	Not reported	15 weeks Resistance training, information, posture correction, exercises: 1×/day for five weeks followed by 1–2×/day for 10 weeks (n = 36)	No intervention (n = 17)	Intensity	Cross-over study: after five, 10 and 15 weeks intervention/observation
Söderberg et al. 2011; Sweden (35)	TTH	IHS	Acupuncture 10–12 × (n = 30) OR 10 × relaxation and home program (n = 30) OR 10 × physical training and home program (n = 30)	No intervention	Intensity Duration Frequency	After final intervention; follow-up after three and six months
Torelli et al. 2004; Italy and Denmark (70)	TTH	IHS	Eight weeks physiotherapy: Massage, relaxation, stretching, home exercises (n = 24)	Observation (n = 24)	Intensity Frequency	Cross-over study: After eight weeks’ intervention/observation; follow-up after 12 weeks
van Ettekoven and Lucas 2006; The Netherlands (48)	TTH	IHS	Six weeks physiotherapy: Massage, mobilization, posture correction, craniocervical exercises (n = 39)	Six weeks physiotherapy without craniocervical exercises (n = 42)	Intensity Duration Frequency	After final treatment; follow-up after six months
Varkey et al. 2009; Sweden (52)	Migraine	IHS	12 weeks relaxation 1×/week with PT, daily at home with CD (n = 30) OR aerobic training (n = 30)	Topiramate (n = 31)	Intensity Frequency	During the last month of training; follow-up after three and six months
von Piekartz and Luedtke 2011; The Netherlands and Germany (49)	CGH with CMD signs	IHS and CMD signs	Four to six weeks; six sessions physiotherapy including orofacial techniques (n = 22)	Four to six weeks; six sessions physiotherapy without orofacial techniques (n = 21)	Intensity	After final treatment; follow-up after six months
Ylinen et al. 2010; Finland (51)	CGH	Not reported	12-day physical training and 4 × physiotherapy strength training (n = 57) OR endurance training +12 months independent training (n = 59)	Instruction: 3×/week aerobic training and stretching (n = 63)	Intensity	After 12 months
Yousseff and Shanb 2013; Egypt (50)	CGH	Headache and neck pain >2 months -unilateral -reduced cervical movement -ipsilateral shoulder pain -ipsilateral arm pain -mechanical trigger such as neck movement, neck position, mechanical pressure	Six weeks; 12 sessions Mobilization (n = 18)	Six weeks; 12 sessions massage (n = 18)	Intensity Duration Frequency	After final treatment

CGH: cervicogenic headaches; CMD: craniomandibular dysfunction; IHS: International Headache Society; TTH: tension-type headache; SNAG: Sustained natural apophyseal glides; PT: physical therapy; CD: compact disc; IASP: International Association for the Study of Pain; US: United States.

All trials focusing on migraine patients used aerobic exercise or multidisciplinary treatment as an intervention apart from one trial that included a relaxation group as well as an aerobic exercise group (52). Treatment approaches for TTH were more heterogeneous and included muscle techniques such as trigger point treatment (55), physical training (35), mobilization (63) and mixed physiotherapy approaches (47,48,53,69).

Interventions for CGH were primarily mobilization of the cervical spine (50,64,65,68) or a different technique plus mobilization of the cervical spine (49) but also included trigger point therapy (62), exercises (65), and physical training (61) (Table 3).

Synthesis of the results

Meta-analyses results for each headache type are shown in Figures 2 –4. The results of sensitivity analyses evaluating the effect of methodological quality on the combined mean effects are detailed in Table 4. Sub-analyses for the different types of physiotherapy interventions are shown in Table 5.

Figure 2.

(a)–(c) Meta-analyses showing the reduction in TTH intensity (top), duration (middle) and frequency (bottom).

Figure 3.

(a)–(c) Meta-analyses showing the reduction in migraine intensity (top), duration (middle) and frequency (bottom).

Figure 4.

(a)–(c) Meta-analyses showing the reduction in CGH intensity (top), duration (middle) and frequency (bottom).

Table 4.

Meta-analyses results with and without inclusion of high risk of bias trials.

		All trials			Excluding trials with a high risk of bias
Outcome measure	Headache type	Mean effect	95% CI	p value	Mean effect	95% CI	p value
Headache intensity (0–10 VAS)	Migraine	−0.62 (n = 5)	−2.89 to1.65	0.59	−1.94 (n = 2)	−2.61 to −1.27	<0.00001
	TTH	−1.11 (n = 3)	−1.64 to −0.57	<0.0001	High risk of bias elements in all trials
	CGH	−2.52 (n = 4)	−3.86 to −1.19	0.0002	−2.75 (n = 3)	−4.42 to −1.08	0.001
Mixed	0.24 (n = 4)	−0.25 to 0.72	0.34	−0.09 (n = 1)	−1.05 to 0.87	0.85
Headache frequency (days per month)	Migraine	−2.99 (n = 5)	−7.85 to 1.87	0.23	−9.07 (n = 2)	−9.52 to −8.62	p < 0.00001
	TTH	−7.58 (n = 3)	−18.13 to 2.97	0.16	High risk of bias elements in all trials
	CGH	−1.34 (n = 1)	−1.40 to −1.28	p < 0.00001	−1.34 (n = 1)	−1.40 to −1.28	p < 0.00001
Mixed	−2.14 (n = 2)	−2.78 to −1.50	p < 0.00001	High risk of bias elements in all trials
Duration of headache episodes (hours per day)	Migraine^a	−22.39 (n = 2)	−33.90 to −10.88	0.0001	−27.62 (n = 1)	−29.42 to −25.82	p < 0.00001
	TTH	−2.99 (n = 2)	−7.41 to 1.44	0.19	High risk of bias elements in all trials
	CGH	−1.68 (n = 2)	−2.09 to −1.26	p < 0.00001	−1.65 (n = 1)	−2.10 to −1.21	p < 0.00001
Mixed	−0.99 (n = 2)	−2.10 to 0.12	0.08	High risk of bias elements in all trials

CGH: cervicogenic headaches; CI: confidence interval; TTH: tension-type headache; VAS: visual analog scale.

Hours without relief. P values in bold indicate statistically significant effects (p < 0.05).

Table 5.

Meta-analyses results for individual physiotherapy interventions for each headache type.

				All trials
Headache type	Outcome measure	Physiotherapy intervention	Number of combined trials	Mean effect	95% CI	p value
TTH	Intensity (VAS 0–10)	Strength training	1	−0.09	−0.49 to 0.31	0.66
		Manual therapy	3	−0.65	−1.70 to 0.40	0.22
		Triggerpoint treatment	1	−1.52	−2.82 to −0.22	0.02
		Physical and psychological	1	−0.80	−1.68 to 0.08	0.07
	Aerobic exercise	0
	Frequency (days per month)	Strength training	0
		Manual therapy	1	−16.70	−19.45 to −13.95	<0.00001
		Triggerpoint treatment	1	−1.40	−6.01 to 3.21	0.55
		Physical and psychological	1	−4.20	−9.34 to 0.94	0.11
	Aerobic exercise	0
	Duration (hours per day)	Strength training	0
		Manual therapy	1	−5.5	−9.56 to −1.44	0.008
		Triggerpoint treatment	1	−0.96	−3.79 to 1.87	0.51
		Physical and psychological	0
Aerobic exercise	0
Migraine	Intensity (VAS 0–10)	Strength training	0
		Manual therapy	0
		Triggerpoint treatment	0
		Physical and psychological	2	−0.40	−3.47 to 2.68	0.80
	Aerobic exercise	4	−0.79	−4.41 to 2.83	0.67
	Frequency (days per month)	Strength training	0
		Manual therapy	0
		Triggerpoint treatment	0
		Physical and psychological	2	−4.97	−13.17 to 3.23	0.23
	Aerobic exercise	4	−1.63	−3.58 to 0.33	0.10
	Duration (hours without relief)	Strength training	0
		Manual therapy	0
		Triggerpoint treatment	0
		Physical and psychological	1	−27.62	−29.42 to −25.82	<0.00001
Aerobic exercise	2	−15.80	−23.87 to −7.73	0.0001
CGH	Intensity (VAS 0–10)	Strength training	0
		Manual therapy	2	−1.64	−2.22 to −1.06	<0.00001
		Triggerpoint treatment	1	−5.40	−6.48 to −4.32	<0.00001
		Physical and psychological	0
	Aerobic exercise	0
	Frequency (days per month)	Strength training	0
		Manual therapy	2	−1.32	−1.39 to −1.24	<0.00001
		Triggerpoint treatment	0
		Physical and psychological	0
	Aerobic exercise	0
	Duration (hours per day)	Strength training	0
		Manual therapy	3	−1.88	−2.04 to −1.72	<0.00001
		Triggerpoint treatment	0
		Physical and psychological	0
Aerobic exercise	0

CGH: cervicogenic headaches; CI: confidence interval; TTH: tension-type headache; VAS: visual analog scale. P values in bold indicate statistically significant effects (p < 0.05).

TTH

Three trials (234 participants) were included in the meta-analyses (Figure 2 (a)–(c)) that evaluated the effect of a physiotherapy intervention compared to a control group of usual care (53,55,57). All of these trials had at least one high risk of bias rating; hence sensitivity analyses to evaluate the effect of methodological quality on outcome were not conducted. Combined results indicated statistically significant results for pain reduction only. The analyses of different types of physiotherapy interventions indicated a small but significant effect of trigger point therapy on the intensity of TTH (one trial) and of manual therapy (plus exercises) for the reduction of the frequency and duration of TTH (Table 5).

Four trials compared two active interventions (35,47,48,63): Carlsson et al. (1990) compared acupuncture and physiotherapy interventions (relaxation, exercises, education, tape) and reported significantly more pain reduction in the physiotherapy group after 10–12 sessions (reduction of −1.21 (SD 0.9) on a one-to-five scale versus a reduction of −0.54 (SD 1.01) in the acupuncture group (p < 0.05)) (47). Two manual therapy techniques were applied in the study by Demirturk et al. (2002). Results indicated no statistically significant difference regarding pain intensity between the groups after connective tissue mobilization or Cyriax vertebral mobilization (63). Söderberg et al. compared three interventions: acupuncture, physical training and relaxation training. The only significant between-group difference after the final of 10–12 treatments was significantly more headache-free days (p < 0.01) and headache-free periods (p < 0.05) in the relaxation group compared to the acupuncture group. Pain intensity and duration were reduced in all groups but not significantly different across groups (35). Van Ettekoven and Lucas (2006) evaluated additional craniocervical exercises to a physiotherapy intervention and found that frequency, duration and intensity were not significantly different between groups immediately after the six-week intervention but all three outcome measures differed significantly at six-month follow-up (48). Data from the trial by Torelli et al. (70) were not entered into the meta-analyses because of the reporting of results and the trial design. Physiotherapy interventions compared with an observation period in this crossover-trial was reported to reduce frequency of headache episodes but did not change the severity of the headache or the duration of the episodes after an eight-week intervention period.

Migraine

Five trials (316 participants) were included in the meta-analyses (52,56 –58,66) (Figure 3 (a)–(c)). Combined results for pain intensity, frequency and duration were statistically significant in the two trials with a low risk of bias. Including three additional trials with high risk of bias ratings did not result in statistically significant changes (Table 4).

Sub-analyses for the different types of physiotherapy interventions indicated that aerobic exercises or the combination of physical and psychological interventions (such as relaxation) resulted in a reduction of the duration of migraine attacks (Table 5).

However, Darabaneanu et al. reported no significant difference between a group that had received aerobic training and a control group (58). This trial could not be entered into the meta-analysis since the authors had conducted a time series analysis and measured duration in hours per month.

CGH

Four trials (388 participants) that evaluated the effectiveness of interventions used by physiotherapists compared to a control group or usual care were combined in meta-analyses (62,64,65,68) (Figure 4 (a)–(c)). The combined mean effect for pain reduction, reduced frequency and duration were statistically significant with and without inclusion of high risk of bias trials (Table 4).

Sub-analyses for the different types of physiotherapy interventions indicated that manual therapy resulted in a reduction in intensity, frequency and duration of CGH. Trigger point therapy reduced the intensity of CGH (Table 5).

Youssef and Shanb compared mobilization and massage as an intervention to reduce the duration of CGH. Mobilization resulted in a significantly larger reduction of headache duration in this trial (p = 0.008) (50).

Mixed headache populations

Four trials evaluated change in headache intensity after a physiotherapy intervention compared to a control group or standard care (59,60,61,69). The combined mean results were statistically significant for the reduction of frequency and duration but not for pain intensity (Table 4). Two large trials (2225 participants), investigating a workplace intervention for the reduction of headache and neck pain, dominated the combined results for trials evaluating frequency of headache in mixed or undefined headache populations (46,65). Retrospective analyses indicated that two-thirds of the participants suffered from TTH and one-third from migraine, but results were not distinguished by headache types.

Discussion

Since the publication of the Cochrane review by Bronfort et al. (2004) on non-invasive physical treatments for chronic/recurrent headache (7), the number of research reports has increased significantly. Published trials were less heterogeneous than in 2004 and allowed for a combination of results in meta-analyses. Combined mean effects confirmed the general conclusions by Bronfort et al. that non-invasive physical treatments seem to play a role in the prevention of headache attacks and reduction of headache symptoms.

Results from this current review further suggest that physiotherapy interventions may have a positive effect on all types of headache included in this review. None of the meta-analyses indicated a negative effect for physiotherapy interventions on any type of headache or any outcome measure; however, some of the combined mean effects were very small and possibly not clinically relevant. For example, the statistically significant reduction of the pain intensity in TTH was only −1.11 on a 0–10 VAS. We could not identify any publications that defined clinical meaningfulness in headache populations, whereas in other chronic pain populations, pain reduction was perceived as worthwhile if it reached at least 30% or 2.4 points on a 0–10 numerical scale (73,74). Clinically meaningful change has to be viewed in relation to the time, effort and costs of the chosen treatment approach, hence an effect of −0.80 on a 0–10 VAS (95% CI from −1.49 to −0.11) after a 96-hour multidisciplinary program compared to standard care seems too small to justify the resources (57). On the other hand, a reduction of 3.4 migraine days per month (95% CI from −4.66 to −2.14) may justify the effort of a three-times weekly aerobic and strength training program considering the low costs of physical training in relation to the potential side effects of pain medication. Furthermore, pain intensity, frequency and duration of attacks are only three of a variety of possible outcome measures and might not be sensitive enough to reflect patient perceptions of well-being. Other outcome measures such as quality of life (75), disability (75) or global perceived improvement (76) might provide more detailed information about treatment effects.

A limitation of this review is that trials in languages other than German and English were not considered. Furthermore, this review can provide only a trend toward the most effective physiotherapy approach for specific headache types because of the heterogeneity of techniques and methods used in the included trials. Not all types of physiotherapy interventions have been applied to all types of headache, and for some physiotherapy interventions results are based on a single publication. Sub-analyses for the different physiotherapy interventions showed that aerobic exercise and a combination of physical and psychological interventions was effective for the reduction of migraine attack duration; however, no trials were available that used either manual therapy, trigger point therapy, or strength training. Manual therapy showed a highly significant effect for the reduction of TTH frequency and duration, but these results were based on one trial, only. CGH had been treated only with manual therapy and trigger point therapy. Both techniques showed highly significant results. However, no evidence for the effect of aerobic exercises, strength training and combined physical and psychological interventions was available.

The choice of interventions for the treatment of migraine and TTH used in included trials seemed to be based on theoretical knowledge and beliefs rather than on the patient’s individual signs and symptoms identified by the treating therapist. These standardized treatment approaches do not reflect the clinical reasoning-guided physiotherapy practice that is postulated by the World Confederation for Physical Therapy (72). There is a clear need for more and better research to identify the role of, for example, the cervical spine, muscle tension, postural changes, stabilizing muscles and other physical aspects in different headache types, especially in migraine and TTH, and subsequently to develop treatment strategies that effectively target such clinical findings.

A further difficulty is the classification of headache types within trials. Most authors state that the International Headache Society (IHS) classification was used, but did not report who diagnosed patients and whether patients were excluded who did not fulfill all of the required IHS criteria. There is substantial overlap across headache types in the different classifications; for example, CGH is described as mostly but not always located unilaterally (71,77,78) and one study reported that 6% of TTH is associated with nausea (79) and therefore probably misdiagnosed as migraine. Moreover, patients might suffer from more than one type of headache (80). Especially the diagnosis CGH is difficult to prove since laboratory and imaging evidence, as suggested by the IHS classification, were not available in most trials. Interestingly, the efficacy of physiotherapy interventions in trials that defined their study sample as CGH was particularly high. The diagnostic title CGH implies a treatable pathology in the cervical spine. The exact source of the symptoms is unknown and could involve cervical muscles or cervical joints connected via afferents to the trigeminal nuclei (78).

In conclusion, physiotherapy is low cost, has nearly no side effects and seems beneficial for the reduction of most headache symptoms. It should, therefore, be considered to support the medical management of headache and migraine. Considering the time and effort that is required for some approaches, and the fact that efficacy is reached only after longer training periods (e.g. aerobic and strength training), patient preference for specific treatment approaches can play a role in the choice of the most appropriate physical treatment.

Using GRADE (22), the overall quality of published trials remains low. This can be interpreted as “future research is likely to change the results of this review.” Further RCTs of high methodological quality and including appropriate numbers of participants are required to evaluate the role of physiotherapy interventions in headache and migraine treatment. This is clinically and scientifically relevant, given that irrespective of evidence, most national and international treatment guidelines recommend and most patients currently receive some sort of physiotherapy as a treatment for headache.

Clinical implications

Physiotherapy interventions resulted in a statistically significant effect on the intensity of tension-type headache (TTH) and cervicogenic headache (CGH), the frequency of CGH, and the duration of migraine and CGH when combined in meta-analyses.

Removing trials with high risk of bias domains resulted in an additional significant effect on migraine intensity and frequency.

Statistically significant effects were identified for manual therapy for the reduction of TTH frequency and duration and for all outcomes in CGH, trigger point treatment for the reduction of the intensity of TTH and CGH, combined physical and psychological interventions as well as aerobic exercises for the reduction of the duration of migraine.

The level of evidence for this effect based on methodological quality and external validity factors is low.

Randomized controlled trials of high methodological rigor with adequate sample sizes are required to confirm the results of the meta-analyses.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This work was supported by the 7th Framework EU-project EuroHeadPain (#602633) to A.M. and an unrestricted scientific grant from the German Headache Society (DMKG) to K.L.

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Efficacy of interventions used by physiotherapists for patients with headache and migraine—systematic review and meta-analysis

Abstract

Aim

Methods

Results

Discussion

Keywords

Introduction

Methods

Eligibility criteria for trial inclusion

Types of studies

Types of participants

Types of interventions

Types of comparisons

Types of outcome measures

Search methods for identification of studies

Information sources

Literature search

Population

Intervention

Comparison

Outcome

Study selection

Data extraction and management

Assessment of risk of bias in included studies

Synthesis of results

Overall level of evidence

Results

Study selection

Risk of bias

Data extraction

Synthesis of the results

TTH

Migraine

CGH

Mixed headache populations

Discussion

Clinical implications

Footnotes

Declaration of conflicting interests

Funding

References