The effect of manipulation plus massage therapy versus massage therapy alone in people with tension-type headache. A randomized controlled clinical trial

Eur J Phys Rehabil Med. 2016 Oct;52(5):606-617. Epub 2016 Mar 18.


Background: Manipulative techniques have shown promising results for relief of tension-type headache (TTH), however prior studies either lacked a control group, or suffered from poor methodological quality. The aim of this study was to compare the effect of spinal manipulation combined with massage versus massage alone on range of motion of the cervical spine, headache frequency, intensity and disability in patients with TTH.

Design: Randomized, single-blinded, controlled clinical trial.

Setting: University clinic.

Population: We enrolled 105 subjects with TTH.

Methods: Participants were divided into two groups: 1) manipulation and massage; 2) massage only (control). Four treatment sessions were applied over four weeks. The Headache Disability Inventory (HDI) and range of upper cervical and cervical motion were evaluated at baseline, immediately after the intervention and at a follow-up, 8 weeks after completing the intervention.

Results: Both groups demonstrated a large (ƒ=1.22) improvement on their HDI scores. Those that received manipulation reported a medium-sized reduction (ƒ=0.33) in headache frequency across all data points (P<0.05) compared to the control group. Both groups showed a large within-subject effect for upper cervical extension (ƒ=0.62), a medium-sized effect for cervical extension (ƒ=0.39), and large effects for upper cervical (ƒ=1.00) and cervical (ƒ=0.27) flexion. The addition of manipulation resulted in larger gains of upper cervical flexion range of motion, and this difference remained stable at the follow-up.

Conclusions: These findings support the benefit of treating TTH with either massage or massage combined with a manipulative technique. However, the addition of manipulative technique was more effective for increasing range of motion of the upper cervical spine and for reducing the impact of headache.

Clinical rehabilitation impact: Although massage provided relief of headache in TTH sufferers, when combined with cervical manipulation, there was a stronger effect on range of upper cervical spine motion.

Publication types

  • Comparative Study
  • Randomized Controlled Trial

MeSH terms

  • Adult
  • Ambulatory Care
  • Combined Modality Therapy
  • Disability Evaluation
  • Female
  • Follow-Up Studies
  • Hospitals, University
  • Humans
  • Male
  • Manipulation, Spinal / methods*
  • Massage / methods*
  • Middle Aged
  • Pain Measurement
  • Patient Satisfaction
  • Severity of Illness Index
  • Single-Blind Method
  • Tension-Type Headache / diagnosis*
  • Tension-Type Headache / rehabilitation*
  • Treatment Outcome