Tension-type headache (TTH) is the most common type of primary headache and it represents 47% of headache disorders in adult population worldwide. The cause of TTH has not been established, whereas secondary headaches have a known cause. Most of the patients suffering from TTH are women, with ages around 40 yearsold, with a mild to moderate average headache pain intensity. Manual treatment reduces headache frequency and intensity (Moraska and Chandler, 2008) and cervical spine manipulation has been shown to be effective in reducing frequency, duration and intensity of headaches in patients with TTH.

Eighty-four patients diagnosed with episodic tensiontype headache (ETTH) and chronic tension-type headache (CTTH) participated in a recent study from Espí-López (2014). Sixty-eight of participants were women (81%). Mean age was 39.7 years within an age range of 18-65 years.

Patients were randomly divided into 4 groups (3 treatment groups and 1 control group):

Group 1) SI (soft tissue) treatment;

Group 2) OAA manipulative (occiputatlas-axis) treatment;

Group 3) combination of SI + OAA;

Group 4) placebo control.

Four treatment sessions, with an interval of one session per week, which is the estimated time for all treatments to achieve a positive effect, were carried out by two physiotherapists with over 10 years experience in the treatment of headaches and a good knowledge of the techniques used.

The SI treatment aims to release the suboccipital muscle spasm that determines the occiputatlas-axis joint dysfunction. In order to apply this treatment, the patient was placed supine on the couch. The therapist’s hands are placed under the patient’s head making contact with the suboccipital muscles in the region of the posterior arch of the atlas, where pressure was progressively and deeply applied. This technique was administered for 10 min to produce an inhibitory effect.

The OAA manipulation was bilaterally administered attempting to restore the motion dysfunction of this complex.

The control group received no treatment, although patients of this group attended the same sessions as the intervention groups. In the sessions the
control group underwent the artery test and remained 10 min in a resting position, five more than groups with treatment.

Regarding the impact of headache, the OAA group stands out since it reported statistically significant changes after the four-week treatment period. In the follow-up at 8 weeks, the three treatment groups (SI, OAA, and SI þ OAA) showed statistically significant differences.

Regarding the ranges of motion, craniocervical flexion significantly improved after the treatment period in all study groups. This improvement was only maintained at follow-up in the three treatment groups (SI, OAA and SI + OAA), and disappeared in the control group.

Craniocervical extension improved significantly after the treatment in OAA, SI þ OAA and control groups. This improvement was maintained at follow-up only in the treatment groups.

Regarding the frequency of headache, the headache diary kept by patients in the OAA and SI + OAA groups showed statistically significant reductions after the treatment; at 8-week follow-up, only the SI + OAA group still showed statistically significant differences. As for the weekly average of pain intensity, the groups with OAA and SI + OAA treatment, as well as the control group, showed statistically significant improvements both at posttreatment and at follow-up. As for the weekly frequency of pericranial tenderness, the three treatment groups (SI, OAA and SI + OAA) showed significant reductions both after the treatment and at follow-up.

The OAA and SI + OAA groups proved to be the most effective ones, both of them showing significant differences and a large effect size. The records of headache frequency kept by patients during the trial period, when comparing outcomes at baseline, after the treatment and at follow-up, showed statistically significant differences in the SI + OAA group, with a large effect size.

Manual Therapy Improves Headaches Summary

The combined SI + OAA treatment is effective in reducing impact of headache, functional disability, frequency and intensity of headache, pericranial tenderness, and in increasing craniocervical flexion and extension. Moreover, the combined SI + OAA treatment has proved to be more effective than each treatment separately.

If you have headaches, don’t overlook the possibility of an orthopedic cause and see a physical therapist. If you want, there are soft tissue methods you can try on your own, please ease into these soft tissue therapies and monitor closely, ideally with the supervision of a medical professional.

SMR Suboccipitals

SMR Scalenes


  1. Espí-López GV, Gómez-Conesa A, Gómez AA, Martínez JB, Pascual-Vaca AO, Blanco CR. Treatment of tension-type headache with articulatory and suboccipital soft tissue therapy: A double-blind, randomized, placebo-controlled clinical trial. J Bodyw Mov Ther. 2014 Oct;18(4):576-85. doi: 10.1016/j.jbmt.2014.01.001. Epub 2014 Jan 10.

Written by John Mullen, DPT, CSCS.

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