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Review
Efficacy of interventions used by
physiotherapists for patients with
headache and migraine—systematic
review and meta-analysis
Kerstin Luedtke, Angie Allers, Laura H Schulte and Arne May
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 ¼ 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 ¼ 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
Date received: 16 April 2015; revised: 4 June 2015; 18 June 2015; accepted: 27 June 2015
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 head-
ache 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 ther-
apy are also recommended but guidelines criticize the
low level of evidence.
Department of Systems Neuroscience, Center for Experimental
Medicine, University Medical Center Hamburg-Eppendorf, Germany
Corresponding author:
Arne May, Department of Systems Neuroscience, University Medical
Center Hamburg-Eppendorf, Martinistrasse 52, D-22046 Hamburg,
Germany.
Email: a.may@uke.de
Cephalalgia
0(0) 1–19
! International Headache Society 2015
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DOI: 10.1177/0333102415597889
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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 system-
atic 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 stu-
dies 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 par-
ticipants 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 neuralgi-
form 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 interven-
tion applied by a chiropractor, masseur, osteopath,
psychologist, alternative healer, yoga teacher or acu-
puncturists were excluded.
Types of comparisons. Acceptable comparator interven-
tions were any type of placebo intervention or any
other active intervention as well as waiting list or stand-
ard care.
Types of outcome measures. Based on the results of a
scoping search and in order to facilitate the combin-
ation 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 per-
formed 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
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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.
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 coeffi-
cient (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) includ-
ing numbers of participants in intervention group;
. Type of control intervention(s) and numbers of par-
ticipants 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
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
Luedtke et al. 3
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 rea-
sons, 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 meas-
ures pain intensity, frequency and duration for each
headache type individually using a random-effects
model allowing for population and intervention param-
eters to vary between trials (20). For comparability
reasons, only trials that compared physiotherapy inter-
ventions 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 inter-
ventions 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 con-
ducted 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 physio-
therapy 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 treat-
ment, combined physical and psychological interven-
tions (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 cri-
teria are fulfilled (22).
Results
Study selection
A total of 77 studies were identified during the elec-
tronic 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 com-
pared 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).
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 interven-
tion 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 histor-
ical control group (57) and statistically significant base-
line differences (51). Small sample sizes additionally
4 Cephalalgia 0(0)
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 discus-
sion are presented in Table 2.
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).
All trials focusing on migraine patients used aerobic
exercise or multidisciplinary treatment as an interven-
tion apart from one trial that included a relaxation
group as well as an aerobic exercise group (52).
Treatment approaches for TTH were more heteroge-
neous and included muscle techniques such as trigger
point treatment (55), physical training (35), mobiliza-
tion (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 tech-
nique 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 eval-
uating the effect of methodological quality on the com-
bined mean effects are detailed in Table 4. Sub-analyses
for the different types of physiotherapy interventions
are shown in Table 5.
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 methodo-
logical quality on outcome were not conducted.
Combined results indicated statistically significant
Records identified through
database searching
(n=50)
Screening Included
Eligibility
Identification
Additional records identified
through other sources
(n=27)
Records after duplicates removed
(n=77)
Records screened
(n=77)
Records excluded
(n=27)
Full-text articles assessed
for eligibility
(n=50)
Studies included in
qualitative synthesis
(n=26)
Studies included in
quantitative synthesis
(meta-analysis)
(n=20)
Full-text articles excluded
(n=24)
Reasons:
-no control group (n=10)
-not a physiotherapy
intervention (n=8)
-no headache related
outcome measures (n=5)
-double reporting (n=1)
Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for trial inclusion.
Luedtke et al. 5
results for pain reduction only. The analyses of differ-
ent 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
Table 2. Risk of bias evaluation.
Author, year, countr y 1 2 3 4 5 6 7 8 Additional comments
Andersen et al. 2011; Denmark (61) þ ?NAþ ? þ ? Exercises not supervised; how often
were exercises really performed?
Bodes-Pardo et al. 2013; Spain (62) þ ?? NAþþ? þ Participant blinding not evaluated,
can patients detect sham
condition?
Carlsson et al. 1990; Sweden (47) þ ?NANA? ? Patient preference: acupuncture or
physiotherapy?
Castien et al. 2011; The
Netherlands (53)
þþNA NA þ ?? Patient preference: MT versus usual
care
Darabaneanu et al. 2011; Germany
(58)
??NANA? ? þ Eight patients per group, groups not
randomized
de Hertogh et al. 2009; The
Netherlands (59)
þþNA NA þ? Small sample size and losses to
follow up
Demirturk et al. 2002; Turkey (63) þ ?NANA? ? Five out of 35 lost to follow-up
Dittrich et al. 2008; Austria (54) þ ?NANA??? Small sample size; patient
preference?
Foster et al. 2004; US (60) þ ?NANA?þ ? Calculated sample size not reached
Ghanbari et al. 2012; Iran (55) þ ?NANA??? Patient preference? Small sample
size
Gunreben-Stempfle et al. 2009;
Germany (57)
NA NA ? þ ? Historical control group; patient
preference?
Hall et al. 2007; Australia (64) þþþ NA þþ? þ
Jull et al. 2002; Australia (65) þ ?NANAþþ
? þ
Lemstra et al. 2002; Canada (56) þ ?NANAþþ? þ Patient preference?
Mongini et al. 2008; Italy (67) þ ?NA? ? ? Reliability of diary-based data?
Mongini et al. 2012; Italy (46) þ ?NA? ??? Reliability of diary-based data?
Narin et al. 2003; Turkey (66) NA NA ? ? þ
Shin and Lee 2014; Korea (68) þ ?? NA??? Reliability of placebo SNAG?
Sjo
¨
gren et al. 2005; Finland (69) þ ?NANA???þ
So
¨
derberg et al. 2011; Sweden (35) þþNA NA ? þ ? Patient preference?
Torelli et al. 2004; Italy (70) þ ?NANA? þ Cross-over trial; n ¼ 13 lost to
follow-up
van Ettekoven and Lucas 2006; The
Netherlands (48)
þ ?? NAþþ? þ Patient preference?
Varkey et al. 2009; Sweden (52) þþNA NA þþ? Patient preference? Baseline differ-
ences (pain intensity)
von Piekartz and Lu¨dtke 2011; The
Netherlands (49)
þþNA NA þþ? þ Patient preference?
Ylinen et al. 2010; Finland (51) þ ?? NAþþ? Patient preference? Baseline differ-
ences (pain intensity)
Yousseff and Shanb 2013; Egypt (50) þþ?NAþ ?? 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; þ: 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.
6 Cephalalgia 0(0)
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 head-
ache type
10 weeks; 2 min/day resistance train-
ing (Theraband) (n ¼ 64)
OR
12 min/day resistance training
(Theraband) (n ¼ 64)
1/week information
(n ¼ 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 ¼ 10)
3 simulated trigger point
therapy (n ¼ 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 ¼ 29)
Four to eight weeks; eight to
10 sessions
Acupuncture (n ¼ 23)
Intensity After final treatment
Castien et al. 2011;
The Netherlands
(53)
TTH IHS 9 manual therapy: mobilization and
exercises (n ¼ 41)
Usual care according to
Dutch general practice
guidelines (n ¼ 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 ¼ 8)
No training (n ¼ 8) Intensity
Duration
Frequency
After 10 weeks of training, follow-up
after eight weeks
de Herto gh 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 exer-
cises (n ¼ 18)
Usual care according to
Dutch guidelines (n ¼ 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 ¼ 15)
OR
3/week mobilization (n ¼ 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 ¼ 15)
Information about potential
effects of exercise (n ¼ 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 ¼ 11)
Six weeks; 1/week
Medical doctor visit
(n ¼ 6)
No medical doctor visits
(n ¼ 12)
Intensity
Duration
Frequency
After six weeks’ intervention
Ghanbari et al. 2012;
Iran (55)
TTH IHS 5 trigger point therapy (n ¼ 15) Usual care (medication)
(n ¼ 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) multidisciplin-
ary program (n ¼ 42)
20 hours multidisciplinary
program (n ¼ 46)
OR
usual care (n ¼ 80)
Intensity
Duration
Frequency
After 22 weeks
(continued)
Luedtke et al. 7
Table 3. Continued.
Author, year, country Headache type Classification criteria Intervention Control intervention
Outcome
measures Measurement time points
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 ¼ 51)
OR
Exercises (n ¼ 52)
OR
Manual therapy and exercises
(n ¼ 49)
Waiting list (n ¼ 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 psy-
chological interventions (relax-
ation and behavioral therapy)
(n ¼ 41)
Waiting list (n ¼ 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 ¼ 169)
Headache diary (n ¼ 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 ¼ 909)
Headache diary (n ¼ 972) Frequency After six months’ intervention
Narin et al. 2003;
Turkey (66)
Migraine IHS Eight weeks; 3/week
Aerobic training (n ¼ 20)
No intervention (n ¼ 20) Intensity
Duration
Frequency
After eight weeks’ training
Shin and Lee 2014;
Korea (68)
CGH Not reported Four weeks, 3/week
SNAGs (n ¼ 20)
Four weeks; 3/week pla-
cebo SNAGs (n ¼ 20)
Intensity
Duration
After four weeks’ intervention
Sjo
¨
gren 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 ¼ 36)
No intervention (n ¼ 17) Intensity Cross-over study: after five, 10 and
15 weeks intervention/
observation
So
¨
derberg et al. 2011;
Sweden (35)
TTH IHS Acupuncture 10–12 (n ¼ 30)
OR
10 relaxation and home pro-
gram (n ¼ 30)
OR
10 physical training and home
program (n ¼ 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 exer-
cises (n ¼ 24)
Observation (n ¼ 24) Intensity
Frequency
Cross-over study:
After eight weeks’ intervention/
observation; follow-up after 12
weeks
(continued)
8 Cephalalgia 0(0)
Table 3. Continued.
Author, year, country Headache type Classification criteria Intervention Control intervention
Outcome
measures Measurement time points
van Ettekoven and
Lucas 2006; The
Netherlands (48)
TTH IHS Six weeks physiotherapy:
Massage, mobilization, posture
correction, craniocervical exer-
cises (n ¼ 39)
Six weeks physiotherapy
without craniocervical
exercises (n ¼ 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 ¼ 30)
OR
aerobic training (n ¼ 30)
Topiramate (n ¼ 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 ¼ 22)
Four to six weeks; six ses-
sions physiotherapy with-
out orofacial techniques
(n ¼ 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 train-
ing (n ¼ 57)
OR
endurance training þ12 months
independent training (n ¼ 59)
Instruction: 3/week aerobic
training and stretching
(n ¼ 63)
Intensity After 12 months
Yousseff and Shanb
2013; Egypt (50)
CGH Headache and neck
pain >2 months
-unilateral
-reduced cervical
movement
-ipsilateral shoul-
der pain
-ipsilateral arm pain
-mechanical trigger
such as neck move-
ment, neck pos-
ition, mechanical
pressure
Six weeks; 12 sessions
Mobilization (n ¼ 18)
Six weeks; 12 sessions mas-
sage (n ¼ 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.
Luedtke et al. 9
acupuncture and physiotherapy interventions (relax-
ation, exercises, education, tape) and reported signifi-
cantly 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 inten-
sity between the groups after connective tissue mobil-
ization or Cyriax vertebral mobilization (63). So
¨
derberg
et al. compared three interventions: acupuncture, phys-
ical training and relaxation training. The only signifi-
cant 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
Figure 2. (a)–(c) Meta-analyses showing the reduction in TTH intensity (top), duration (middle) and frequency (bottom).
TTH: tension-type headache; CI: confidence interval.
10 Cephalalgia 0(0)
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 cra-
niocervical 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 interven-
tions 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 dur-
ation 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 physiother-
apy interventions indicated that aerobic exercises or
the combination of physical and psychological
Figure 3. (a)–(c) Meta-analyses showing the reduction in migraine intensity (top), duration (middle) and frequency (bottom).
CI: confidence interval.
Luedtke et al. 11
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 com-
bined 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
Figure 4. (a)–(c) Meta-analyses showing the reduction in CGH intensity (top), duration (middle) and frequency (bottom).
CGH: cervicogenic headache; CI: confidence interval.
12 Cephalalgia 0(0)
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 ¼ 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 statis-
tically significant for the reduction of frequency and
duration but not for pain intensity (Table 4). Two
large trials (2225 participants), investigating a work-
place intervention for the reduction of headache and
neck pain, dominated the combined results for trials
evaluating frequency of headache in mixed or unde-
fined headache populations (46,65). Retrospective ana-
lyses 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 treat-
ments 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-ana-
lyses. Combined mean effects confirmed the general
conclusions by Bronfort et al. that non-invasive phys-
ical 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
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 ¼ 5)
2.89 to1.65 0.59 1.94 (n ¼ 2) 2.61 to 1.27 <0.00001
TTH 1.11
(n ¼ 3)
1.64 to 0.57 <0.0001 High risk of bias elements in all trials
CGH 2.52
(n ¼ 4)
3.86 to 1.19 0.0002 2.75 (n ¼ 3) 4.42 to 1.08 0.001
Mixed 0.24
(n ¼ 4)
0.25 to 0.72 0.34 0.09 (n ¼ 1) 1.05 to 0.87 0.85
Headache frequency
(days per month)
Migraine 2.99
(n ¼ 5)
7.85 to 1.87 0.23 9.07 (n ¼ 2) 9.52 to
8.62 p < 0.00001
TTH 7.58
(n ¼ 3)
18.13 to 2.97 0.16 High risk of bias elements in all trials
CGH 1.34
(n ¼ 1)
1.40 to 1.28 p < 0.00001 1.34 (n ¼ 1) 1.40 to 1.28 p < 0.00001
Mixed 2.14
(n ¼ 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 ¼ 2)
33.90 to 10.88 0.0001 27.62 (n ¼ 1) 29.42 to 25.82 p < 0.00001
TTH 2.99
(n ¼ 2)
7.41 to 1.44 0.19 High risk of bias elements in all trials
CGH 1.68
(n ¼ 2)
2.09 to 1.26 p < 0.00001 1.65 (n ¼ 1) 2.10 to 1.21 p < 0.00001
Mixed 0.99
(n ¼ 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.
a
Hours without relief. P values in bold indicate statistically significant effects (p < 0.05).
Luedtke et al. 13
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
(continued)
14 Cephalalgia 0(0)
Table 5. Continued.
All trials
Headache
type Outcome measure
Physiotherapy
intervention
Number of
combined trials Mean effect 95% CI p value
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).
Luedtke et al. 15
combined mean effects were very small and possibly not
clinically relevant. For example, the statistically signifi-
cant 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 poten-
tial 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 per-
ceptions of well-being. Other outcome measures such
as quality of life (75), disability (75) or global per-
ceived 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 physio-
therapy interventions results are based on a single pub-
lication. Sub-analyses for the different physiotherapy
interventions showed that aerobic exercise and a com-
bination of physical and psychological interventions
was effective for the reduction of migraine attack dur-
ation; 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 signifi-
cant results. However, no evidence for the effect of aer-
obic 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 reason-
ing-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 classifi-
cations; 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 cer-
vical 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 con-
sidered to support the medical management of head-
ache and migraine. Considering the time and effort
that is required for some approaches, and the fact
that efficacy is reached only after longer training peri-
ods (e.g. aerobic and strength training), patient prefer-
ence 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 interven-
tions in headache and migraine treatment. This is clin-
ically 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.
16 Cephalalgia 0(0)
Clinical implications
. Physiotherapy interventions resulted in a statistically significant effect on the intensity of tension-type head-
ache (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.
Funding
This work was supported by the 7th Framework EU-project
EuroHeadPain (#602633) to A.M. and an unrestricted scien-
tific grant from the German Headache Society (DMKG)
to K.L.
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.
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