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Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache

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SOURCE:  Duke University Evidence-based Practice Center

Douglas C. McCrory, MD, MHSc, Donald B. Penzien, PhD,
Vic Hasselblad, PhD. Rebecca N. Gray, DPhil

Duke University Evidence-based Practice Center
Center for Clinical Health Policy Research
2200 W. Main Street, Suite 230
Durham, NC 27705

EXECUTIVE SUMMARY

Background

Tension-type headache and cervicogenic headache are two of the most common non-migraine headaches. Population-based studies suggest that a large proportion of adults experience mild and infrequent (once per month or less) tension-type headaches, and that the one-year prevalence of more frequent headaches (more than once per month) is 20%-30%; a smaller percentage of the population (roughly 3%) has been estimated to have chronic tension-type headache (180 days per year). Estimates of the prevalence of cervicogenic headache have varied considerably, due in large part to disagreements about the precise definition of the condition. A recent population-based study, which used the diagnostic criteria of the International Headache Society (IHS), found that 17.8% of subjects with frequent headache (5 days per month) fulfilled the criteria for cervicogenic headache; this was equivalent to a prevalence of 2.5% in the larger population. This agrees with an earlier clinic-based study which found that 14% of headache patients treated had cervicogenic headache.

The impact of tension-type headache on individuals and society appears to be significant. According to one population-based study, regular activities were limited during 38% of tension-type headache attacks, and 4% of respondents indicated that their headaches affected their attendance at work. Eighty-nine percent of tension-type headache sufferers reported that their headaches had negatively affected their relationships with friends, colleagues, and family. Little is known about the personal and societal impact of cervicogenic headache.

Nearly all patients with tension-type headache have used medications at one time or another to treat their headaches. But pharmacological treatments are not suitable for all patients, nor are they universally effective. Drug treatments may also produce undesired side effects. Partly for these reasons, significant interest has developed among both patients and health care providers in alternative treatments for tension-type headache, including behavioral and physical interventions. Cervicogenic headache, when diagnosed as such, is commonly treated with non-pharmacological interventions, especially physical treatments.

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Spinal Manipulation vs. Amitriptyline for the Treatment of Chronic Tension-type Headaches: A Randomized Clinical Trial

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SOURCE:   J Manipulative Physiol Ther 1995 (Mar); 18 (3): 148–154

Patrick Boline, DC, Kassem Kassak, MPH, PhD,
Gert Bronfort, DC, PhD, Craig Nelson, DC,
A.V. Anderson, DC, MD

Funding was provided by:
Foundation for Chiropractic Education and Research (FCER)

This article is reprinted with the permission of National College of Chiropractic and JMPT.   Our special thanks to the Editor, Dr. Dana Lawrence, D.C. for permission to reproduce this article exclusively at Chiro.Org

This study compared the effects of spinal manipulation and pharmaceutical treatments for chronic tension headaches. Four weeks following the cessation of treatment, the pharmaceutical group demonstrated no improvement from the baseline. In the spinal manipulation group, headache intensity dropped 32 percent; frequency dropped 42 percent; and there was an overall improvement of 16 percent in functional health status.

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Perhaps the best known clinical trial on chiropractic and Tension-type Headaches was the Boline et al study, which compared chiropractic care to the medication amitriptyline. These investigators found that one month of chiropractic care (approximately 2 visits per week) was more effective than amitriptyline for long-term relief of headache pain.

During the treatment phase of the trial, pain relief among those treated with medication was roughly comparable to the chiropractic group. But chiropractic patients maintained their levels of improvement after treatment was discontinued, while those taking medication returned to pretreatment status in an average of 4 weeks after its discontinuation.
(Thanks to Daniel Redwood, DC)

This study compared the effects of spinal manipulation and pharmaceutical treatments for chronic tension headaches. Four weeks following the cessation of treatment, the pharmaceutical group demonstrated no improvement from the baseline. In the spinal manipulation group, headache intensity dropped 32 percent;   frequency dropped 42 percent;   and there was an overall improvement of 16 percent in functional health status.

Background:   In the United States headaches are responsible for more than 18 million office visits annually, and are the most common reason for using over-the-counter medications. It is estimated that 156 million work days are lost each year because of headaches, translating to $25 billion in lost productivity. Of the categories of chronic headaches, tension-type headaches are most common.

Headaches are commonly treated by chiropractic doctors with spinal manipulation, and several studies have reported good outcomes. These trials however, suffered from either a lack of a control group or inadequate statistical power. The purpose of this randomized clinical trial was to evaluate the effectiveness of spinal manipulation and a common pharmaceutical treatment (amitriptyline) for chronic tension-type headache.

Methods:   One-hundred-fifty patients between the ages of 18 and 70 were randomly assigned to receive either six weeks of chiropractic or pharmaceutical treatment which was preceded by a two week baseline period and included a four week, post-treatment follow up period. Main outcome measures were change in patient-reported daily headache intensity, weekly headache frequency, over-the-counter medication usage, and functional health status using the SF-36 Health Survey.

Results:   During the treatment period both groups improved at very similar rates in all primary outcomes. Four weeks following the cessation of treatment patients who received spinal manipulative therapy showed a reduction of 32% in headache intensity, 42% in headache frequency, 30% in over-the-counter medication usage and 16% in functional health status. By comparison, patients that received amitriptyline showed no improvement or a slight worsening from baseline values in the same outcome measures. The group differences at four week post-treatment follow up were considered to be clinically important and statistically significant. There is further need to assess the effectiveness of spinal manipulative therapy beyond four weeks and to compare spinal manipulative therapy to an appropriate placebo such as sham manipulation in future clinical trials.

Conclusion:   The results of this study show that spinal manipulative therapy is an effective treatment for tension headaches. Amitriptyline was slightly more effective in reducing pain by the end of the treatment period, but was associated with more side effects. Four weeks after cessation of treatment however, patients who received spinal manipulation experienced a sustained therapeutic benefit in all major outcomes in contrast to the amitriptyline group, who reverted to baseline values. The sustained theraputic benefit associated with spial manipulation seemed to result in a decreased need for over-the-counter medication. There is a need to assess the effectiveness of spinal manipulative therapy beyond four weeks and to compare SMT to an appropriate placebo such as sham manipulation in future clinical trials.   (see the Problem with Placebo/Shams Page for other issues associated with sham treatments provided in previous studies.)

Key words:   clinical guidelines; low back pain; evidence based medicine; systematic reviews

From the Full-Text Article:

INTRODUCTION

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