Abstract
Background: Tension-type headache (TTH) is a disease with a great incidence on quality of life and with a significant socioeconomic impact. Objectives: The aim of this review is to determine the effectiveness of physical therapy by using manual therapy (MT) for the relief of TTH. Data sources: A review was done identifying randomized controlled trials through searches in MEDLINE, PEDro, Cochrane and CINAHL (January 2002 – April 2012). Study selection: English-language studies, with adult patients and number of subjects not under 11, diagnosed with episodic tension-type headache (ETTH) and chronic tension-type headache (CTTH) were included. Data extraction: Initial search was undertaken with the words Effectiveness, Tension-type headache, and Manual therapy (39 studies). In addition, a search which included terms related to treatments such as physiotherapy, physical therapy, spinal manipulation was performed (25 studies). Results: From the two searches 9 studies met the inclusion criteria and were analysed finding statistically significant results: 1) myofascial release, cervical traction, neck muscles trigger points in cervical thoracic muscles and stretching; 2) Superficial heat and massage, connective tissue manipulation and vertebral Cyriax mobilization; 3) cervical or thoracic spinal manipulation and cervical chin-occipital manual traction; 4) massage, progressive relaxation and gentle stretching, program of active exercises of shoulder, neck and pericranial muscles; 5) massage, passive rhythmic mobilization techniques, cervical, thoracic and lumbopelvic postural correction and cranio-cervical exercises; 6) progressive muscular relaxation combined with joint mobilization, functional, muscle energy, and strain/counterstrain techniques, and cranial osteopathic treatment; 7) massage focused on relieving myofascial trigger point activity; 8) pressure release and muscle energy in suboccipital muscles; 9) combination of mobilizations of the cervical and thoracic spine, exercises and postural correction. All studies used a combination of different techniques and none analyzed treatments separately, also all the studies have assessed aspects related to TTH beyond frequency and intensity of pain. Conclusions: The findings from these studies showed evidence that physiotherapy with articulatory MT, combined with cervical muscle stretching and massage are effective for this disease in different aspects related with TTH. No evidence was found of the effectiveness of the techniques applied separately.
Keywords: Physical therapy, Manual therapy, Tension-type headache, Effectiveness
The types and characteristics of tension-type headaches (TTH) were included in primary headaches by the International Headache Society (IHS) in 20041). The most common tension type headaches are episodic tension headaches (ETTH), which frequency is less than 15 days per month, and chronic tension-type headaches (CTTH), which frequency is more than 15 days per month. This last type also is characterised for its episodes of pain ranging from 30 minutes to 7 days. To be considered chronic, the headache should meet 2 or more of the following characteristics: bilateral location, non-pulsatile pressure, mild or moderate pain and does not increase with physical activity.
TTH also constitute an important area of primary care visits. Due to the effectiveness obtained from symptomatic medication, both migraines and tension headaches are often self-treated by patients who suffer from them2). Both frequency and intensity of pain can produce serious disturbances on the patient. Moreover, when it becomes chronic, it turns into an important problem for both the doctor and the patient. Diagnosis of this disease is exclusively done on the clinical data and there are no other complementary diagnostic tests to confirm TTH, so it is often done by exclusion of other diseases. Prevalence rates range from 22.65% to 30% of the population, and it has repercussions on work, social fields, daily living activities and quality of life3). Both human and socio-economic impact are considerable due to lost workdays or days with reduced work efficiency TTH may as well affect quality of life, impairing relationships with family, friends and colleagues. It can even result in the cancellation of family and social activities4). In recent studies conducted in Spain, it was shown that 31% of people who suffered headaches were disabling during the episode, whereas 53% reduced the efficiency of their daily life activities. For Lenssink et al., 2004, from all types of headaches, TTH is the most common form, constituting a major health problem with great socioeconomic impact4).
Primary headaches have a high incidence and prevalence in general population. Migraine and TTH are the leading types of primary headaches. Not only have social and health transcendence but also have an important repercussion in the public health system. Due to them, a high average of appointments are made to different health professionals and lead to a large number of medical prescriptions which cause high costs5).
Additionally, muscle disorders play an important role in headaches. Even ETTH could become chronic because of these disorders. In fact, it has been proved that neck and head trigger points in TTH patients score higher in pain intensity and frequency than in healthy people6). Buchgreitz et al., 20087), believe that central sensitivity caused by long periods of suffering pain can make the process chronic.
Fernández et al., 2006, evaluated pericranial and neck muscles trigger points (TrP) both in patients with CTTH and in healthy subjects. They studied bilateral TrP in trapezium, sternocleidomastoid and temporalis muscles. Subjects with TTH with active points showed a greater intensity and duration of headache compared with those who had latent points (P < 0.05)8,9).
Serrano et al., 200710), published a study in which they showed that pericranial muscle contracture and stress played an important role in headache's physiopathology, which justifies the presence of pericranial pain hypersensitivity and decreased pain threshold.
Manual therapy is considered one of the main treatments for TTH. It is based on the treatment of neuro-musculoskeletal dysfunction through muscle and joint analytical manipulations based on their biomechanical study. There is a wide range of manual therapy treatments used in physiotherapy11). The characteristics of the headache have to be studied to achieve an accurate diagnosis before applying any of these manual treatments12).
The reviews we have found so far show either the non-effectiveness of treatments4), or always include spinal manipulation13,14). However, there are recent studies that include manual therapy techniques which were not studied in previous reviews. Therefore, it is necessary to collect recent studies in order to focus on those treatments with scientific quality, and incorporate and compare studies that include both manipulative and articulatory therapy.
The novelty of this systematic review in relation to other reviews, is that we want to find the effectiveness of treatments applied in patients with TTH, not only spinal manipulation but also other treatments which include manual therapy. Moreover, in our study we review which other aspects related to TTH have been assessed beyond frequency and intensity of pain which are the most common aspects.
Objective
The aim of this review is to determine the effectiveness of physical therapy by using manual therapy (MT), manipulative or not, in TTH treatment, as well as the assessed aspects.
Methods
From February to April 2012 systematic searches of scientific literature were undertaken on MEDLINE, PEDro, Cochrane and CINAHL, for randomized controlled studies published from January 2002 to April 2012. For this review the initial search terms were obtained from the MeSH and were: effectiveness, tension-type headache, and manual therapy. An additional search was done using the following keywords also obtained from MeSH: treatment, physiotherapy, physical therapy, physiological and spinal manipulation.
Study selection
Studies were included if they: 1) were in English language, 2) included adult patients, 3) the sample size was never below 10, 4) subjects were diagnosed with ETTH and CTTH according to the IHS criteria1) 5) included manual therapy techniques applied more than one session per treatment, 6) studies from 2002 until 2012 and 7) at least one of the following parameters were measured: pain intensity, pain frequency y , other evaluations concerning headache.
The title, abstract and keywords of each article were assessed to determine if it fulfilled the inclusion criteria outlined above. Studies which met inclusion criteria were included for full-text review.
Data extraction
The selection of studies and data extraction was carried by two reviewers. Initial search was undertaken on randomized controlled trials with adult patients diagnosed with TTH (IHS criteria), using the words effectiveness, tension-type headache, and manual therapy. This way 39 studies were obtained and reviewed. Reviews were excluded for not being the subject of study, but they were considered for the discussion.
Additionally, the following MeSH terms were added in the search: treatment, physiotherapy, physical therapy, physiological and spinal manipulation. Therefore, 25 more studies were obtained and reviewed. One of them was excluded since it included headache with symptoms of vertigo. Finally, the studies meeting the inclusion criteria were reviewed and analyzed.
Results
Study selection
From the search strategy, 64 potentially relevant studies were found, from which 7 reviews were excluded, as well as one study which examined both headache and vertigo. Also repeated studies were excluded. The 9 remaining studies met the inclusion criteria and were analyzed. Fig. 1 shows the procedure used in study selection.
Fig. 1.
Flow diagram of study selection procedure
Interventions
The treatments that each of the 9 studies included for TTH were: 1) massage, myofascial release, traction, trigger point therapy, stretching and relaxation15); 2) superficial heat, massage, connective tissue manipulation and spinal mobilization16); 3) chiropractic manipulation17); 4) initial gentle massage, progressive relaxation and gentle stretching, adding a daily home program of active exercises for shoulder, neck and pericranial muscles18); 5) friction massage, rhythmic passive mobilization techniques based on the Maitland method and cervical, thoracic and lumbopelvic postural correction, as well as cranio-cervical exercises19); 6) progressive muscular relaxation, joint mobilization, functional, muscle energy, and strain/counterstrain techniques, and cranial osteopathic treatment20); 7) massage focusing on myofascial trigger point activity21); 8) pressure release and muscle energy in suboccipital muscles22); 9) cervical and thoracic spine mobilization and postural correction23).
Description of included studies
The characteristics, results and main conclusions of the 9 analyzed studies are as follows and are presented summarized in Table 1.
Table 1. Characteristics of studies with MT and their efficacy (1).
| Author | n | Treatment duration | Type of study | Treatment | Effect |
|---|---|---|---|---|---|
| Quinn and Chandler 200213) | 25 | 4 weeks | Trial without control group | Massage, myofascial inhibition, traction, trigger point therapy, stretching and relaxation | Frequency P=0.00 Pain Duration P=0.58 Intensity P=0.19 |
| Demirturk et al., 200214) | 35 | 4 weeks | Comparative trial | G1: Superficial heat and massage + connective tissue manipulation G2: Superficial heat and massage + spinal Cyriax mobilization |
Pain index, intensiy and movement range P>0.05 in both groups. |
| Donkin et al. 200215) | 30 | 4 weeks | Comparative pilot study | G1: Thoracic spinal manipulation G2: chiropractic manipulation and cervical occipital manual traction |
Perception of pain, disability, CROM, frequency, intensity and duration p<0.05 in , both groups, but better results for manipulation without traction |
| Torelli et al., 200416) | 50 | G1: 8 weeks treatment + 12 weks observación G2: 8 weeks observación + 8 weeks treatment + 12 obsevación |
Comparative trial | G1: Treatment (gentle massage, progressive relaxation gentle stretching, and active exercises) + observation G2: Observation+ Treatment as G1 |
G1 and G2: Frequency reduced P<0.001 Compared G1 and G2 results in the CTTH compared with ETTH P<0.002 Intensity, duration, and consumption of medication no significatn results in any group no results |
| van Ettekoven and Lucas, 200617) | 81 | 6 weeks | Randomized controlled trial | G1: friction massage, passive rhythmic mobilization techniques based on Maitland method, cervical, thoracic and lumbopelvic postural correction and cranio-cervical exercises G2: Control group treatment was the same except that cranio-cervical exercises were not applied |
G1: Frequency P=0.0001; Intensity P=0.001; Duration P=0.01; Quality of life P <0.001 G2: All parameters p>0.05 |
| Anderson and Seniscal, 200618) | 26 | 3 weeks | Randomized controlled trial | G1: progressive muscular relaxation + treatment (3 session with + joint mobilization, muscle energy and strain/counterstrain techniques, osteopathy). G2: progressive muscular relaxation |
G1: Frequency P=0.016 Intensity, degree of pain no results positive; degree of pain improved on 57,5%. G2: Degree of pain only imporved on 15,6%. |
| Moraska and Chandler, 200819) | 18 | 6 weeks | Pilot study one group | Massage focused on relieving myofascial trigger point activity | Frequency P<0.001 Intensity P<0.01 Duration P<0.05 Disability P<0.001 |
| Toro-Velasco et al., 200920) | 11 | 2 sessions | Pilot study | G1: Pressure release and muscle energy in suboccipital muscles G2: placebo treatment with ultrasound therapy |
G1: Index of HRV P=0.01 Anxiety P=0.03 Hostility, anger P=0.04 Intensity P<0.05 G2: Parameters p>0.05 |
| Castien et al., 201121) | 82 | 8 weeks | Randomized controlled trial | G1: Mobilization of cervical and thoracic spine, postural correction exercises. G2: usual care by general practitioner |
G1: Impact P<0.001 Disability P=0.001 Movement P=0.023 Algometry P=0.001 Strength P=0.011 G2: Parameters p>0.05 |
Quinn and Chandler, 200215) performed a headache treatment recruiting 25 patients between 18 and 55 years old. The treatment was done for 4 weeks, 2 times per week, 30 minutes each session with the following 6 phase sequence: 3 minutes of preparatory tissue warmup, 5 minutes of myofascial release, 2 minutes of cervical traction, 5 minutes of TrP in trapezius, sternocleidomastoid, suboccipital, splenius capitis and elevator scapulae muscles, 5 minutes of stretching and 3 to 5 minutes of relaxation. After 4 weeks relevant outcomes were extracted for frequency (P = 0.009), duration of pain (P = 0.58), and pain intensity (P = 0.19). Therefore there was an improvement of the three measures after the manual therapy treatment.
Demirturk et al., 200216) conducted a comparative study on the efficacy of two different manual treatment methods in patients with TTH. The study included 35 patients with a mean age of 38.27 years old, who were randomly allocated into two groups. Only 30 patients completed the treatment programs. Superficial heat and massage were applied to both groups, as well as connective tissue manipulation to group 1 (n = 15) and vertebral Cyriax mobilization to group 2 (n = 15). The treatment program consisted of 20 sessions over 4 weeks plus 1 month of follow-up. For comparing the effectiveness of the methods the following parameters were evaluated before and after treatment and in a month follow-up: headache pain intensity, cervical active movement range, and pain threshold to pressure. The study results indicated that all parameters had significant improvements in both groups (P > 0.05). Thus, both treatments improved the measures.
Donkin et al., 200217) performed a study with 30 patients between 20 and 62 years old divided into two groups with 15 subjects each. The treatment was undertaken in 9 sessions over 4 weeks. The first group received cervical or thoracic spinal manipulation and the second received chiropractic manipulation and cervical chin-occipital manual traction 20 times (10 seconds of traction followed by 10 seconds of pause). Perception of pain was assessed by the McGill questionnaire, disability by the Neck Disability Index, intensity by the Numerical Pain Rating Scale 101, and also cervical range of motion (CROM) and a daily register of pain frequency, intensity and duration were evaluated. The first group improved as well in all parameters of daily pain. Moreover, compared with the second group the first group improved in pain intensity (P = 0.042), pain perception (P = 0.082) and its daily pain improved in intensity (P = 0.005) and in frequency (P = 0.018), while the rest of parameters remained unchanged. The study concludes that manipulation without traction is the most effective technique.
Torelli et al., 200418) evaluated results of physiotherapy for TTH in 50 patients, aged between 18 and 70: 26 diagnosed with ETTH and 24 with CTTH. Patients received physiotherapy treatment for 8 weeks: group 1 was treated with initial gentle massage, progressive relaxation and gentle stretching, adding daily home program of active exercises of shoulder, neck and pericranial muscles, plus 12 weeks of follow-up. Group 2 had 8 weeks of observation, then 8 weeks of identical physiotherapy treatment as Group 1, followed by 12 weeks of follow-up. Comparing headache frequency before and after the treatment a significant and equal decrease was shown in both groups (P < 0.001). These results were significant for CTTH compared with ETTH (P < 0.002). The intensity, duration and medication, did not change throughout the study and showed no variations between chronic tension headache or between episodic tensiontype headache. The study was limited by the lack of double-blind design.
van Ettekoven and Lucas, 200619) conducted a multicenter, randomized controlled trial with a treatment period of 6 weeks, immediate evaluation after them and a 6 months follow-up. The objective was to determine the effectiveness of a cranio-cervical exercise program combined with other physiotherapy treatments in patients with TTH. The study recruited 81 participants with TTH and a mean age of 48.3 years (SD 18.39) who were randomly allocated into two groups. One group was treated with friction massage, passive rhythmic mobilization techniques based on Maitland method, cervical, thoracic and lumbopelvic postural correction and cranio-cervical exercises with a latex band (150 cm). The control group treatment was the same except that cranio-cervical exercises were not applied. Frequency, intensity and duration of pain, were evaluated, as well as quality of life with the SF-36, and the multidimensional aspect with the Multidimensional Health Locus of Control scale (MHLC). The cranio-cervical exercise group showed significant reduction in most of the parameters. This trial showed that cranio-cervical physiotherapy including an exercise program is effective for a long period of time in TTH.
Anderson and Seniscal, 200620) conducted a study to compare the effects of a treatment based only on progressive muscle relaxation, with a treatment based on progressive muscular relaxation combined with joint mobilization, functional, muscle energy, and strain/counterstrain techniques, and cranial osteopathic treatment. It was a single-blind, randomized, clinical trial undertaken with 26 patients with TTH (12 in the control group and 14 in the experimental group). Both groups practiced relaxation exercises for 20 minutes at home, while the experimental group also received 3 osteopathic treatments (1 per week) that focused on the pelvis, cranium, cervical and upper thoracic spine, clavicles, and upper ribs. Pain frequency was registered and it decreased significantly in the experimental group (P = 0.016), but the level of improvement in pain and headache intensity was not statistically significant. The pain rate also improved 57.5% in the experimental group, while in the control group it improved 15.6%. Therefore, progressive muscle relaxation combined with osteopathic treatment was more effective than only progressive muscle relaxation.
Moraska and Chandler, 200821) performed a study to evaluate the short-term changes in patients with TTH. The physiotherapy program was based on massage focused on relieving myofascial trigger point activity. The study recruited 18 participants with a mean age of 43.8 years, who received the treatment 2 times per week, in 45 minute massage sessions, which began after a three week base-line period. Disability evaluation was done using the Headache Disability Inventory (HDI) and with a record of frequency, intensity and duration of pain. The headaches were registered during base-line period, 6 week treatment period and 3 week follow-up. Pain frequency decreased from 4.7 (SD 0.7) episodes per week to 3.7 (SD 0.9) during treatment period and to 3.2 (SD 1.0) during the follow-up. The headache intensity was reduced by 30% and headache duration decreased from 4.0 (SD 1.3) to 2.8 (SD 0.5) hours. Disability index also showed significant improvement. This results show that massage combined with myofascial trigger point treatment is effective.
Toro-Velasco et al., 200922) studied the immediate effects of head and neck massage on heart rate variability (HRV), mood states and pressure pain thresholds (PPT) in patients with CTTH. The sample had 11 patients with a mean age of 51 years (SD 15). Group 1 received the experimental treatment (pressure release and muscle energy in suboccipital muscles for 40 minutes) and group 2 had placebo treatment with ultrasound therapy. Evaluation was performed by holter, electrocardiogram, and PPT on temporalis, suboccipital, upper trapezius, splenius capitis, sternocleidomastoid, levator scapulae, and semispinalis capitis. The mood profile was evaluated with the Profile of Mood States questionnaire (POMS). The data were obtained before intervention, immediately after it and 24 hours later. Paired comparisons after the intervention showed that the group treated with MT had an increased rate of HRV (P = 0.01), whereas no changes were found after intervention in placebo group (P = 0.7). There were also differences for tension-anxiety (F = 5.3, P = 0.03), and for hostility and anger (F = 4.6, P = 0.04). Paired comparisons showed that pain intensity was reduced 24 hours after the MT (P <0.05) but not after placebo intervention (P = 0.9). Therefore, the application of a single session of MT produces an immediate increase in heart rate variability index and a decrease in tension, in anger state and perceived pain in patients with CTTH.
The study performed by Castien et al., 201123) evaluated the effectiveness of MT in the CTTH with 82 subjects that were randomly allocated: 41 received MT treatment and 41 received usual care by general practitioner. The MT treatment consisted of a combination of mobilizations of the cervical and thoracic spine, exercises and postural correction for 8 weeks, with a maximum of 9 sessions of 30 minutes each. Evaluation included pain frequency, use of medication, headache severity, impact and disability produced by headache evaluated with the Headache Impact Test-6 (HIT-6), algometry, strength of cervical flexors and cervical range of motion. Evaluation was done at the end of the 8 week treatment and had a follow-up of 26 weeks. Significant differences were found for the MT group in frequency (−6.4 days, 95% CI −8.3 to −4.6), duration of headache (−5.3 hours, 95%, CI −9.5 to −1.2) and headache intensity (−1.8, 95% CI −3.1 to −0.7). After 8 weeks pain frequency was reduced to 50% in 87.5% of participants in MT group and in 27.5% in the usual care group (Table 1). At 26 weeks follow-up the differences between groups were statistically significant in headache frequency (−4.9 days, 95% CI −6.95 to −2.98) pain intensity (−1.4, 95% CI −2.7 to −0.2) and impact of pain (P = 0.012) in favour of the MT group. Therefore, MT was proved to be more effective than usual care.
All the analyzed studies combine different techniques and no study applies manual therapy separately and evaluates its effectiveness, making it difficult to know which of the techniques is most effective. 4 of them include massage, 2 include suboccipital inhibition and 2 spinal manipulation in a different region.
Common techniques to most of the studies are postural correction exercises or similar and myofascial techniques.
The 3 higher methodological quality studies are RCTs, but they combine a greater number of manual therapy techniques and none of them focuses on the treatment of suboccipital or craniocervical region.
Discussion
This review found that manual therapy can be an alternative for treatments and therapies used for TTH which do not have complete effectiveness.
The studies found in this review show that massage combined with: cervical exercises, myofascial techniques, postural techniques, cervical relaxation exercises, cervical mobilization, gentle and progressive stretching or TrP treatment are effective in reducing pain frequency, intensity and duration, as well as increasing range of motion. Relaxation exercises combined with cervical exercises were only effective in reducing pain frequency in CTTH, and were not in ETTH. The reviewed studies that apply only manipulation showed positive results, however, they did not have control group or their methodological quality was low and systematic reviews show no conclusive results of its effectiveness. However this therapy appears to be effective when it is combined with massage.
Other authors13) conducted a review which evaluated the effectiveness of manipulation in headache. It included 8 randomized studies and the Jadad scale was used for assessing the validity of the scientific article. 6 trials were included in the study and only 3 treated TTH. No conclusive results referring to the effectiveness of spinal manipulation were obtained since the studies were limited for not having control group or only single-blind control.
Along the same lines, Fernández de las Peñas et al.14) performed a review of the effectiveness of manual therapy for reducing pain in TTH based on the methodology scale of PEDro. Only 6 studies had used manual therapy. According to PEDro scale evidence changed from 2 to 8 (mean 5.8 SD = 2.1). Quality and results analysis of all trials did not provide evidence that manual therapy had a positive effect in reducing TTH: spinal manipulation showed evidence of effectiveness (level 4), while soft tissue techniques showed limited evidence (level 3).
Lenssinck et al., 20044) performed a systematic review of randomized controlled trials (RCTs) to determine the effectiveness of physiotherapy and spinal manipulation in patients with TTH. A total of 8 RCTs that used physiotherapy or spinal manipulation in the treatment of TTH in adults were selected. These studies showed a variety of interventions such as spinal chiropractic manipulation, connective tissue manipulation or physiotherapy. Only two studies were considered of high quality, but showed opposite results. Due to clinical heterogeneity and low methodological quality of many of the studies, it did not seem possible to show valid conclusions. Therefore, there is insufficient evidence to support or refute the efficacy of physiotherapy and spinal manipulation in patients with TTH according to this review. Table 2 shows different reviews that study the effectiveness of MT in TTH.
Table 2. Summary of other systematic reviews of effectiveness of MT in CTTH.
| Author | Type of treatment | n | Results |
|---|---|---|---|
| Espí and Gómez, 201011) | Drugs, manual therapy | 15 studies | Joint therapy, functional techniques, with muscle relaxation have good results. |
| Astin and Ernst, 200222) | Vertebral manipultaion | 8 studies | Only 3 treated TTH and do not show conclusive results referring to effectiveness. |
| Fernández et al., 200623) | Vertebral manipulation, massage, vertebral mobilization, manual traction, cranium therapy | 6 studies | Studies using spinal manipulation showed evidence of effectiveness (level 4), while soft tissue techniques showed limited evidence (level 3). |
| Lenssinck et al., 20044) | Physiotherapy and spinal manipulation | 8 studies | Insufficient evidence to support or refute the efficacy of physiotherapy and spinal manipulation in patients with TTH |
As shown in this review, massage combined with other physiotherapy techniques is usually effective, but we still do not know if other physiotherapy techniques are effective separately. Likewise, so are MT techniques. However, few studies have implemented specific physiotherapy techniques based on MT for the treatment of headache, probably this is due to the effectiveness for relieving pain of pharmacological measures11). Therefore, greater number of evidence-based studies is needed to determine the effectiveness of physiotherapy for patients with TTH. In addition, due to the application of treatments that combine several techniques, it is not possible to distinguish whether the same results would be shown for each treatment on its own.
The highlight of this review was to determine other physiotherapy techniques which include manipulative manual therapy or not and the assessments which are important in different spheres such as quality of life, disability, impact of pain and pain perception, and not just pain frequency and intensity of pain during crisis which decreases in most of the treatments. The main limitation of this study is that the results are not taken into account the risk of bias and reporting bias.
Conclusion
Cervical exercises, relaxation, massage, postural exercises, cranio-cervical techniques, thermotherapy, vertebral mobilization and stretching are effective in reducing TTH symptoms such as pain frequency and intensity. In the studies that have applied joint mobilization, cervical range of motion has improved. Other parameters such as quality of life, impact and pain disability and psychological aspects have improved with MT. Therefore it would be advisable to use it both to improve the quality of life of patients and to reduce the socioeconomic cost of the disease. However, it is noteworthy that all studies reviewed, as well as other previous reviews include more than two techniques so it becomes difficult to know which one of them is most effective. Therefore, it would be desirable to implement studies that showed the effectiveness of techniques on their own. Conflict of interest: None declared
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