International Journal of Osteopathic Medicine (2016) 22, 11e20

www.elsevier.com/ijos

ORIGINAL ARTICLE

Efficacy of manual therapy on anxiety and

depression in patients with tension-type
headache. A randomized controlled clinical
trial
Gemma Victoria Espı́-López a,*, Laura López-Bueno a,
M. Teófila Vicente-Herrero b, Francisco M. Martinez-Arnau a,
Lucas Monzani c

a
Physiotherapy Department, University of Valencia, Spain
b
Occupational Health Service, Correos Group of Valencia, Spain
c
Richard Ivey Business School at Western Ontario University, Ontario, N6G 0N1, Canada

Received 16 June 2015; revised 23 May 2016; accepted 31 May 2016

KEYWORDS Abstract Introduction: Tension-type headache (TTH) is a highly prevalent disor-

Efficacy; der with a significant socio-economic impact. The purpose of this study was to test
Manual therapy; the efficacy of three manual therapy treatments for reducing TTH-related anxiety
Tension-type head- and depression.
ache; Subjects and methods: A clinical trial was conducted on 84 participants diag-
Depression; nosed with tension-type headache forming 4 groups: the first group received sub-
Anxiety; occipital soft tissue treatment (ST); the second group was treated with
Spinal manipulation articulatory techniques (AT); the third group underwent a combination of both
techniques (ST and AT), while the fourth group was the control group. Treatment
sessions were administered over four weeks, with post-treatment assessment,
and follow-up at one month. We conducted repeated measures analysis of
covariance (RM-MANCOVA) to evaluate the effect of treatment on between
and within-subject conditions and their interaction on reported depression and
anxiety.

* Corresponding author. Physiotherapy Department, University of Valencia, C/ Gascó Oliag 5, 46010 Valencia, Spain. Tel.: þ34
963983853; fax: þ34 963983852.
E-mail addresses: gemma.espi@uv.es (G.V. Espı́-López), laura.lopez@uv.es (L. López-Bueno), MTVH@ono.com (M.T. Vicente-
Herrero), francisco.m.martinez@uv.es (F.M. Martinez-Arnau), lmonzani@ivey.uwo.ca (L. Monzani).

http://dx.doi.org/10.1016/j.ijosm.2016.05.003
1746-0689/ª 2016 Elsevier Ltd. All rights reserved.
12 G.V. Espı́-López et al.

Results: All treatments resulted in a ‘moderate’ reduction of psychological

symptoms associated with TTH (Cohen’s f ¼ .31 for anxiety trait; f ¼ .35 for
anxiety state and f ¼ .35 for depression). However, their efficacy varied across
treatments, TTH types and the elapsed time between measurements.
Conclusion: Treatments including an articulatory technique showed a greater ef-
ficacy than a soft tissue technique, or a combination of both, for the reduction
of TTH-related anxiety and depression levels in these participants.
Clinical Trials.gov Identifier: NCT02170259.
ª 2016 Elsevier Ltd. All rights reserved.

alternative to medication-based treatments; spi-

Implications for practice
 Manual treatments in the suboccipital region
contribute to reduce negative emotional
states in TTH patients.
 The effect of these manual treatments varies
according to the duration of a patient’s TTH.
We recommend adequate diagnosis of a TTH’s
chronicity.
 An articulatory treatment had the best over-
all results on negative emotional states, and
thus we recommend its use.
Introduction
The International Headache Society (IHS) devel-
oped a classification for headache disorders and
their characteristics,1,2 wherein tension-type
headache (TTH) is the most common form of pri-
mary headache. TTH has a great socio-economic
impact,3,4 negatively affecting people’s quality of
social and work life.5 A recent study exploring
chronic tension-type headache (CTTH), reported
that CTTH moderately affected working or social
spheres in 60% of participants and seriously
impaired these areas in 9% thereof; 37% suffered
sleep disorders; 35% experienced changes in en-
ergy levels and 33% an alteration of emotional
well-being.6
Some authors reported that participants
suffering from TTH experience an increased
tenderness in pericranial myofascial tissues and
several trigger points (TrPs), which suggests that
tension in the craniocervical muscles may be a
possible physiological cause of TTH.7 Moreover,
prior studies show physiotherapy and muscle
relaxation therapies as effective treatments for
such muscular tension.8 The muscle relaxation
therapies include manual therapy as a non-invasive
nal manipulation shows positive results in reducing
headache frequency, duration and intensity.9 For
example, manual therapy aimed at active TrPs of
the sternocleidomastoid muscle is an effective
technique to reduce cervicogenic headaches and
to improve overall cervical movement.10 In addi-
tion, articulatory mobility (articulatory normali-
zation) and muscular relaxation treatments, when
applied to the craniocervical soft tissues and joints
of the suboccipital region, not only improve TTH,
as certain evidence suggests, but also reduce
adverse TTH-related psychological states, such as
anxiety and depression.11
However, in view of the poor methodological
quality of previous trials (e.g., single blind studies or
no control group), a better understanding of the
efficacy of these manual treatments is needed.12
Spinal manipulations in previous studies were
applied according to participants’ joint mobility
dysfunction; therefore, the manipulation level
differed for each patient,13 which makes it impos-
sible to establish if these techniques would render
similar results if applied separately. Furthermore,
while only one study combined treatment of the
craniocervical region with other techniques (e.g.,
inhibition of soft tissues with muscle-energy tech-
niques),14 we found no studies applying a joint
manipulation in this region for TTH participants
(e.g., combining suboccipital soft tissue treatment
with other techniques). While a joint manipulation
may have two advantages (e.g. increased muscular
relaxation and balance between the suboccipital
and pericranial regions), the efficacy of combined
manual treatments on TTH frequency and intensity
of pain, and in consequence on anxiety and depres-
sion, is unknown.
On the other hand, existing TTH literature is un-
clear in terms of the causal direction between TTH
and depression and anxiety. Early studies considered
anxiety and depression as psychogenic causes of
TTH. For example, a study of 25 TTH participants
reported that anxiety affected their headache
Manual therapy for tension-type headache
frequency, pain, vitality and social functioning. In
turn, other authors established that anxiety and
depression are associated with an increased burden
of accompanying symptoms, such as intestinal or
sleep disorders.15 Finally, it appears that TTH is
one possible cause and not an effect of negative
emotional states such as depression and anxiety.16,17
For example, Holroyd (2000)6 reported that partici-
pants with Chronic Tensional Type Headache (CTTH)
experience higher levels of anxiety and depression
than matched controls, but did not compare these
values with those found in people with episodic
Tensional Type Headache (ETTH).
The present study proposes that because
focusing treatment on the suboccipital region can
neutralize pain, it should also reduce TTH-related
psychological symptoms. Although this study is
framed within a larger project that includes
recently published studies,18,19 it extends prior
findings by exploring the secondary benefits of
manual therapy on TTH participants’ negative
emotional states (e.g., anxiety and depression).
These psychosocial criteria require a separate
study due to their impact on the emotional tone of
TTH participants and their well-being.18 Thus, this
study’s objective were to evaluate if treating TTH
participants with (1) a suboccipital soft tissue (ST)
technique, (2) an articulatory technique (AT), or
(3) combining both techniques (ST þ AT) would
reduce negative emotional states associated with
TTH, namely, depression and anxiety. Secondly, we
investigated if the efficacy of the above-mentioned
treatments varied depending on the TTH type
(episodic vs. chronic) and the elapsed time.
Participants and methods
Participants
Participants in this study were recruited from two
primary healthcare centers in Spain over a period
from January 2010 to December 2011. All partici-
pants had been previously diagnosed by a neurol-
ogist with frequent episodic tension-type
headache (ETTH) or chronic tension-type head-
ache (CTTH) as described by the International
Headache Society (IHS).1,2 Before commencing our
study a clinical interview was conducted, in order
to confirm that the initial diagnosis was consistent
with the IHS criteria. All participants reported
suffering from TTH for a period greater than six
months and were pharmacologically stable.
In addition to the above, a vertebral artery test
was performed bilaterally for all potential
13
participants. Even though there is some contro-
versy about the efficacy of this test in detecting
vascular injury,20,21 we included the latter as a
main exclusion criterion. In consequence, any
participant with vertebrobasilar insufficiency
symptoms was excluded from our study. Other
exclusion criteria were: participants with second-
ary headaches suffering from photophobia or
phonophobia, nausea or vomiting, cases of head-
ache aggravated by head movements, rheumatoid
arthritis, previous neck trauma, vertigo, dizziness,
arterial hypertension, arthritis or advanced
degenerative osteoarthritis, participants with
heart devices, excessive emotional stress, neuro-
logical disorders, radiological alterations and
pregnancy.
Clinicians
The clinicians who conducted were certified ther-
apists in the country in which the study was con-
ducted (Spain). More precisely, in addition to their
bachelor’s degree in physiotherapy, our clinicians
held a post-graduate degree in osteopathy. In
addition to such vocational qualifications, clini-
cians had more than 10 years of clinical experience
in the assessment and treatment of osteopathic
issues.
Study design
Prior to data collection, the design and method of
this study was reviewed and approved by the
research committee of the first author’s univer-
sity. Informed consent of all participants was ob-
tained, and all procedures were conducted
according to the Declaration of Helsinki and the
study was approved by the institutional ethics
committee. Moreover, the present clinical trial is
registered on ClinicalTrials.gov (NLM identifier
NCT02170259).
This study was a pragmatic, randomized,
double-blind, controlled trial, with blinding of
participants and examiners. Participants were
randomly divided into 4 groups (3 treatment
groups and 1 control group): Group 1 received the
ST treatment; group 2 was applied the AT treat-
ment and group 3 received the combined ST þ AT
treatment. The required number of participants in
each group was estimated using nQuery Advisor
(Statistical Solutions, Boston, MA). For an RM-
ANCOVA with one inter-subject factor, with 4
groups, and aiming to detect medium (0.5e0.8) to
large (>0.8)22 effects with a p < .05, at least 19
participants in each group are required.
14
Both participants and clinicians were blinded to
treatment group allocation. Participants were
randomly assigned to either one of the treatment
groups or to the control group using a computer-
generated sequence after an initial clinical inter-
view was conducted. Clinicians were unaware of
the type of study in which they were participating,
or its objectives. Blinding was achieved through a
research assistant who provided the clinicians with
a patient number, a treatment protocol and eval-
uation criteria in a closed, previously coded, en-
velope at the beginning of each session.
Confidentiality provisions were fulfilled following
the Spanish legislation on personal data protection
(Act 15/1999 of December 13th, 1999). All partic-
ipants were assessed under the same conditions
before treatment, after treatment (at 4 weeks),
and at follow-up (after 8 weeks) in the same
location where treatment was conducted.
Recruitment concluded when the required number
of participants was obtained.
Experimental intervention
The whole intervention lasted one month, over
which period each participant received one treat-
ment session per week, totalling 4 sessions, within
each group. Each treatment session lasted
approximately 20 min. After each treatment, par-
ticipants stayed in supine resting position for 5 min.
The control group did not receive any treatment
but rested in supine position for 10 min.23
The suboccipital technique (ST) aims to relieve
affected sub-occipital muscle dysfunction associ-
ated with tension-type headaches as these struc-
tures may contribute to mobility dysfunction of
the occiput-atlas-axis joint.7,9 As mentioned, par-
ticipants lay on a treatment table, in supine posi-
tion, with their occiput resting against the
clinician’s hands, with the fingertips contacting
the posterior arch of atlas so that it ‘hung’ from
the fingers. A deep and progressive pressure was
applied, perpendicularly to muscle fibers, until the
clinicians perceived a decrease in participants’
muscular tone. The duration of ST was 10 min and
was performed with participants’ eyes closed due
to the connection between craniocervical muscle
tone and eye movements.14,18,23
The articulatory technique (AT) was adminis-
tered to correct and restore the mobility of joints
between occiput, atlas and axis. This technique
was conducted in the same position as the ST
technique (supine position), bilaterally and in two
phases that lasted 5 min in all. First, a gentle ce-
phalic decompression as described by Espı́-López
G.V. Espı́-López et al.
et al.23 was applied, followed by small circum-
duction searching for the joint barrier in rotation
through selective tension. Second, a high-velocity
thrust manipulation in occiput-atlas-axis (OAA)
was conducted, performing a cranially directed
rotation towards the same side as the circum-
duction and around a vertical axis passing through
the axis, without cervical flexion or extension and
minimal side-bending.18,19,24
After the administration of each experimental
group treatment, all participants stayed in supine
position for 5 min, with neutral ranges of head
flexion, extension, lateral flexion and rotation, to
allow the tissues to adapt to the changes under-
gone after the treatment.
Combined treatment (ST and AT). Combined
treatment consisted of applying ST and AT in the
same sequence: first, treatment with ST (10 min)
and subsequently AT (5 min), thereafter main-
taining the resting position for 5 min.18,19
Control intervention. The control group did not
receive any treatment technique; however, this
group attended the same number of sessions and
were evaluated in a similar way as the treatment
groups. In each session, after the evaluation,
instead of receiving treatment, participants stayed
in a resting position for 10 min.18,19
Assessment
Prior to commencing the trial, but after the
randomization of participants was conducted, a
clinical interview was carried out by a research as-
sistant, who was blind to the study objectives, and
participants’ treatment groups. The clinical inter-
view collected socio-demographic data and trigger
factors, which were assessed through a multiple
choice questionnaire inquiring about their head-
aches in the four weeks prior to treatment. Further,
the same assistant administered two psychometric
scales, measuring anxiety and depression. Instead,
the clinicians who applied the respective treatments
were not present neither in the clinical interview,
nor when these scales were administered.
Anxiety was assessed with the State-Trait Anxi-
ety Inventory (STAI-SA and STAI-TA).25,26 This in-
strument is designed for the self-assessment of
anxiety, both as a temporary psychological state
and a latent permanent trait, with 20 questions
and 4-item Likert scale ranging from 0 ¼ “not at
all” to 3 ¼ “very much”. Overall scores range from
0 to a maximum of 60 points; scoring above the
50th percentile indicates the presence of anxiety.
For males, this percentile correlates with a score
of 19 points, both for STAI-state and STAI-trait. For
Manual therapy for tension-type headache
females, scores over 21 for STAI-state and 24 for
STAI-trait determine this level. Cronbach’s a
for this scale ranges from .83 to .92.27
Depression was assessed with the Beck Depres-
sion Inventory (BDI),28 which consists of 21 items,
assessing depressive symptoms on a Likert scale of
0e3, ranging from 0 ¼ “rarely or not at all” to
3 ¼ “most of the time or always”, with overall
scores ranging from 0 to a maximum of 63 points.
15 of the 21 items measured cognitive or psycho-
logical symptoms while the other 6 measure
physiological or somatic symptoms. A total score of
0e13 indicates no depression; 14e19 mild
depression; 20e28 moderate depression and 29
suggest a severe depression. The BDI was adapted
to Spanish and validated by Conde and Useros,
showing very good psychometric properties
(Cronbach’s a ¼ .86).29e31
Statistical analysis
We performed a repeated measures analyses of
covariance (RM-ANCOVA) using pre, post and
follow-up measurements as time-points for within-
subject factors, and treatment type and TTH type
(dummy coded 0 ¼ Episodic TTH/1 ¼ Chronic TTH)
as between-subject factors, taking p < .05 as sig-
nificance level and rating effect sizes as ‘small’
(Cohen’s f ranging from 0.1 to 0.3), ‘medium’
(f ¼ 0.3e0.5) or ‘large’ (>0.5).22
In terms of overall treatment efficacy, signifi-
cant mean differences in the expected direction
between pre-test, post-test or follow-up measures
would indicate that a specific treatment had an
Fig. 1 Flowchart according to CONSORT statement for the report of randomized trials.
15
impact of participants’ psychological symptoms.
Furthermore, non-significant differences between
post-test and the follow-up measurements would
indicate that the treatments’ effect remained
stable in time, whereas significant differences
between the pre-test and the follow-up would
evidence a time-lagged effect of TTH treatments.
Moreover, to compare the efficacy of different TTH
treatments on depression or anxiety, we explored
mean differences over our control group, using
pairwise estimated marginal mean differences
(IeJ) adjusted using Bonferroni’s method. A main
effect would suggest differences in TTH treatment
efficacy, only if they significantly differed from the
control group. Instead, significant two-way or
three-way between-within subject interactions
would indicate that TTH treatment efficacy varies
across data points, TTH types, or both.
To ensure the validity of our conclusions, before
interpreting our results we checked that all as-
sumptions of linear models were met. First, we
tested the normality assumption by calculating the
Skewness and Kurtosis levels of our dependent vari-
ables (which was in all cases between the accepted
1 to 1 range).32 Furthermore, we verified the ho-
mogeneity of the variance assumption using Lev-
ene’s test (which was not significant in all between-
subject analyses); and lastly, due to the repeated
measures design, we used Mauchly’s33 statistic to
test for violations of the assumption of Sphericity.
Following Girden,34 we applied Huynh-Feldt’s
correction if ε > .75 in both Greenhouse-Geisser35
and Huynh-Feldt36 tests whenever the assumption
of Sphericity was violated.
16 G.V. Espı́-López et al.

Table 1 Mean differences between estimated marginal means of depression and anxiety by TTH treatment type,
TTH type and data point.
Measure Treatment type TTH type Time point Est. Marginal means SE 95% LLCI 95% ULCI
Depression Control ETTH Pre-test 6.24 1.45 3.35 9.13
Post-test 4.67 1.27 2.12 7.18
Follow-up 3.67 1.25 1.18 6.16
CTHH Pre-test 15.98 1.99 12.01 19.96
Post-test 14.23 1.74 10.75 17.70
Follow-up 12.53 1.72 9.10 15.95
AT ETTH Pre-test 4.93 1.53 1.87 7.99
Post-test 3.34 1.34 .67 6.01
Follow-up 2.02 1.32 -.61 4.66
CTHH Pre-test 7.70 2.02 3.69 11.73
Post-test 5.23 1.76 1.71 8.75
Follow-up 6.57 1.74 3.10 10.04
ST ETTH Pre-test 9.34 1.81 5.74 12.94
Post-test 7.19 1.58 4.05 10.33
Follow-up 7.22 1.55 4.12 10.32
CTHH Pre-test 13.36 1.63 10.10 16.61
Post-test 13.39 1.43 10.55 16.24
Follow-up 9.32 1.41 6.52 12.13
AT þ ST ETTH Pre-test 8.28 1.57 5.14 11.42
Post-test 5.48 1.37 2.74 8.22
Follow-up 4.05 1.35 1.35 6.76
CTHH Pre-test 11.87 1.82 8.24 15.50
Post-test 11.51 1.59 8.34 14.68
Follow-up 10.57 1.57 7.45 13.70
Anxiety State Control ETTH e 23.95 1.72 20.52 27.39
CTHH e 22.52 2.45 17.63 27.40
AT ETTH e 24.53 1.83 20.87 28.19
CTHH e 18.79 2.32 14.16 23.43
ST ETTH e 16.81 2.09 12.64 20.98
CTHH e 22.10 1.92 18.27 25.94
AT þ ST ETTH e 19.39 1.80 15.80 22.98
CTHH e 21.18 2.15 16.89 25.47
Anxiety Trait Control e Pre-test 22.39 2.02 18.37 26.41
e Post-test 24.64 2.00 20.65 28.64
e Follow-up 23.46 1.77 19.92 26.99
AT e Pre-test 23.75 2.05 19.65 27.84
e Post-test 21.04 2.04 16.98 25.11
e Follow-up 21.17 1.80 17.57 24.77
ST e Pre-test 21.55 1.93 17.69 25.41
e Post-test 21.73 1.92 17.89 25.56
e Follow-up 21.29 1.70 17.90 24.68
AT þ ST e Pre-test 27.90 1.95 24.02 31.79
e Post-test 24.96 1.93 21.10 28.82
e Follow-up 21.95 1.71 18.53 25.36
Note: A Bonferroni’s correction has been applied for multiple comparisons. AT ¼ Articulatory technique; ST ¼ suboccipital
technique; AT þ ST ¼ Combined Technique. Only statistically significant interactive effects are shown.

Results characteristics, 97.6% had bilateral pain, and non-

There were 84 participants in this study: 68 women
(81%) and 16 men (19%). Mean age was 39.7 years (SD
11.38), while the age range was from 18 to 65 years.
54.8% of the participants suffered from ETTH and
45.2% from CTTH. According to headache
pulsating pain in 81% cases. 92% of participants
perceived pain intensity as mild and 8% as moderate.
Once the headache was established, for 71.4% of
participants, the performance of physical activity
did not increase pain intensity. Stress was the most
important trigger factor for 70.2% of the sample,
Manual therapy for tension-type headache
followed by work-related factors (48.8%), emotional
factors (34.5%) and family-related factors (19%) and
those related to academic matters (8.3%). Four
participants dropped out of the study: Two partici-
pants dropped out of the AT group during the treat-
ment period, (one due to slight physical discomfort
after starting treatment and one due to personal
reasons). Similarly, two participants dropped out of
the control group (one due to a transient ordinary
disease during the treatment period and one during
the follow-up period in the absence of pain relief).
Our final sample consisted of 80 participants who
completed the trial in full (see Fig. 1). Table 1 shows
estimated marginal means, standard errors and 95%
CI for our RM-ANCOVAS having anxiety-state, anxi-
ety-trait and BDI scores as dependent variables.
Anxiety-trait
With regard to anxiety-trait, our multivariate ana-
lyses show that the three-way interaction between
Treatment type, TTH type, and time was only
marginally significant (Wilks’ L ¼ .86; F (6,
136) ¼ 1.84, p < .10; h2 ¼ .07). However, a two-way
interaction between TTH treatment types and
elapsed time (F (6, 144) ¼ 2.25, p < .05; h2 ¼ .09),
suggested that the efficacy of our treatments varied
across treatment sessions, but not across TTH types.
As compared to the control group, ST is initially more
efficient than AT treatment, but the latter eventu-
ally has a slightly stronger effect, independently of
the participants’ TTH type (see Fig. 2).
Anxiety-state
For Anxiety-state, multivariate analyses were non-
significant. However, between-subject analyses
show an interaction effect between treatment
Fig. 2 Effect of different TTH Treatments on Anxiety (trait and state) by participants with episodic (ETTH) and
chronic TTH (CTTH) or time point (Error bars represent standard errors).
17
types and TTH types (F (3, 68) ¼ 2.90* h2 ¼ .11),
indicating that mean differences across treatment
types vary according TTH type. More precisely,
Fig. 2 shows that for participants suffering CTTH,
as compared to the control group, the AT treat-
ment group report the lower Anxiety-state scores,
but ETTH participants report a lower anxiety state
in the ST group.
Depression
For depression, our multivariate analyses (Wilks’
L ¼ .80; F (6, 138) ¼ 2.74*, h2 ¼ .11) show a three-
way interaction between TTH treatment types,
TTH types, and elapsed time. Depression levels in
the AT (I) group were significantly lower than in
the control group (J; IeJ ¼ 4.58*, 95% CI [8.44;
.72]). Taken as a whole, Table 1 and Fig. 3 show
that while participants of ETTH in the AT group
report lower absolute BDI scores, mean differ-
ences between the AT group and the control group
are higher for CTTH participants.
Discussion
Our result show that in general, vertebral manip-
ulative techniques (AT) in this study appear to
have greater efficacy than inhibitory techniques
(ST), perhaps due to the global bilateral effect
that AT may have on the peripheral cervicocranial
muscles. In other words, articulatory techniques
enable a more effective muscular relaxation in this
region than that achieved with direct muscular
work (ST) only. As suggested by some scholars, our
results show mixed findings regarding the second-
ary benefit of manual therapies on negative psy-
chosocial symptoms associated with TTH.37,38 On
18
Fig. 3 Effect of different TTH Treatments on Beck Depression Inventory scores for participants with episodic and
chronic TTH (Error bars represent standard errors).
the one hand, for anxiety-state, a more situational
form of anxiety, we found that CTTH participants
in the AT group report lower anxiety (state) than
those in the ST group. The opposite occurs for
ETTH participants; ETTH participants in the ST
treatment group report lower anxiety-state than
those in the AT group. We believe this may be due
to the fact that manual techniques in participants
with chronic headache pain, such as CTTH, may
break the existing tensional sensitivity, reducing
the weekly frequency and intensity of headache
pain, showing an improvement whereby partici-
pants’ TTH-related anxiety levels are reduced.
Because ETTH is not chronic, as in CTTH, a ST
seems to suffice to reduce anxiety. We speculate
that this is because this type of TTH does not
affect the articulatory complex, but the muscular
level instead.
We found that for anxiety trait, understood as a
natural disposition to feel anxious, the beneficial
effects of TTH treatments did not vary between
TTH types, however, the duration of effects
differed. While as compared to the control group,
participants in the ST treatment group showed
lower initial scores of anxiety trait, these scores
did not change after the treatment, nor at follow-
up sessions. However, participants in the AT
treatment group showed an important improve-
ment during the treatment, and its scores for
Anxiety-trait remained the lowest of all groups at
the follow-up evaluation. We believe that this may
be due to the fact that the AT treatment has
G.V. Espı́-López et al.
stronger impact on articulatory movement and
especially on the muscles of an area which may
naturally accumulate tension in those individuals
with a tendency towards anxiety.
Finally, we found that the beneficial effect of
TTH treatments on BDI scores is contingent on both
the TTH type and the treatment received. This
suggests that the observed decrease in BDI scores
associated with TTH treatments, will vary
depending on whether the TTH is episodic or
chronic. More precisely, our results suggest that AT
treatment participants report significantly lower
scores on the BDI than the control group, and this
difference was even larger for ETTH participants
(Cohen’s f ¼ .35).
In short, manual therapy treatments can posi-
tively impact the health of people with TTH,
relieving TTH episodes in the various affected
areas. Our research helps to provide evidence
regarding the scope of efficacy of manual therapy
in headache treatment. More specifically, treat-
ments focusing on the suboccipital area effectively
reduce TTH-related physiological symptoms (e.g.,
headache pain frequency and intensity) and as a
secondary benefit, reduce depression and anxiety
in participants suffering from different TTH types.
This study compared manual techniques that
focused on the suboccipital region, using sub-
occipital soft tissue and manipulative treatments.
ST was chosen with the aim of reducing cranio-
cervical muscle tension, a possible cause of
headache onset, while we chose AT for its
Manual therapy for tension-type headache
releasing and normalizing effect on movement and
soft tissues. Taken as a whole, our findings indicate
that AT was superior than ST.
Strengths and limitations
A strength of this study is its robust design
employing a randomized, double-blinded,
controlled clinical trial, investigating both indi-
vidual and combined therapeutic approaches.
Further, the characteristics of TTH in our sample
are consistent with the 2004 IHS classification.1,2
Finally, clinicians who administered the treat-
ments in our study had more than 10 years of
clinical experience. Therefore, our study repre-
sents a valuable contribution to existing research
on the treatment of physiological symptoms of
different TTH types and secondary benefits on
associated psychosocial symptoms.
However, our work entails certain limitations
that future research should address. First of all, a
more extended evaluation of the positive effects
of our treatments is required. Even though we
conducted a short-term follow-up, a longer moni-
toring period would be desirable to better under-
stand the temporal stability of our TTH treatment
effects. This seems particularly relevant when
evaluating the positive effect of TTH treatment on
negative psychological states of TTH participants
(e.g., anxiety and depression), because other
environmental factors not considered in this study,
such as risk factors in the patient’s workplace, may
aggravate stress-related tension in craniocervical
muscles. In this line, future research should
explore the role played by TTH in work-related
symptoms such as distress or burnout. Further-
more, the effect of treatment on physical mea-
sures was not assessed, as it exceeded the scope of
this study; accordingly, this would be another
subject to be explored in future studies.
Conclusions
Overall, all treatments applied in this study have
shown to have a moderate yet positive effect in
reducing the secondary effect on TTH-related
psychosocial variables, such as depression and
anxiety. In this study, an AT treatment, which
included both articulatory and high-velocity thrust
manipulation, applied to the suboccipital region
was more effective than a ST in reducing negative
emotional states, such as anxiety state for CTTH
participants. Conversely, even though failing to
reach statistical significance at the p < 0.5 level,
19
ETTH participants also show a small improvement
with ST techniques in their anxiety scores. Finally,
for TTH-related depression symptoms, both the AT
treatment alone, or combined with an ST treat-
ment, were more effective for participants
suffering from ETTH than for those suffering CTTH.
Among all TTH treatments explored in this study,
AT shows better overall results, although it should
be noted that all treatments used in this study
improve both ETTH and on CTTH. Therefore, we
recommend using AT treatment due to its greater
efficacy in reducing the TTH-related negative
emotional states (anxiety and depression).
Conflict of interest
None declared.
Ethical approval
Research Ethics approval received from the Insti-
tutional Ethics Committee of the University of
Valencia, Spain.
Funding
None declared.
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