Effectiveness of physiotherapy interventions on headache intensity,frequency,duration and quality of life of patients with tension-type headache. A systematic review and network meta-analysis

Abstract

Background

This systematic review assesses the effectiveness of physiotherapy on headache parameters and quality of life of patients with tension-type headache using network meta-analysis.

Methods

A systematic search was conducted in the databases Web of Science, Medline, Cochrane Library and Physiotherapy Evidence Database up to August 2021. Randomised controlled trials investigating the effect of physiotherapy on tension-type headache were included. Risk of bias assessment was performed using the Risk of bias tool 2.0. Results were presented according to the Cochrane handbook and the PRISMA statement.

Results

Twenty reports were eligible and 15 were included in network meta-analysis for pain intensity and frequency. Transcutaneous electrical stimulation combined with physiotherapy was the most effective approach to reduce pain intensity compared to control (mean difference (MD): −4.18, moderate confidence) and usual care (MD: −3.8, moderate confidence) Manual therapy (joint mobilisation) plus exercise was the most effective intervention to reduce headache frequency compared to control (MD: −13.03, low confidence) and usual care (MD: −13.95, moderate confidence).

Conclusion

Results suggest a combination of passive physiotherapy techniques with exercise and/or transcutaneous electrical stimulation as the most effective physiotherapy intervention to reduce pain intensity and frequency in the short term. More research is needed to investigate mid-term and long-term effects.

Trial registration: This review was prospectively registered in www.aspredicted.org under the registration number #46098 and an updated protocol was registered in the Open Science Framework (OSF) with the registration DOI: https://doi.org/10.17605/OSF.IO/RVUEY

Keywords

Tension type-headache physiotherapy physical therapy systematic review network meta-analysis

Background

The prevalence of tension-type headache (TTH) ranges from 2.2% to 38.3% (1). For the treatment of acute phases and the reduction of headache frequency, pharmacological and non-pharmacological approaches can be used. A commonly used non-pharmacological treatment for TTH is physiotherapy (2), involving various modalities such as exercises, electrical stimulation, massage, joint mobilisation, trigger-point therapy and many more. But despite the abundance of physiotherapy interventions available, the majority of these have not been thoroughly evaluated for effectiveness. Hence, only a weak recommendation for their use is given by clinical guidelines (2). Several reviews and meta-analyses have confirmed a general effectiveness of physical therapy modalities on patients with TTH in the past (3 –5). However, an evaluation of the most effective physiotherapy intervention using network meta-analysis (NMA) has never been attempted. The advantages of NMA, such as improvement in precision, the ability to compare treatments that have not been directly compared as well as the quantitative comparison of more than two treatments, suggest that this quantitative method could serve decision-making better than conventional pairwise meta-analysis (6). The purpose of this review was to assess the effectiveness of physiotherapy interventions on the intensity, frequency, and duration of headaches, as well as on the quality of life of patients with TTH using NMA.

Methods

The present systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses Statement for network meta-analysis (PRISMA-NMA) (7), as well as the Cochrane Handbook for Systematic Reviews of Interventions (8). The review protocol was prospectively registered on 12 August 2020 in www.aspredicted.org under the registration number #46098 and an updated protocol was registered on 23 February 2021 in the Open Science Framework (OSF) with the registration DOI: https://doi.org/10.17605/OSF.IO/RVUEY.

Information sources

A systematic literature search was carried out on 5 October 2020 in the following databases: Physiotherapy Evidence Database (PEDro), Web of Science, Medline via Pubmed and Cochrane Library. This search was updated on 23 August 2021. In addition, reference lists of included studies were reviewed to identify additional studies. The search strategy for each database is presented in Supplementary material A and the search was performed by two research clinicians independently.

Eligibility criteria

Records were screened using the following eligibility criteria (Table 1): Randomised controlled studies (RCTs) examining the effect of physiotherapy interventions on an adult TTH population were included. If TTH was not diagnosed according to the third edition of the International Classification of Headache Disorders (ICHD-3) (9) or previous editions (10,11), the study was excluded. Comparisons with control interventions including waiting list, sham therapy, placebo, standard care, or other active interventions were required for inclusion. In case of multi-arm trials, only data of eligible interventions (-arms) were extracted for quantitative synthesis. Data from outcome measurements assessing headache intensity, duration, frequency or quality of life were included.

Table 1.

Eligibility criteria.

	Inclusion criteria	Exclusion criteria
P(Population)	Diagnosis/classification of tension-type headache according to the criteria of IHS classification: ICHD-3 (9) (or previous editions (10,11))	<18 years of age
I(Intervention)	Physiotherapy interventions, such as massage, manual therapy, trigger point therapy and exercises, etc	Interventions that are not considered conventional physiotherapy treatment or that were not carried out by a physiotherapist, e.g. yoga, tai-chi, dance therapy, acupuncture, psychological, chiropractic or osteopathic treatmentMultidisciplinary interventions in which physiotherapy played a minor role
C (Comparison)	Waiting list, standard care or any type of placebo or other active intervention or any combinations of the above	N/A
O(Outcome)	At least one of the following outcomes: Frequency, intensity, or duration of tension-type headache or quality of life measure
S(Study design)	Randomised controlled trials	Reviews, meta-analyses, observational studies, case-control studiesLanguage other than German or English

ICHD-3: International Classification of Headache Disorders (3rd edition); IHS: International Headache Society.

Study selection

Titles and abstracts as well as full-texts were screened by two independent reviewers according to predefined eligibility criteria (Table 1). The inter-rater reliability of the reviewers’ agreement regarding study eligibility was expressed using Cohen’s kappa coefficient. In the event of a disagreement between the two investigators, a third reviewer was consulted to reach consensus.

Data collection process

Included data were manually extracted by one reviewer and controlled for accuracy by a second reviewer. The data items were extracted into a pre-specified extraction table: i) Author, date and country; ii) classification used for diagnosis; iii) participant numbers, age, sex (for each group); iv) type of the intervention including data on intervention and/or control intervention: Frequency, intensity, timing, length of treatment, staff qualification and setting; v) outcome measures (for each group): Measurement tools and timepoint of assessment. Where key data was missing, corresponding study authors were contacted.

Risk of bias assessment

Risk of bias (RoB) assessment was performed by two independent reviewers using the revised Cochrane Collaboration RoB 2.0 tool (12), which is a domain-based assessment tool addressing bias arising at different stages of the RCT. The RoB assessment was conducted according to the manual (https://www.riskofbias.info/welcome/rob-2-0-tool) and pilot tested prior to the data extraction. Since there is no explanation in the manual of how to rate the RoB in studies with retrospectively registered trial protocols, it was decided to treat them equally to non-existent protocols and the domain “bias in selection of the reported results” was rated as “some concerns”. Trial protocols that were retrospectively registered, but before unblinded data were available, were treated as prospective, since they do not raise concerns about bias according to the manual (13). RoB plots were created using the robvis tool (14).

Certainty of the evidence

The certainty of evidence of NMA was assessed using the Confidence in Network Meta-analysis (CINeMA) web application (https://cinema.ispm.unibe.ch), which is based on the framework described by Salanti et al. (15). This software allows to run a semi-automated assessment of the quality of evidence (16). Six different components are considered: Within study bias, reporting bias, indirectness, imprecision, heterogeneity, and incoherence. An examination of publication bias using a comparison-adjusted funnel plot (17) and linear regression test of funnel plot asymmetry (Egger test) were considered if there were more than 10 studies included in NMA for each outcome (18).

Analysis

Prior to statistical analyses, data was assessed for transitivity according to Salanti (6). Similarities of included reports were compared by age, sex, diagnostic/classification criteria, treatment parameters as well as study setting to evaluate if interventions included in the NMA were “jointly randomizable” (6). NMA was performed using a frequentist method with the statistical package “netmeta” (version 1.4-0) in R (https://www.r-project.org/). The “netgraph” function was used to present the network structure and to inspect the network geometry for each outcome of interest. Outcomes were pooled and analysed as mean difference (MD) for pain intensity and headache frequency using a random effects model and their 95% confidence interval (CI). Post-scores with its standard deviations (SD) were used to pool data in NMA. If no post-score of pain intensity or frequency was available in a trial, the reported change-score (from baseline) and its SD was considered, since it is legitimate to pool post- and change-scores together using the (unstandardised) MD according to the Cochrane Handbook (19). For headache frequency, the data of included trials was rescaled to a timeframe of 30 days. It was planned to pool data for short-term results (≤12 weeks), mid-term results (13 weeks to 6 months) and long-term results (>7 months) of each outcome individually. If two or more results were available for the same time-period described above, the last one was extracted for quantitative analysis. To assess for incoherence (inconsistency between direct and indirect evidence), two approaches, a local and a global approach, were used. For the local approach, the node-split function “netsplit” was used and differences between direct and indirect comparisons were tested statistically and reported using p-values. For the global approach, the design‐by‐treatment interaction test was performed by the CINeMA app (16). Statistical heterogeneity was assessed using I² and Cochrane’s Q tests of heterogeneity within designs and between designs. The ranking of treatments was assessed using the P-score, which is a frequentist analogue to the SUCRA-value of the Bayesian approach (20). The P-score is a value between 0 and 1. The larger the P-score, the greater the likelihood of being the best treatment. Sensitivity analysis excluding studies with high RoB was considered.

There are no publications investigating clinically important changes of pain intensity, pain duration or pain frequency in patients with TTH. Therefore, clinically important changes were derived from other chronic pain populations (21) and recommendations in behavioural headache research (22). A reduction of 2.4 points on a 0–10 numerical scale was considered clinically important for pain intensity (21). For pain duration and pain frequency, a reduction of 50% was considered clinically important (22). For the latter two, a weighted mean of all included baseline data in NMA was derived based on sample size, to calculate the threshold for clinically important changes in NMA. Thus, the clinically important change for NMA of headache frequency and duration was a reduction of 7.5 headache days within a month and a reduction of 7.3 h respectively.

Results

A total of 378 records were identified through the electronic and hand search (Figure 1). After removing duplicates and title/abstract screening (Table 1), 40 reports were reviewed in full text. Twenty reports were included for qualitative synthesis, 20 were excluded due to reasons specified in Supplementary material B. The screening of reports reached a substantial inter-reviewer agreement (k = 0.78).

Figure 1.

PRISMA flow-chart for study inclusion.

The characteristics of included studies are summarised in Table 2. The 20 studies included in this review evaluated numerous physiotherapy interventions such as cryotherapy, transcutaneous electrical nerve stimulation (TENS), trigger point therapy, soft tissue techniques, various mobilisation and manipulation techniques. Eight studies assessed a single modality (23 –30), while the remaining studies evaluated multiple modalities. In all studies, participants were allowed to use abortive (acute) medication, regardless of the intervention allocation. The most common outcome measured was headache intensity via the visual analogue scale (VAS) (24,26,30 –34), the numerical rating scale (NRS) (25,27,29,35 –38), the verbal rating scale (28) or the 3-point severity index of the headache disability inventory (HDI) (39,40). Headache frequency was measured via a headache diary (1 week to 3 months) (23,25,26,28 –32,35,36,38), the 3-point scale of the HDI (39,40), a 4-point scale (33) or a 5-point Likert scale (27). Quality of life was measured in three studies (24,38,41) (using SF-12 and SF-36) and headache duration was evaluated in five studies (25,28,30,31,38). With the exception of three studies (28,35,38), all included reports exclusively assessed the short-term effectiveness of physiotherapy interventions.

Table 2.

Characteristics of included studies.

Author, year, country	Diagnosis	Sample size	Experimental intervention I, prescription	Experimental intervention II, prescription	Experimental intervention III, prescription	Control intervention, prescription	Outcome, time of measurement	Results Mean (SD) as reported by trial authors
Alvarez-Melcón (2018) (31), Spain	ETTH or CTTH	n = 152	n = 50 f, 26 m; 20.23 ± 2.5 yearsRelaxation techniques, exercises for the head, neck, and shoulders, and guidelines on ergonomics and postural hygieneSingle session, instruction on daily practice for 4 weeks	–	–	n = 34 f, 42 m; 20.62 ± 2.21 yearsRelaxation techniquesSingle session, instruction on daily practice for 4. weeks	Frequency: Headache diary (headache days/4 weeks) Intensity: VAS (0–10) Duration: headache diary (h/day) At baseline, 4 weeks after end of treatment and 3 months after end of treatment	E I: frequencyBaseline: 12.96 (4.75) Post: 9.1 (3.57) F1: 7.14 (3.5) Control: frequencyBaseline: 12.71 (4.07) Post: 10.25 (3.88) F1: 8.64 (3.59) E I: intensityBaseline: 5.82 (1.26) Post: 4.58 (1.53) F1: 4.23 (1.66) Control: IntensitBaseline: 5.57 (1.32) Post: 5.19 (1.5) F1: 4.96 (1.59) E I: durationBaseline: 6.35 (3.04) Post: 5.09 (2.43) F1: 4.77 (2.28) Control: durationBaseline: 5.94 (3) Post: 4.96 (2.49) F1: 4.62 (2.5)
Ajimsha (2011) (23), India	ETTH or CTTH	n = 56	n = 15 f, 7 m; 43.7 ± 5.6 yearsDT-MFR technique (based on Stanborough), performed bilaterally with 3 min/side1h/session, 2×/week with 2 days gap each for 12 weeks	n = 14 f, 8 m; 44.7 ± 5.2 yearsIDT-MFR technique (based on Manheim), steps 5 and 6 performed bilaterally with 5 min/side1h/session, 2×/week with 2 days gap each for 12 weeks	–	n = 7 f, 5 m; 43.0 ± 5.4 yearsSlow soft stroking with finger pads all over the head1 h/session, 2×/week with 2 days gap for 12 weeks	Frequency: Headache diary (headache days/4 weeks) 1 month before randomisation, 4 weeks after end of treatment	E I: frequencyBaseline: 12 (2.8) Post: 4.9 (1.7) E II: frequencyBaseline: 12.4 (2.8) Post: 5.7 (1.3) Control: frequencyBaseline: 12 (2.5) Post: 10.4 (2.7)
Berggreen (2012) (24), Denmark	CTTH	n = 39	n = 20 f, 0 m; 38.8 ± 13.7 yearsTrigger point massage (according to Trigger Point Manual) on active trigger points held for 2–5 min at each treatment with ischemic compression. Pressure increased as tolerated and maintained for 30 sec to 1 min. 1×/week for 10 weeks	–	–	n = 19 f, 0 m; 42.3 ± 10.2 yearsUsual medical care (no active) intervention	Intensity: VAS scale daily diary4 weeks before and 4 weeks post treatmentQoL: Danish SF-36 questionnaire At baseline and end of treatment	E I: intensity (morning) Baseline: 28 (15.9) Post: 16.2 (11.8) Control: intensity (morning) Baseline: 26.6 (12.6) Post: 24.9 (14.5) E I: intensity (evening) Baseline: 34.7 (21.9) Post: 22.2 (21.4) Control: intensity (evening) Baseline: 29.8 (18.2) Post: 25.5 (16.3) Data on QoL not fully reported by trial authors
Castien (2011) (35), Netherlands	CTTH	n = 82	n = 32 f, 9 m; 40.2 ± 10.2 yearsCombination of mobilisation (MT) of cervical and thoracic spine, exercises and postural correctionNine sessions, 30 min/session for 8 weeks	–	–	n = 32 f, 9 m; 40.6 ± 11.3 yearsAdvice on benefits of lifestyle changes. If necessary, medications were prescribed (usual medical care) 2–3 visits each for 8 weeks	Frequency: headache diary (headache days/14 days) Intensity: NRS (0–10) Duration: headache diary (h/day) At baseline (14 days before treatment), at 8 weeks and at 26 weeks	E I: frequencyBaseline: 12 (2.5) Post: −9.1 (3.8) F1: −9.1 (4.2) Control: frequencyBaseline: 11.6 (2.7) Post: −2.7 (4.3) F1: −4.1 (4.4) E I: intensityBaseline: 6.3 (1.9) Post: −2.7 (0.9) F1: −3.1 (2.8) Control: intensityBaseline: 5.7 (1.5) Post: −0.9 (2.4) F1: −1.7 (2.5) E I: durationBaseline: 12.8 (8.9) Post: −5.9 (8.7) F1: −7 (10.4) Control: durationBaseline: 13 (9.1) Post: −0.6 (10) F1: −3.5 (7.3)
Demirturk (2002) (42) Turkey	CTTH	n = 30	n = 15 f, 0 m; 39.47 ± 12.42 yearsSuperficial heat and classical massage + CTM 30 min each20 sessions for 4 weeks	n = 15 f, 0 m; 37.07 ± 10.07 yearsSuperficial heat and classical massage + Cyriax’s vertebral mobilisation20 sessions for 4 weeks, including 3×/week	–	–	Headache Index (HI) = Frequency × IntensityAt baseline, end of treatment and 1 month after end of treatment	E I: HIBaseline: 3.17 (2.62) Post: −1.19 (2) F1: −1.53 (2.55) E II: HIBaseline: 4.31 (2.75) Post: −2.31 (3) F1: −3.69 (2.81)
Espi-Lopez (2014a) (39), Spain	ETTH or CTTH	n = 7662 f, 14 m; 39.9 ± 10.9 years,	n =19Suboccipital Soft Tissue Inhibition (SI) 5 min in supine position with neutral ranges of neck4 × 20 min 1/week for 4 weeks	n = 19Occiput Atlas Axis manipulation 5 min in supine position with neutral ranges of neck4 × 20 min 1/week for 4 weeks	n = 19Combination of SI and SM5 min in supine position with neutral ranges of neck4 × 20 min 1/week for 4 weeks	n = 19No treatment but 10 min in resting position (usual medical care) 4 × 20 min with 7 days intervals for 4 weeks	Frequency: HDI(3-point scale: once a month, >1/month but less than 4/month, and more than 1/week) Intensity: HDI severity (mild, moderate, and severe) At baseline, end of treatment	E I: HDI frequencyBaseline: 2.63 (0.59) Post: 2.47 (0.61) E II: HDI frequencyBaseline: 2.42 (0.6) Post: 2.05 (0.7) E III: HDI frequencyBaseline: 2.58 (0.5) Post: 2.32 (0.47) Control: HDI frequencBaseline: 2.63 (0.59) Post: 2.63 (0.59) E I: HDI severityBaseline: 2.26 (0.65) Post: 2.05 (0.78) E II: HDI severityBaseline: 2.37 (0.68) Post: 1.63 (0.76) E III: HDI severityBaseline: 2.16 (0.5) Post: 1.74 (0.65) Control: HDI severitBaseline: 2.05 (0.7) Post: 2 (0.81)
Espi-Lopez (2014b) (36), Spain	CTTH and ETTH	n = 77	n = 19SI, pressure applied for 10 minVAT test (bilaterally), 2 min gentle neck massage without lubricants and with no therapeutic effect before Intervention1/week for 4 weeks	n = 18Occiput-atlas-axis joint manipulationVAT test (bilaterally), 2 min gentle neck massage without lubricants and with no therapeutic effect before intervention1/week for 4 weeks	n = 19 Combination of SI and manipulative therapyVAT test (bilaterally), 2 min gentle neck massage without lubricantsand with no therapeutic effect before Intervention1/week for 4 weeks	n = 21No treatment but stayed in supine resting position 10 min (usual medical care) VAT test (bilaterally), 2 min gentle neck massage without lubricants and with no therapeutic effect before Intervention1/week for 4 weeks	Frequency: Patient record with daily register (headache days/week) Intensity: Patient record with NRS (0–10) with daily registerAt baseline, end of treatment, and 1 month after end of treatment	E I: frequencyBaseline: 3.25 (2.29) Post: 2.6 (2.13) F1: 2.45 (2.08) E II: frequencyBaseline: 2.9 (1.86) Post: 1.7 (2) F1: 2.15 (2.25) E III: frequencyBaseline: 3.8 (1.79) Post: 1.55 (1.5) F1: 1.65 (1.75) Control: frequencyBaseline: 3.24 (1.57) Post: 2.45 (1.5) F1: 2.85 (1.92) E I: intensityBaseline: 4.79 (2.26) Post: 3.77 (2.51) F1: 2.82 (2.2) E II: intensityBaseline: 5.12 (1.95) Post: 3.03 (2.8) F1: 3.28 (2.39) E III: intensityBaseline: 4.8 (1.68) Post: 3.24 (2.72) F1: 3.02 (2.6) Control: intensityBaseline: 5.24 (1.8) Post: 3.95 (2.12) F1: 3.86 (2)
Espi-Lopez (2016a) (41), Spain	ETTH or CTTH	n = 76	n = 17 f, 2 m; 43.74 ± 13.73 yearsSI5 min in supine position with neutral ranges of neck4 × 20 min 1/week for 4 weeks	n = 17 f, 2 m; 34.05 ± 8.35 yearsSuboccipital Spinal Manipulation (SSM) 5 min in supine position with neutral ranges of neck4 × 20 min 1/week for 4 weeks	n = 17 f, 2 m; 41.58 ± 10.02 years, Combination of SI and SSM5 min in supine position with neutral ranges of neck4 × 20 min 1/week for 4 weeks	n = 11 f, 8 m; 41.58 ± 10.02 yearsNo treatment but 10 min resting position (usual medical care) 4 × 20 min with 7 days intervals for 4 weeks	QoL: SF-12At baseline, end of treatment, and 1 month after end of treatment	E I: QoLBaseline: 37.26 (3.6) Post: 38.15 (4.16) F1: 39.16 (3.89) E II: QoLBaseline: 41 (3.48) Post: 40.89 (2.92) F1: 41.42 (2.36) E III: QoLBaseline: 39.57 (4.93) Post: 39.89 (3.6) F1: 40.21 (3.32) Control: QoLBaseline: 39.1 (2.55) Post: 40.05 (2.85) F1: 39.58 (2.43)
Espi-Lopez (2016b) (40), Spain	FTTH and CTTH	n = 102	n = 41 f, 10 m; 37.69 ± 10.64 yearsOcciput-atlas-axis joint manipulation and massage + in supine resting position VAT test (bilaterally) at first session30 min, 1/week for 4 weeks	–	–	n = 38 f, 13 m; 40.47 ± 11.33 yearsSuperficial cervical spine placebo massage and resting positionVAT test (bilaterally) at first session20 min, 1/week for 4 weeks	Frequency: HDI (once a month, from 2–3× a month, and more than 1/week) Intensity: HDI (mild, moderate, and severe) At baseline, at end of treatment and 1 month after end of treatment	E I: HDI frequencyBaseline: 2.55 (0.54) Post: 2.25 (0.63) F1: 1.86 (0.69) Control: HDI frequencyBaseline: 2.65 (0.56) Post: 2.47 (0.61) F1: 2.29 (0.67) E I: HDI intensityBaseline: 2.24 (0.59) Post: 1.71 (0.64) F1: 1.57 (0.64) Control: HDI intensityBaseline: 2.16 (0.64) Post: 1.98 (0.76) F1: 1.76 (0.68)
Ferragut-Garcias (2017) (32), Spain	FETTH and CTTH	n = 97	n = 17 f, 6 m; 38.1 ± 10.9 yearsSoft tissue techniques6 × 15 minTwo sessions in first week, two in second week, one in third and fourth weeks	n = 20 f, 5 m; 39.4 ± 11.0 yearsNeural mobilisation technique6 × 15minTwo sessions in first week, two in second week, one in third and fourth weeks	n = 21 f, 4 m; 40.8 ± 12.1 yearsCombination of soft tissue techniques and neural mobilisation techniques – 7.5 min per protocol6 × 15 minTwo sessions in first week, two in second week, one in third and fourth weeks	n = 20 f, 4 m; 40.5 ± 12.0Placebo superficial massage with US gel to minimise skin stimulation 6 × 15 minTwo sessions in first week, two in second week, one in third and fourth weeks	Frequency: Daily headache diary (headache days/15 days) Intensity: Headache diary VAS (0–10) At baseline, end of treatment, 15 and 30 days after end of treatment	E I: frequencyBaseline: 8.6 (2.3) Post: 4.7 (1.7) F1: 4.7 (1.4) F2: 4.8 (1.7) E II: frequencyBaseline: 7.9 (2.7) Post: 4.2 (1.7) F1: 4.3 (2.2) F2: 4.3 (2.2) E III: frequencyBaseline: 8 (2.6) Post: 3.5 (1.7) F1: 3.5 (1.7) F2: 3.4 (1.9) Control: frequencyBaseline: 7.2 (2.7) Post: 6.7 (2.5) F1: 6.9 (2.5) F2: 6.8 (2.3) E I: intensityBaseline: 4.4 (1.1) Post: 2.8 (1) F1: 2.8 (0.8) F2: 2.8 (1) E II: intensityBaseline: 5.7 (0.8) Post: 4 (1) F1: 4 (0.9) F2: 4.1 (0.9) E III: intensityBaseline: 5.1 (1) Post: 2.9 (1) F1: 2.9 (1) F2: 3 (1.1) Control: intensityBaseline: 5.6 (1.1) Post: 5.4 (1.2) F1: 5.4 (1) F2: 5.4 (1.1)
Ghanbari (2012) (25), Iran	TTH	n = 30	n = 14 f, 1 m; 37.66 ± 8.6 yearsPositional release technique according to D’Amborgio and Roth method Five sessions in two weeks	–	–	n = 14 f, 1 m; 36.26 ± 7.46 yearsRoutine medication: NSAIDs as abortive drugs and TCAs as prophylactic drugs(Usual medical care)	Frequency: Daily headache diary, (headache days/2 weeks) Intensity: NRS (0–10) Duration: Daily headache diary (hours/day) At baseline, treatment phase and 2 weeks after end of treatment (post)	E I: frequencyBaseline: 12.4 (2.22) Post: 7.66 (4.45) Control: frequencyBaseline: 11.13 (1.99) Post: 10.2 (2.4) E I: intensityBaseline: 5.8 (1.75) Post: 4.96 (2.49) Control: intensityBaseline: 6.03 (0.99) Post: 6.36 (1.14)
Hamed (2018) (33), Saudi Arabia	CTTH	n = 45	n = 10 f, 5 m; 37.0 ± 7.1 yearsStandardised Physiotherapy Treatment Program and supraorbital transcutaneous electrical stimulation3×/week for 8 weeks, 20 min/day (+ 20 min extra during a headache attack) for 8 weeks	n = 9 f, 6 m; 36.6 ± 7.2 yearsStandardised Physiotherapy Treatment Program 3×/week for 8 weeks	–	n = 10 f, 5 m; 35.6 ± 4.6 yearsPatients received prescribed medications (aspirin and/or ibuprofen) (Usual medical care)	Frequency: Self-administered questionnaire2 months prior and post intervention (four categories) Intensity: VAS 1 day before treatment and at end treatment	Frequency reported in descriptive wayE I: intensityBaseline: 70 (1) Post: 26 (6) E II: intensityBaseline: 71 (12) Post: 51 (1) Control: intensityBaseline: 70 (11) Post: 64 (1)
Kamali (2019) (26), Iran	TTH	n = 40	n = 16 f, 4 m; 37.45 ± 12.57 yearsDry needling according to Dommerholt & Fernandez-de-las-Penas 2013 on trigger pointsThree sessions in 1 week	n = 19 f, 1 m; 33.70 ± 9.94 yearsFriction massage on trigger points with gradual increase of pressure until reduction of pain was reportedThree sessions in one week	–	–	Frequency: Self-reported(Headache days/week) Intensity: VASAt baseline and 48 h after last treatment	E I: frequencyBaseline: median: 5Post: 1.95 (2.08) E II: frequencyBaseline: median: 7Post: 2.85 (2.56) E I: intensityBaseline: median: 8Post: 3 (2.31) E II: intensityBaseline: median 9.5Post: 4.22 (3.51)
Kumar (2014) (34), India	TTH	n = 30	n = 8 f, 7 m; 21.2 ± 2.4 yearsProgressive Muscle Relaxation15 min/day for 7 days	n = 12 f, 3 m; 19.9 ± 1.5 yearsTENS with bilateral electrodes on occipital or temporal area depending on pain15 min/day for 7 days	–	–	Intensity: VAS At baseline and end of treatment	E I: intensityBaseline: 6.4 (1) Post: 4.5 (0.9) E II: intensityBaseline: 6.8 (1.1) Post: 5.9 (2.1)
Meng (2018) (27) South Korea	ETTH	n = 53	n = 12 f, 15 m; 33.1 ± 7.83 years10% weighted bamboo fibre pack30 min/session for 4 consecutive weeks (sessions per day is not limited)	n = 11 f, 15 m; 36.2 ± 8.91 yearsPure water ice pack30 min/session for 4 consecutive weeks (sessions per day is not limited)	–	–	Frequency: Likert 5-point scale questionnaireIntensity: NRS (0–10) At baseline and end of treatment	Results on frequency not reportedE I: intensityBaseline: 4.08 (0.1) Post: 3.33 (0.78) E II: intensityBaseline: 3.91 (0.7) Post: 3.18 (0.75)
Mohamadi(2020) (29) Iran	CTTH	n = 26	n = 11 f, 2 m, 39 ± 11 yearsProgressive Muscle Relaxation techniques for every active trigger point Patient placement in a specific position for every Myofascial Trigger point for 20 min5 weeks, two sessions per week	–	–	n = 10 f, 3 m; 38 ± 9 yearsParticipants were requested to take 200 mg of ibuprofen for headache during study period(Usual medical care)	Frequency: Self-reported (Headache days/month) Intensity: Self-reported, NRS (0–10). At baseline and end of treatment	E I: frequencyBaseline: 18.3 (6.29) Post: 5.84 (3.76) Control: frequencyBaseline: 16.69 (6.14) Post: 17.3 (6.57) E I: intensityBaseline: 7.46 (1.8) Post: 4.38 (1.66) Control: intensityBaseline: 6.53 (1.89) Post: 7 (1.47)
Moraska (2015) (30) USA	TTH	n = 56	n = 15 f, 2 m; 32.1 ± 12.0 years15 min myofascial release, 20 min TPR massage (bilaterally) to MTrPs, 10 min post isometric relaxation45 min 2×/week separated by at least 48 h for 6 weeks	n = 17 f, 2 m; 34.7 ± 11.1 yearsPlacebo-detuned US administered to four regions of upper back and neck, 10 min/region45 min 2×/week separated by at least 48 h for 6 weeks	–	n = 16 f, 4 m; 33.4 ± 9.0ait-list group (usual medical care)	Frequency: Daily headache diary (headache days/week) Intensity: VAS Duration: Daily headache diary (hours/day) At baseline, end of treatment and 4 weeks after end of treatment	E I: frequencyBaseline: 3.72 (0.95) Post: 2.37 (1.48) F1: 2.61 (1.44) E II (placebo): frequencyBaseline: 3.81 (0.92) Post: 2.92 (1.48) F1: 2.96 (1.44) Control: frequencyBaseline: 3.69 (0.94) Post: 3.67 (1.48) F1: 3.19 (1.43) E I: intensityBaseline: 31.4 (11.1) Post: 27.3 (12.5) F1: 22.8 (12.5) E II (placebo): intensityBaseline: 33.3 (11) Post: 29.8 (12.3) F1: 31.5 (12.2) Control: intensityBaseline: 31.2 (11) Post: 29.5 (12.3) F1: 29 (12.3) E I: durationBaseline: 3.15 (1.77) Post: 2.81 (2.06) F1: 2.65 (1.94) E II (placebo): durationBaseline: 2.86 (1.74) Post: 2.84 (2.01) F1: 3.01 (1.92) Control: durationBaseline: 3.02 (1.74) Post: 3.36 (2.01) F1: 3.12 (1.92)
Perez-Llanes et al. (2020) (37), Spain	CTTH	n = 25	n = 10 f, 3. m; 43.3 ± 18.07 yearsSuboccipital muscle inhibition and TENS (simultaneously) 2×/week for 4 weeks			n = 11 f, 1 m; 46.2 ± 16.37 yearsStandard treatment (usual medical care)	IntensityNRS (0–10) At baseline and end of treatment	E I: intensityBaseline: 4.6 (2.9)* Post: 2 (2.8)* Control: intensityBaseline: 4.7 (2.6)* Post: 3.5 (2.7)*
Schiller et al. (2021) (28), Germany	ETTH and CTTH	n = 47	n = 17 f, 7 m; 38.7± 14.6 yearsMedical training therapy12 treatments in 6 weeks (decreasing frequency of treatment application)			n = 18 f, 5 m; 37 ± 15.3 yearsUsual medical care	Frequency: headache diary (post and follow up: headache days/month) IntensityVRS (0–10) Duration (hours) At baseline, 6 weeks post intervention and 18 weeks post intervention	E I: frequencyBaseline (days/3 months): 28.2 (24.5) Post: −6.1 (3.5) F1: −3.3 (6.7) Control: frequencyBaseline (days/3 months): 36.7 (32.6) Post: −11.1 (9.7) F1: −4.3 (7.7) E I: intensityBaseline: 5.4 (1.4) Post: −1 (2.2) F1: −2.4 (1.8) Control: intensityBaseline: 5.5 (1.1) Post: −0.6 (1.6) F1: −0.98 (1.4) E I: durationBaseline: not reportedPost: −3.6 (5.9) F1: +0.23 (4.3) Control: durationBaseline: not reportedPost: −2.1 (6) F1: +0.2 (4.9)
van Ettekoven and Lucas (2006) (38) The Netherlands	ETTH and CTTH	n = 81	n = 31 f, 8 m; 48.3 ± 18.39 yearsConventional massage, oscillation techniques following Maitland, instruction on postural correction + CTPCTP at home 2 × 10 min/day for 6 weeks	n = 35 f, 7 m; 43.4 ± 15.68 yearsConventional massage, oscillation techniques following Maitland and instruction on postural correction6 weeks, regulated by the physiotherapists	−	−	Frequency (days/week) Intensity NRS (0–10): Daily diaryQoL: SF-36Duration (hours/day) At baseline, end of treatment and 6 months after end of treatment	Frequency, intensity and duration presented graphicallyThe following data was taken from Luedtke et al. (5) E I: IntensityBaseline: 5.72 (1.43) Post: 3.16 (1.43) Control: intensityBaseline: 5.86 (1.84) Post: 3.29 (1.85)

CTM: connective tissue manipulation; CTP: craniocervical training program; CTTH: chronic tension-type headache; DT-MFR: direct technique myofascial release; E: experimental intervention; ETTH: episodic tension-type headache; IDT-MFR: indirect technique myofascial release; MT: manual therapy; MTrP: myofascial trigger point; NRS: numerical rating scale; NSAID: non-steroidal anti-inflammatory drug; QoL: quality of life; TCA: tricyclic antidepressants; TENS: transcutaneous electrical nerve stimulation; TPR: trigger point release; US: ultrasound; VAS: visual analogue scale; VAT: vertebral artery test; VRS: verbal rating scale.

*corrected data provided from corresponding author.

Narrative synthesis

Risk of bias within studies

In Figure 2 the results of the RoB assessment are presented. Most studies had “some concerns” as an overall rating, four had a “high risk of bias” (23,26,27,42) and one was rated as of “low risk of bias” (37). The lack of pre-registered protocols as well as the registration of retrospective protocols was the most critical factor, which highlighted “some concerns” in the domain “bias in selection of the reported result” (n = 15).

Figure 2.

Risk of bias within studies.

Reports not included in NMA are being described in the following section. Demirturk et al. (42) investigated the effect of a combination of heat, massage and soft tissue techniques compared to heat, massage and manual therapy (MT). Both groups reported a statistically significant decrease of Headache Index values immediately after treatment and 1 month after treatment. However, there were no significant differences between groups.

One four-arm trial by Espi-Lopez et al. (39,41) compared spinal manipulative treatment versus suboccipital soft tissue inhibition (SI) versus a combination of both therapies versus no active treatment. Results showed that patients receiving the spinal manipulative treatment alone and a combination of both experimental treatments experienced significantly reduced HDI scores on headache frequency (39). The SI group experienced a significantly reduced headache intensity but no change in headache frequency (39). Only the SI group had significant improvements in the overall quality of life score at follow-up, while there were no significant improvements for any of the interventions post-treatment (41). Espi-Lopez et al. (40) evaluated the effectiveness of spinal manipulative treatment combined with gentle cervical massage versus gentle massage alone. Outcome measurements resulted in a significant reduction of headache frequency at follow-up for the manipulation group, while no significant changes were reported on all other timepoints as well as pain intensity in both groups.

Meng et al. (27) evaluated two cryotherapy treatment groups: A 10% weighted bamboo fibre pack group and a pure water ice pack group. Although both groups reported significant improvements regarding headache intensity and frequency after treatment, there was no difference between intervention groups.

Quantitative synthesis

After evaluation of transitivity, collation of treatments into treatment nodes and examination of the network geometry, a total of 15 reports (23 –26,28 –38) were included in NMA (14 reports for pain intensity and 10 reports for pain frequency). The remaining reports (n = 5) (27,39 –42) could not be included in NMA because of a lack of transitivity, the outcome measurement method reported was not adequate to (statistically) pool, or because they had no connection to the network. No comprehensive networks could be built for headache duration and quality of life. Furthermore, mid-term or long-term results were reported by only three reports (28,35,38). Thus, NMA was only possible for the outcomes “headache intensity and frequency” in the short term (≤12 weeks). For all other outcomes, and for mid-term as well as long-term results, NMA was not possible. An overview of the treatment nodes and their description can be seen in Table 3.

Table 3.

Presentation and definition of treatment nodes.

Treatment nods	Definition
Combination PT techniques	Combination of various physiotherapy modalities including heat, massage, traction, stretching and instructions on postural correction
Control (intervention)	Placebo or sham intervention, including sham massage therapy or sham ultrasound therapy (detuned)
Dry needling	Dry needling on trigger-points of the following muscles: Sub-occipital, temporalis, sternocleidomastoid and upper trapezius muscles
Exercise	Exercise therapy
Manipulation	Manipulative manual therapy techniques addressing the cervical or thoracic spine in terms of high-velocity low-amplitude (HVLA) techniques
Manual therapy (MT)	Manual therapy techniques including low-velocity high-amplitude (LVHA) (joint mobilisation) techniques addressing the cervical or thoracic spine
Manual therapy (MT) + Exercise	Manual therapy techniques including low-velocity high-amplitude (LVHA) (joint mobilisation) techniques addressing the cervical or thoracic spine combined with exercise and postural correction
Neural mobilisation	Neural mobilisation or neurodynamics aiming to mobilise the nervous system itself or the structures that surround the nerves
Relaxation	Relaxation exercises
Soft tissue techniques	Passive techniques addressing the soft tissues aiming to decrease muscular tension amongst others
Soft tissue techniques + Manipulation	Passive techniques addressing the soft tissues combined with HVLA techniques (manipulation)
Soft tissue techniques + Neural mobilisation	Passive techniques addressing the soft tissues combined with neural mobilisation
Trigger point therapy (TriggerT)	Ischemic compression or positional release techniques addressing active trigger points in muscles of the shoulders and the neck
TENS	Transcutaneous electrical nerve stimulation
TENS + Comb. PT techniques	Transcutaneous electrical nerve stimulation combined with a combination of various passive physiotherapeutic techniques including heat, massage, traction, stretching and instructions on postural correction
TENS + soft tissue technique	Simultaneous application of transcutaneous electrical nerve stimulation and suboccipital inhibition
Usual medical care	Use of abortive medicaments (analgesics or NSAIDs) and/or prophylactic medicaments; no use of other non-pharmacological interventions

In the present review, a total of 136 comparisons in headache intensity and 66 comparisons in headache frequency were analysed. Only statistically significant results of experimental interventions compared to control intervention or usual care are presented in the following sections. All results (forest plots) of NMA of headache intensity and frequency can be viewed in Supplementary material C and the certainty of the evidence of all comparisons in NMA can be viewed in Supplementary material D.

NMA of pain intensity for TTH

Summary of network structure and geometry

Fourteen reports (24 –26,28 –38) comprising a total of 820 patients with TTH were included in NMA of pain intensity. The network structure for pain intensity can be seen in Figure 3. Seventeen interventions were investigated in this network. Studies with multiple treatment arms are highlighted in Figure 3 as blue-coloured areas between treatment nodes. Most direct comparisons were evaluated by single studies. Only one direct treatment comparison was investigated by more than one study: Trigger-point therapy versus usual medical care (four studies).

Figure 3.

Network for headache intensity.

Exploration of inconsistency

There was evidence of statistical heterogeneity (p = 0.0161) according to the Cochrane’s Q test (Table 4). This was also confirmed by the I² test (I² = 67.1%, CI: 14.7% to 87.3%), representing substantial heterogeneity. According to the global test (p = 0.476) and the node split function (local test), there was no evidence of incoherence (Supplementary material E). Based on the funnel plot symmetry and the Egger test (p = 0.9778) (Supplementary material C) there was no sufficient evidence for publication bias.

Table 4.

Tests of heterogeneity (within designs) and inconsistency (between designs) for headache intensity.

	Q	df	p-value
Total	12.17	4	0.0161
Within designs	6.36	2	0.0415
Between designs	5.8	2	0.0549
Incoherence: global test based on a random-effects design-by-treatment interaction model: x² = 1.485 (2 df), p = 0.476
df: degrees of freedom; Q: Cochrane’s Q test.

Synthesis of results

TENS with various passive physiotherapy modalities was the most effective intervention according to the ranking of treatments (Table 5). Six interventions were significantly better when compared to control (placebo) intervention: TENS plus a combination of various passive physiotherapy techniques (MD: −4.18, CI: −6.16 to −2.19; moderate confidence), dry needling (MD: −2.76, CI: −5.49 to −0.03; low confidence), soft tissue techniques (MD: −2.13, CI: −3.46 to −0.79; low confidence), soft tissue techniques plus neural mobilisation (MD: −2.16, CI: −3.69 to −0.63; low confidence), MT (joint mobilisation) plus exercise (MD: −2.18, CI: −4.29 to −0.06; low confidence) and trigger point therapy (MD: −1.54, CI: −2.91 to −0.16; low confidence). Only four interventions were significantly better than usual medical care: TENS plus a combination of various passive physiotherapy techniques (MD: −3.8, CI: −5.3 to −2.3; moderate confidence), soft tissue techniques (MD: −1.75, CI: −3.21 to −0.3; low confidence), MT (joint mobilisation) plus exercise (MD: −1.8, CI: −3.47 to −0.13; low confidence) and trigger point therapy (MD: −1.16, CI: −2.07 to −0.26; low confidence). These results are presented in the two forest plots for headache intensity ranked by treatment effectiveness (Figure 4).

Table 5.

Treatment ranking (headache intensity): 17 treatments.

Treatment nodes	P-score*
TENS + Combination PT techniques	0.9711
Dry needling	0.7680
Soft tissue techniques	0.6894
Soft tissue techniques + Neural mobilisation	0.6860
MT (joint mobilisation) + Exercise	0.6831
MT (joint mobilisation)	0.6326
TENS + soft tissue technique	0.5928
Combined PT techniques	0.5631
Soft tissue techniques + Manipulation	0.5276
Trigger point therapy	0.5272
Manipulation	0.4601
Neural mobilisation	0.3973
Exercise	0.3583
Relaxation	0.2221
Usual medical care	0.2116
Control	0.1479
TENS	0.0619

PT: physiotherapeutic; TENS: transcutaneous electrical nerve stimulation; MT: manual therapy.

*A larger P-score indicates a better treatment or “the probability of being superior to a competing treatment” (20).

Figure 4.

Forest plots for headache intensity, other interventions vs. control (top) and other interventions vs. usual medical care (bottom), ranked by P-score.

NMA of headache frequency for TTH

Ten studies (23,25,26,28 –32,35,36) assessing a total of 659 patients with TTH were included in NMA of headache frequency. The network structure for headache frequency can be seen in Figure 5. Twelve interventions were investigated in this network. Three studies had multiple treatment arms, which are indicated by the blue coloured areas between treatment nodes (Figure 5). Similar to the network on headache intensity, most direct comparisons were evaluated by single studies. Only two direct treatment comparisons were investigated by more than one study: Soft tissue techniques versus control (two studies) and trigger-point therapy versus usual medical care (three studies).

Figure 5.

Network for headache frequency.

Exploration of inconsistency

There was evidence of statistical heterogeneity (p = 0.0076) according to Cochrane’s Q test (Table 6). and the I² test (I² = 71.2%, CI: 27.1% to 88.6%) also suggested substantial statistical heterogeneity. Based on the global test (p = 0.455) and the local test (Supplementary material E) there was no evidence of incoherence between indirect and direct comparisons. No funnel plot was created for headache frequency, given that there were not more than 10 studies included in the NMA.

Table 6.

Tests of heterogeneity (within designs) and inconsistency (between designs) for headache frequency.

	Q	df	p-value
Total	13.91	4	0.0076
Within designs	2.91	1	0.0878
Between designs	10.99	3	0.0118
Incoherence: global test based on a random-effects design-by-treatment interaction model: x² statistic: 2.616 (3 df), p-value: 0.455
df: degrees of freedom; Q: Cochrane’s Q test.

Synthesis of results

Headache frequency is presented as the average of headache days per month (30 days). MT (joint mobilisation) combined with exercise was the most effective intervention according to the ranking of treatments (Table 7). Only three interventions were superior to a control intervention (placebo, sham): MT (joint mobilisation) plus exercise (MD: −13.03, CI: −20.90 to −5.16; low confidence), soft tissue techniques plus neural mobilisation (MD: −6.74; CI: −11.78 to −1.69; low confidence) and soft tissue techniques (MD: −3.88, CI: −7.39 to −0.37; low confidence). Five interventions were significantly superior to usual medical care: MT (joint mobilisation) plus exercise (MD: −13.95, CI: −20.24 to −7.66; moderate confidence), dry needling (MD: −9.95, CI: −18.76 to −1.13; low confidence), soft tissue techniques plus neural mobilisation (MD: −7.66, CI: −14.19 to −1.12; low confidence), soft tissue techniques plus manipulation (MD: −6.55, CI: −12.88 to −0.22; low confidence) and trigger point therapy (MD: −6.1, CI: −9.89 to −2.3; very low confidence). These results are presented in the two forest plots for headache frequency ranked by treatment effectiveness (Figure 6).

Table 7.

Treatment ranking (headache frequency): 12 treatments.

Treatment nodes	P-score*
MT (joint mobilisation) + exercise	0.9574
Dry needling	0.8062
Soft tissue techniques + Neural mobilisation	0.7328
Soft tissue techniques + Manipulation	0.6512
TriggerT	0.6185
Neural mobilisation	0.6024
Soft tissue techniques	0.5211
Manipulation	0.5037
Control	0.2581
Usual medical care	0.2218
Exercise	0.0855
Relaxation	0.0412

PT: physiotherapeutic; TENS: transcutaneous electrical nerve stimulation; MT; manual therapy.

*A larger P-score indicates a better treatment or “the probability of being superior to a competing treatment” (20).

Figure 6.

Forest plots for headache frequency, other interventions vs. control (top) and other interventions vs. usual medical care (bottom), ranked by P-score.

Discussion

This is the first systematic review providing an NMA to evaluate the effectiveness of physiotherapy interventions on treatment outcomes of patients with TTH. A total of 20 reports of 19 studies were included for qualitative synthesis. Of these, 15 reports were included in the NMA.

The results of the quantitative analysis through NMA indicated that a combination of various passive physiotherapy techniques (including massage, traction, stretching and advice on postural correction) plus TENS as well as the combination of MT (joint mobilisation) with exercise and postural correction are likely to be the most effective physiotherapy approaches to reduce headache intensity or frequency in patients with TTH. Dry needling was also one of the most effective treatments to reduce pain intensity or frequency. Nevertheless, the effectiveness of dry needling should be interpreted with caution, since the results of this intervention are based on one report with a high RoB (26).

Interestingly, individual physiotherapy techniques were not as effective as combinations of approaches. For example, TENS or a combination of various passive physiotherapy techniques (individually) did not differ significantly from control or usual care, but they were superior to control or usual care and ranked as the most effective intervention to reduce pain intensity when combined. Likewise, MT or exercise (individually) were not as effective as the combination of both to reduce pain intensity or frequency compared to control or usual care. One possible explanation might be that each intervention adds a treatment and placebo response effect, and that the more interventions used, the greater the effect of placebo response could be expected to be (43). However, there are several factors (44) to consider and not enough information (from included studies) in order to confirm this hypothesis. Another interesting observation is that the combination of TENS and SI had no significant results when used simultaneously. The results for both outcomes are based on moderate to very low confidence in the NMA. The evidence regarding the most effective interventions to improve headache intensity or frequency compared to control or usual care is based on a moderate quality of evidence. Clinically relevant effect sizes for pain intensity (≥2.4) were reached by two interventions: TENS plus a combination of various physiotherapy techniques and dry needling. For headache frequency, clinically relevant effect sizes (≥7.5 days) were reached by three interventions: MT plus exercise, dry needling and soft tissue techniques plus neural mobilisation. Nonetheless, more research on minimal important change for the outcomes of headache intensity, frequency and duration of headache disorders is required.

Unfortunately, headache duration and quality of life could not be pooled in NMA. Additionally, no mid-term or long-term results could be assessed quantitatively, since all but three articles reported only on short-term results.

Although there are no other NMAs evaluating the effectiveness of physiotherapy on TTH, there are some reviews with a similar scope with and without meta-analyses. Kamonseki et al. (4) concluded after quantitative analysis that spinal manipulative treatment was not superior to “no therapy” (usual care), whereas soft tissue techniques and dry needling were superior to “no therapy” (usual care) for the reduction of pain intensity and frequency, thereby confirming the results of the current NMA. In the reviews by Fernández-de-Las-Peñas and Cuadrado (45) as well as Cumplido-Transmonte et al. (46), it was also affirmed that individual physiotherapy techniques seem not to be as effective as the combination of various physiotherapy techniques.

Overall, results of this current systematic review and previous reviews indicate that a combination of various physiotherapy interventions, including hands-on techniques (such as MT and soft tissue techniques), advice on postural correction, exercises, and/or TENS, are more effective than usual medical care alone. Whether physiotherapy can reduce or even replace medication intake cannot be assessed with the current data, since patients in the majority of studies were allowed to continue their medication regimen for ethical reasons.

Implications for future research

Most direct comparisons in the networks were based on single studies with “some concerns” regarding their RoB. More RCTs with “low” RoB are needed to confirm the results of the present review. Trial authors should be encouraged to pre-register their trials prospectively before unblinded data is available, since the lack of pre-registered protocols as well as the registration of retrospective protocols was the most critical factor which highlighted “some concerns” while evaluating the RoB of included studies. The use of a combination of various physiotherapy techniques should also be encouraged in future research, since there is evidence for their superiority regarding their effectiveness compared to individual physiotherapy intervention techniques. The assessment of mid-term and long-term results should be pursued in future trials.

Limitations

A limitation is that most studies included both episodic and chronic TTH patients and no subgroup analysis was provided by the authors. Therefore, baseline data for headache frequency was heterogenous between studies (between 11.6 and 23.7 headache days in a month). We were unable to separate both types for analysis. It is very likely that this affected the results for the outcome of headache frequency in the NMA, which could explain the presence of statistical heterogeneity. Nevertheless, it is unlikely that the inclusion of both classifications of TTH could have affected the outcome headache intensity since this is not dependent on the classification of TTH. A factor that could have led to the substantial statistical heterogeneity might be the heterogeneous intervention parameters (frequency, duration and length of interventions) in all included studies. However, sensitivity analysis to evaluate this potential limitation was not possible. Furthermore, presence of or controlling for other headache disorders (e.g. migraine) was not reported in five studies (25,26,29,32,36), which could limit the applicability of results. Lastly, no grey literature was searched and only reports in German or English language were included.

Conclusions

The results of the present review suggest that a combination of various passive physiotherapy techniques (including MT (joint mobilisation) and soft tissue techniques) with exercise, postural correction and/or TENS are the most effective physiotherapy interventions to reduce headache intensity and frequency of patients with TTH in the short term. Hence, these interventions can be considered in addition to usual care. Individual physiotherapy techniques seem not to be as effective as the combination of various physiotherapy techniques. This is supported by moderate to very low quality of evidence. More research is needed to confirm the results and especially to investigate mid-term to long term effects.

Clinical implications

Combined physiotherapy interventions are effective to reduce headache intensity and frequency and can be used as adjunct therapy to pharmacological interventions.

Individual physiotherapy techniques seem not to be as effective as the combination of various physiotherapy techniques.

More research on mid-term to long-term effects is needed. More studies with low risk of bias are needed.

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Footnotes

Original publication

The authors declare that this manuscript contains original unpublished work and is not being submitted for publication elsewhere at the same time. There were no previous submissions.

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Availability of data and materials

All data generated or analysed during this study are available from the corresponding author on reasonable request.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Authors' contributions

All authors contributed to the design of the study. JS and WT designed the search strategy and conducted the systematic search. JS, WT, AJ and KL screened titles and abstracts as well as full-text reports. Data extraction was performed by JS and checked by WT. Quality appraisal and data analysis was performed by AJ, R-CE and KL. Statistical analysis was conducted by AJ and checked by KL. JS and AJ drafted the manuscript. R-CE and KL critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript.

ORCID iD

Andres Jung

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