Multimodal manual therapy vs. pharmacological care for management of tension type headache: A meta-analysis of randomized trials

Cephalalgia. 2015 Dec;35(14):1323-32. doi: 10.1177/0333102415576226. Epub 2015 Mar 6.


Background: Manual therapies are generally requested by patients with tension type headache.

Objective: To compare the efficacy of multimodal manual therapy vs. pharmacological care for the management of tension type headache pain by conducting a meta-analysis of randomized controlled trials.

Methods: PubMed, MEDLINE, EMBASE, AMED, CINAHL, EBSCO, Cochrane Database of Systematic Reviews, Cochrane Collaboration Trials Register, PEDro and SCOPUS were searched from their inception until June 2014. All randomized controlled trials comparing any manual therapy vs. medication care for treating tension type headache adults were included. Data were extracted and methodological quality assessed independently by two reviewers. We pooled headache frequency as the main outcome and also intensity and duration. The weighted mean difference between manual therapy and pharmacological care was used to determine effect sizes.

Results: Five randomized controlled trials met our inclusion criteria and were included in the meta-analysis. Pooled analyses found that manual therapies were more effective than pharmacological care in reducing frequency (weighted mean difference -0.8036, 95% confidence interval -1.66 to -0.44; three trials), intensity (weighted mean difference -0.5974, 95% confidence interval -0.8875 to -0.3073; five trials) and duration (weighted mean difference -0.5558, 95% confidence interval -0.9124 to -0.1992; three trials) of the headache immediately after treatment. No differences were found at longer follow-up for headache intensity (weighted mean difference -0.3498, 95% confidence interval -1.106 to 0.407; three trials).

Conclusion: Manual therapies were associated with moderate effectiveness at short term, but similar effectiveness at longer follow-up for reducing headache frequency, intensity and duration in tension type headache than pharmacological medical drug care. However, due to the heterogeneity of the interventions, these results should be considered with caution at this stage.

Keywords: Tension type headache; effectiveness; manual therapy; medication.

Publication types

  • Comparative Study
  • Meta-Analysis
  • Review

MeSH terms

  • Analgesics / therapeutic use
  • Combined Modality Therapy / methods
  • Disease Management*
  • Humans
  • Musculoskeletal Manipulations / methods*
  • Randomized Controlled Trials as Topic / methods*
  • Tension-Type Headache / diagnosis
  • Tension-Type Headache / epidemiology*
  • Tension-Type Headache / therapy*


  • Analgesics