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Manual therapies for migraine: a systematic review Aleksander Chaibi • Peter J. Tuchin •Michael Bjørn Russell Received: 4 November 2010 / Accepted: 14 January 2011 / Published online: 5 February 2011Ó The Author(s) 2011. This article is published with open access at Springerlink.com Migraine occurs in about 15% of the general due to side effects, or contraindications due to co-morbidity population. Migraine is usually managed by medication, but of myocardial disorders or asthma among others. Some some patients do not tolerate migraine medication due to side patients wish to avoid medication for other reasons. Thus, effects or prefer to avoid medication for other reasons. Non- pharmacological management is an alternative treatment physiotherapy and chiropractic may be an alternative option. We systematically reviewed randomized clinical treatment option. Massage therapy in Western cultures uses trials (RCTs) on manual therapies for migraine. The RCTs classic massage, trigger points, myofascial release and suggest that massage therapy, physiotherapy, relaxation and other passive muscle stretching among other treatment chiropractic spinal manipulative therapy might be equally techniques which are applied to abnormal muscle tissue.
effective as propranolol and topiramate in the prophylactic Modern physiotherapy focuses on rehabilitation and exer- management of migraine. However, the evaluated RCTs had cise, while manual treatment emphasis postural correc- many methodological shortcomings. Therefore, any firm tions, soft tissue work, stretching, active and passive conclusion will require future, well-conducted RCTs on mobilization and manipulation techniques. Mobilization is commonly defined as movement of joints within thephysiological range of motion The two most common Manual therapies Á Massage Á Physiotherapy Á chiropractic techniques are the diversified and Gonstead, which are used by 91 and 59% of chiropractors []. Chi-ropractic spinal manipulation (SM) is a passive-controlledmaneuver which uses a directional high-velocity, low- amplitude thrusts directed at a specific joint past thephysiological range of motion, without exceeding the Migraine is usually managed by medication, but some anatomical limit []. The application and duration of the patients do not tolerate acute and/or prophylactic medicine different manual treatments varies among those who per-form it. Thus, manual treatment is not necessarily as uni-form as, for instance, specific treatment with a drug in acertain dose.
A. Chaibi (&) Á M. B. RussellHead and Neck Research Group, Research Centre, This paper systematically review randomized controlled Akershus University Hospital, 1478 Lørenskog, Norway trials (RCTs) assessing the efficacy of manual therapies on migraine, i.e., massage, physiotherapy and chiropractic.
P. J. TuchinDepartment of Chiropractic, Macquarie University,Sydney, NSW 2109, Australia The literature search was done on CINAHL, Cochrane, Institute of Clinical Medicine, Akershus University Hospital,University of Oslo, 1474 Nordbyhagen, Norway Medline, Ovid and PubMed. Search words were migraine and chiropractic, manipulative therapy, massage therapy, while we found no RCTs studies on spinal mobilization or osteopathic treatment, physiotherapy or spinal mobiliza- osteopathic as a intervention for migraine.
tion. All RCTs written in English using manual therapy onmigraine were evaluated. Migraine was preferentially classified according to the criteria of the InternationalHeadache Societies from 1988 or its revision from 2004, Table shows the authors average methodological score of although it was not an absolute requirement The the included RCT studies [–The average score varied studies had to evaluate at least one migraine outcome from 39 to 59 points. Four RCTs were considered to have a measure such as pain intensity, frequency, or duration. The good quality methodology score (C50), and three RCTs methodological quality of the included RCT studies was assessed independently by the authors. The evaluationcovered study population, intervention, measurement of effect, data presentation and analysis (Table ). The max-imum score is 100 points and C50 points considered to be Table shows details and the main results of the different An American study included 26 participants with chronic The literature search identified seven RCT on migraine that migraine diagnosed by questionnaire Massage therapy met our inclusion criteria, i.e., two massage therapy studies had a statistically significant effect on pain intensity as [, one physiotherapy study ] and four chiropractic compared with controls. Pain intensity was reduced 71% in spinal manipulative therapy studies (CSMT) [– the massage group and unchanged in the control group.
Table 1 Criteria list of methodological quality assessment of randomized controlled trials (RCTs) Description of inclusion and exclusion criteria (1 point). Restriction to a homogeneous study population (1 point) Comparability of relevant baseline characteristics: duration of complaint (1 point), value of outcome measures (1 point), age (1 point), recurrences (1 point), and radiating complaints/associated symptoms (1 point) Description of the randomization procedure (2 points). Randomization procedure which excluded bias, i.e., random numbers table (2 Description of dropouts for each group and their reasons (3 points) Loss to follow-up: \20% loss to follow-up (2 points), or \10% loss to follow-up (4 points) Sample size: [50 subjects in the smallest group after randomization (6 points), or[100 subjects in the smallest group after randomization Correct description of the manual intervention (5 points). All interventions described (5 points) Pragmatic study: comparison with an existing treatment modality (5 points) Co-interventions avoided in the design of the study (5 points) Comparison with a placebo control group (5 points) Mention of the experience of the therapist (5 points) Placebo controlled studies: patients blinded (3 points), blinding evaluated and fully successful (2 points) or pragmatic studies: patients fully naive, evaluated and fully successful (3 points), time restriction of no manual treatments for at least 1 year (2 points) (m) Outcome measures: pain assessment (2 points), global measure of improvement (2 points), functional status (2 points), spinal mobility (2 Each blinded outcome measure mentioned under item M earns 2 points Analysis of post-treatment data (3 points), inclusion of a follow-up period longer than 6 months (2 points) Data presentation and analysis (10 points) Intention-to-treat analysis when loss to follow-up is \10% or intention-to-treat analysis as well as worst-case analysis for missing values when loss to follow-up is [10% (5 points) Corrected presentation of the data: mean or median with a standard deviation or percentiles for continuous variables (5 points) Table 2 Quality score of the analyzed randomized controlled trials (RCTs) using manual therapies for treatment of migraine The letters corresponds with letters from the criteria list (Table ) Interpretation of the data is otherwise difficult and results were divided into three study groups; cervical manipulation on migraine frequency and duration are missing.
by chiropractor, cervical manipulation by physiotherapist A New Zealand study included 48 migraineurs diagnosed or physician, and cervical mobilization by physiotherapist by questionnaire The mean duration of a migraine attack or physician. The mean migraine attack duration was was 47 h, and 51% of the participants had more than one skewed in the three groups, as it was much longer in cer- attack per month. The study included a 3 week follow-up vical manipulation by chiropractor (30.5 h) than cervical period. The migraine frequency was significantly reduced in manipulations by physiotherapist or physician (12.2 h) and the massage group as compared with the control group, while cervical mobilization groups (14.9 h). The study had sev- the intensity of attacks was unchanged. Results on migraine eral investigators and the treatment within each group was duration are missing. Medication use was unchanged, while beside the mandatory requirements free for the therapists.
sleep quality was significantly improved in the massage group No statistically significant differences were found between (p \ 0.01), but not in the control group.
the three groups. Improvement was observed in all threegroups post-treatment (Table ). Prior to the trial, chiro- practors were confident and enthusiastic about the efficacyof cervical manipulation, while physiotherapists and phy- An American physical therapy study included female mi- sicians were doubtful about the relevance. The study did graineurs with frequent attacks diagnosed by a neurologist not include a control group although cervical mobilization according to the criteria of the International Headache Society is mentioned as the control group in the paper. A follow-up Clinical effect was defined as[50% improvement in 20 months after the trial showed further improvement in headache severity. Clinical effect was observed in 13% of the physical therapy group and 51% of the relaxation group An American study included 218 migraineurs diagnosed (p \ 0.001). The mean reduction in headache severity was 16 according to the criteria of the International Headache and 41% from baseline to post-treatment in the physical Society by chiropractors ]. The study had three treat- therapy and relaxation groups. The effect was maintained at ment groups, but no control group. The headache intensity 1 year follow-up in both groups. A second part of the study on days with headaches was unchanged in all three groups.
offered persons without clinical effect in the first part of the The mean frequency was reduced equally in the three study, the other treatment option. Interestingly, clinical effect groups (Table ). Over the counter (OTC) medication was was observed in 55% of those whom received physical therapy reduced from baseline to 4 weeks post-treatment with 55% in the second round who had no clinical effect from relaxation, in the CSMT group, 28% in the amitriptyline group and while 47% had clinical effect from relaxation in the second 15% in the combined CSMT and amitriptyline group.
round. The mean reduction in headache severity was 30 and The second Australian study was based on questionnaire 38% in the physical therapy and relaxation groups. Unfortu- diagnoses on migraine [The participants had migraine nately, the study did not include a control group.
for mean 18.1 years. The effect of CSMT was significantbetter than the control group (Table The mean reduc- Chiropractic spinal manipulative treatment tion of migraine frequency, intensity and duration frombaseline to follow-up were 42, 13, and 36% in CSMT An Australian study included migraineurs with frequent group, and 17, 5, and 21% in the control group (data cal- attacks diagnosed by a neurologist ]. The participants culated by the reviewers based on figures from the paper).
The prevalence of migraine was similar based on a ques- tionnaire and a direct physician conducted interview, but it was due to equal positive and negative misclassification by the questionnaire ]. A precise headache diagnosis requires an interview by a physicians or other health professional experienced in headache diagnostics. Three of the seven RCTs ascertained participants by a question- naire, with the diagnostic uncertainty introduced by this The second American study included participants with at least four headache days per months [The mean headache severity on days with headache at baseline variedfrom 4.4 to 5.0 on a 0–10 box scale in the three treatment groups. This implies that the participants had co-occur- rence of tension-type headache, since tension-type head- ache intensity usually vary between 1 and 6 (mild or moderate), while migraine intensity can vary between 4 and 9 (moderate or severe), but usually it is a severe pain between 7 and 9 , ]. The headache severity on days with headache was unchanged between baseline and at follow-up, indicating that the effect observed was not exclusively due to an effect on migraine, but also an effect RCTs that include a control group are advantageous to RCTs that compare two active treatments, since the effect in the placebo group rarely is zero and often varies. An example is RCTs on acute treatment of migraine comparing the effi- cacy of subcutaneous sumatriptan and placebo showed pla- cebo responses between 10 and 37%, while the therapeutic effect, i.e., the efficacy of sumatriptan minus the efficacy of placebo was similar [, Another example is a RCT on prophylactic treatment of migraine, comparing topiramateand placebo []. The attack reduction increased along with increasing dose of topiramate 50, 100 and 200 mg/day. The mean migraine attack frequency was reduced from 1.4 to 2.5 attacks per month in the topiramate groups and 1.1 attacks per month in the placebo group from baseline, with mean attack frequencies varying from 5.1 to 5.8 attacks per month in the Thus, interpretation of the efficacy in the four RCTs without a control group is not straight forward –]. The methodo- logical quality of all seven RCTs had room for improvement as the maximum score 100 was far from expectation, especially a precise migraine diagnosis is important.
Several of the studies relatively include a few partici- pants, which might cause type 2 errors. Thus, power cal- culation prior to the study is important in the future studies.
Furthermore, the clinical guidelines from the International Headache Society should be followed, i.e., frequency is a primary end point, while duration and intensity can be adverse reactions following chiropractic cervical SMT –When to refer migraine patients to manual ther-apies? Patients not responding or tolerating prophylactic medication or who wish to avoid medication for other reasons,can be referred to massage therapy, physical therapy or chi- The two RCTs on massage therapy included relatively a ropractic spinal manipulative therapy, as these treatments are few participants, along with shortcomings mentioned in safe with a few adverse reactions ].
Table [, Both studies showed that massage therapywas significantly better than the control group, by reducingmigraine intensity and frequency, respectively. The 27–28% (34–7% and 30–2%) therapeutic gain in migrainefrequency reduction by massage therapy is comparable Current RCTs suggest that massage therapy, physiother- with the 6, 16 and 29% therapeutic gain in migraine fre- apy, relaxation and chiropractic spinal manipulative ther- quency reduction by prophylactic treatment with topira- apy might be equally efficient as propranolol and topiramate in the prophylactic management of migraine.
The single study on physiotherapy is large, but do not However, a firm conclusion requires, in future, well-con- include a control group [The study defined responders ducted RCTs without the many methodological shortcom- to have 50% or more reduction in migraine intensity. The ings of the evaluated RCTs on manual therapies. Such responder rate to physical therapy was only 13% in the first studies should follow clinical trial guidelines from the part of the study, while it was 55% in the group that did not benefit from relaxation, while the responder rate to relax-ation was 51% in the first part of the study and 47% in the group that did not benefit from physical therapy. A This article is distributed under the terms of the reduction in migraine intensity often correlates with Creative Commons Attribution License which permits any use, dis- reduced migraine frequency. For comparison, the respon- tribution and reproduction in any medium, provided the original der rate was 39, 49, 47 and 23% among those who received topiramate 50, 100 and 200 mg/day and placebo as definedby 50% or more reduction in migraine frequency [Ameta-analysis of 53 studies on prophylactic treatment with propranolol showed a mean 44% reduction in migraine 1. Esposito S, Philipson S (2005) Spinal adjustment technique the activity [Thus, it seems that physical therapy and chiropractic art. Craft Printing, Alexandria relaxation has equally good effect as topiramate and 2. Cooperstein R, Gleberson BJ (2004) Technique systems in chi- ropractic, 1st edn. Churchill Livingstone, New York Only one of the four RCTs on chiropractic spinal 3. Headache Classification Committee of the International Head- ache Society (1988) Classification and diagnostic criteria for manipulative therapy (CSMT) included a control group, headache disorders, cranial neuralgias and facial pain. Headache while the other studies compared with other active treat- Classification Committee of the International Headache Society.
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16. Lundquist YC, Benth JS, Grande RB, Aaseth K, Russell MB 25. Morelli N, Gallerini S, Gori S, Chiti A, Cosottini M, Orlandi G, (2009) A vertical VAS is a valid instrument for monitoring Murri L (2006) Intracranial hypotension syndrome following headache pain intensity. Cephalalgia 29:1034–1041 chiropractic manipulation of the cervical spine. J Headache Pain 17. Rasmussen BK, Olesen J (1992) Migraine with aura and migraine without aura: an epidemiological study. Cephalalgia 12:221–228 26. Marx P, Pu¨schmann H, Haferkamp G, Busche T, Neu J (2009) 18. Ensink FB (1991) Subcutaneous sumatriptan in the acute treat- Manipulative treatment of the cervical spine and stroke. Fortschr ment of migraine. Sumatriptan International Study Group.
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