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Chiropractic Neurology
Research Brief
A Quarterly Newsletter for Health Care Professionals by Mark Saracino, DC, DACAN
Volume two Issue two
Chiropractic’s Effectiveness for Headaches

A Review of Randomized Controlled Trials
Chiropractic is the most common alternative-medical treatment for headaches in the
United States (1). There are a number of randomized controlled trials that have
demonstrated the effectiveness of chiropractic therapy in the treatment of tension,
cervicogenic and migraine headaches.
Tension-Type Headache

In order to determine the effects of spinal manipulation on adults with episodic tension-
type headaches, Bove (2) divided 75 patients into two treatment groups. One group
received deep friction-massage and spinal manipulation. The other group received deep
friction-massage with placebo laser treatment. Both groups received eight treatments
over a four-week period. By week seven, each group experienced significant reductions
in mean daily headache hours and the mean number of analgesics per day. These
improvements were maintained throughout the observation period. This study concluded
as an isolated intervention, spinal manipulation does not seem to have a positive effect on
episodic tension-type headache. A closer look at the study, however, revealed that
manipulation was not used as an isolated treatment because it was combined with deep
friction-massage. It did find improvements in the manipulation group and it found deep
friction-massage might be of some benefit. as well.
Boline (3) compared the effectiveness of chiropractic manipulation and amitriptyline for
chronic tension-type headache. One hundred fifty patients were divided into two groups.
One group received spinal manipulative therapy by chiropractic physicians and the other
group received amitriptyline medication by a medical physician. Both groups were
treated for six weeks. During the treatment period, both groups improved at similar rates
in all primary outcomes. In relation to baseline values four weeks after cessation of
treatment, the spinal manipulation group showed a reduction of 32 percent in headache
intensity, 42 percent in headache frequency, 30 percent in over-the-counter medication
usage and a 16 percent improvement in functional health status. By comparison, the
amitriptyline group showed no improvement or a slight worsening from baseline values
in the same four outcome measures. In addition, the study reported amitriptyline patients
(82 percent) reported more side effects including drowsiness, dry mouth and weight gain
compared to patients receiving chiropractic care (4.3 percent experienced
soreness/stiffness). The results of this study showed chiropractic manipulation is an
effective treatment for tension headache and the benefits were sustained four weeks
following treatment. The therapeutic benefit associated with chiropractic manipulation
resulted in a decreased need for over-the-counter medication.
Cervicogenic Headache

Nilsson (4) studied 39 patients to determine if cervical spinal manipulation as an isolated
intervention had any effect on cervicogenic headache. Half of the group received cervical
manipulation and the other half received low-level laser therapy in the upper cervical
spine and deep friction-massage in the lower cervical and upper thoracic spines. Both
groups were treated twice a week for three weeks. The study found a significant
reduction in the manipulation group on all three outcome measures (headache intensity,
frequency and analgesic use). The results of this study suggest a possible effect of
manipulation on cervicogenic headache. The author, however, mentioned that differences
between the two treatment groups failed to reach statistical significance because of
methodological problems.
Because of the problems with the previous study, Nilsson (5) performed a follow-up
study. Fifty-three subjects were divided and received the same treatment and frequency
of treatment as the previous study. The study found analgesic use decreased by 36
percent in the manipulation group, but was unchanged in the soft tissue group. Headache
frequency decreased by 69 percent in the manipulation group compared to 37 percent in
the soft tissue group. Headache intensity decreased by 36 percent in the manipulation
group compared to 17 percent in the soft tissue group. In this study, the differences in all
outcomes between the two treatment groups were statistically significant.
Jull et al. (6) studied 200 subjects with cervicogenic headache. The subjects were
randomized to receive manipulative therapy, exercise therapy, combined therapies, or
nothing (control group). The study found the manipulation and exercise groups had
significantly reduced headache frequency and intensity following treatment. The
combination of therapies was not significantly superior to either therapy alone, but 10
percent more patients gained relief with combined therapies. The study concluded
manipulative therapy and exercise can reduce the symptoms of cervicogenic headache
and the improvement was maintained at twelve-month follow-up.
Migraine

In one of the earliest randomized controlled trials of spinal manipulation and migraine,
Parker (7) divided 85 subjects into three treatment groups. All treatment groups received
spinal manipulation by an M.D., a physiotherapist or a chiropractor. The authors
concluded, “For the whole sample, migraine symptoms were significantly reduced.”
Manipulation performed by all therapists were equally effective, however, the subjects
treated by chiropractors reported a greater reduction in pain associated with their attacks.
In addition, migraine attacks reduced a further 19 percent at the 20-month follow-up
period (8).

More recently, Nelson (9) studied 218 patients with migraine headache. The patients
received spinal manipulation, amitriptyline or a combination of both treatments for eight
weeks. A reduction in headache index scores during treatment compared with baseline
values was 49 percent for amitriptyline, 40 percent for spinal manipulation and 41
percent for the combined group. Four weeks following treatment, the reduction from
baseline was 24 percent for amitriptyline, 42 percent for spinal manipulation and 25
percent for the combined group. Similar to the Boline (3) study of tension headaches,
amitriptyline appears to only have short-term benefits. Once amitriptyline use is
discontinued, headache index scores revert toward baseline values.
The authors concluded, “There was no advantage to combining amitriptyline and spinal
manipulation for the treatment of migraine headache. Spinal manipulation seemed to be
as effective as a well-established and efficacious treatment (amitriptyline), and on the
basis of a benign side effects profile, it should be considered a treatment option for
patients with frequent migraine headaches.”
One hundred twenty-seven patients with migraine received chiropractic manipulation or
detuned interferential (control). They received a maximum of 16 treatments over a two-
month period. The study found the chiropractic group showed statistically significant
improvements in headache frequency, duration, disability, and medication use compared
to the control group. Twenty-two percent of the chiropractic group reported more than a
90 percent reduction of migraines. Fifty percent of the remaining chiropractic patients
reported significant improvement in the morbidity of each episode (10).
Finally, Duke University released a report after assessing evidence from randomized
controlled trials and other prospective, comparative clinical trials for the efficacy and
safety of behavioral and physical treatments for tension-type and cervicogenic headache.
Interestingly, the report states that physical treatments, such as cervical spinal
manipulation, are primarily aimed at the prevention of headache episodes rather than the
alleviation of symptoms once an attack has begun. After reviewing the studies, the
authors reported cervical spinal manipulation is substantiated by scientific evidence in the
management of both tension-type and cervicogenic headaches. They also suggest
manipulation may be the first choice for most patients and may also be well-suited for
patients who have poor tolerance to medication, have contraindications to medication,
experience insufficient relief from or are unresponsive to medication, wish to become
pregnant (or are nursing), have a history of long-term, frequent, or excessive use of pain
medication, or simply prefer to avoid medication use (11).
Summary

Chiropractic therapy is effective treatment for headaches with reductions in frequency,
intensity and duration and it reduces the need for long-term analgesic use and its side-
effects.
References

Eisenberg et al. Unconventional medicine in the United States: Prevalence, costs, and patterns of use. N Engl J Med 1993; 329: 246-52. Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache. A randomized controlled trial. JAMA 1998; 280 (18): 1576 – 9. Boline et al. Spinal manipulation vs. amitriptyline for the treatment of chronic tension-type headaches: A randomized controlled trial. J Manip Physiol Ther 1995 18 (3): 148-54. Nilsson et al. A randomized controlled trial of the effect of spinal manipulation in the treatment of cervicogenic headache. J Manip Physiol Ther 1995; 18 (7): 435 – 40. Nilsson et al. The effect of spinal manipulation in the treatment of cervicogenic headache. J Manip Physiol Ther 1997; 20 (5): 326 – 30. Jull G. et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002; 27:1835-1843. Parker GB et al. A controlled trial of cervical manipulation of migraine. Aust N Z J Med 1978; 8: 589-93. Parker GB et al. Why does migraine improved during a clinical trial? Further results from a trial of cervical manipulation for migraine. Aust N Z J Med 1980; 2: 192-8. Nelson et al. The efficacy of spinal manipulation, amitriptyline and a combination of both therapies for the prophylaxis of migraine headaches. J Manipulative Physiol Ther 1998; 21 (8): 511-9. 10. Tuchin et al. A randomized controlled trial of chiropractic spinal manipulative therapy for migraine. J Manipulative Physiol Ther 11. McCrory D. et al. Evidence Report: Behavioral and physical treatments for tension-type and cervicogenic headache. Duke University Evidence-Based Practice Center, Center for Clinical Health Policy Research 2001. Mark Saracino, Board Certified Chiropractic Neurologist voice 610 337 3335 Diplomat American Chiropractic Academy of Neurology www.ACNB.org (adjacent to the Valley Forge Convention Center and Radisson Hotel) fax 610 337 4858 1150 First Avenue, suite 120 [email protected] King of Prussia, Pennsylvania 19406 1341 www.DrSaracino.com

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