title: Are manual therapies effective in reducing pain from tension-type headache?: a systematic review.
abstract: OBJECTIVE
  A systematic review was performed to establish whether manual therapies have specific efficacy in reducing pain from tension-type headache (TTH).
  
  
  METHODS
  Computerized literature searches were performed in MEDLINE, EMBASE, AMED, MANTIS, CINAHL, PEDro, and Cochrane databases. Papers were included if they described clinical (open noncontrolled studies) or randomized controlled trials in which any form of manual therapy was used for TTH, and if they were published after 1994 in the English language. The methodologic quality of the trials was assessed using the PEDro scale. Levels of scientific evidence, based on the quality and the outcomes of the studies, were established for each manual therapy: strong, moderate, limited, and inconclusive evidence.
  
  
  RESULTS
  Only six studies met the inclusion criteria. These trials evaluated different manual therapy modalities: spinal manipulation (three trials), classic massage (one trial), connective tissue manipulation (two trials), soft tissue massage (one trial), Dr. Cyriax's vertebral mobilization (one trial), manual traction (one trial), and CV-4 craniosacral technique (one trial). Methodologic PEDro quality scores ranged from 2 to 8 points out of a theoretical maximum of 10 points (mean=5.8+/-2.1). Analysis of the quality and the outcomes of all trials did not provide rigorous evidence that manual therapies have a positive effect in reducing pain from TTH: spinal manipulative therapy showed inconclusive evidence of effectiveness (level 4), whereas soft tissue techniques showed limited evidence (level 3).
  
  
  CONCLUSIONS
  The authors found no rigorous evidence that manual therapies have a positive effect in the evolution of TTH. The most urgent need for further research is to establish the efficacy beyond placebo of the different manual therapies currently applied in patients with TTH.
authors.affiliation: Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos (URJC), Alcorcón, Madrid, Spain. cesarfdlp@yahoo.es
authors.forename: César
authors.initials: C
authors.lastname: Fernández-de-Las-Peñas
authors.forename: Cristina
authors.initials: C
authors.lastname: Alonso-Blanco
authors.forename: Maria Luz
authors.initials: ML
authors.lastname: Cuadrado
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: Miangolarra
authors.forename: Francisco J
authors.initials: FJ
authors.lastname: Barriga
authors.forename: Juan A
authors.initials: JA
authors.lastname: Pareja
mesh_terms: D002986:Clinical Trials as Topic; D006801:Humans; D026201:Musculoskeletal Manipulations / Q000379:methods*; D010146:Pain / Q000209:etiology*; D059408:Pain Management; D018781:Tension-Type Headache / Q000150:complications* / Q000628:therapy*; D016896:Treatment Outcome