Effect of Mulligan manual therapy and exercise on headache frequency, intensity, disability, and upper cervical joint hypomobility in people with episodic tension-type headache: a randomized clinical trial

The effectiveness of Mulligan manual therapy has been investigated in cervicogenic headache but not in tension-type headache (TTH). To compare the effectiveness of exercise + Mulligan manual therapy over exercise or exercise + sham in episodic TTH. Using a randomized clinical trial design, 99 subjects with episodic TTH received six sessions of allocated intervention over 4 weeks. Headache frequency, intensity, duration, medication intake, disability, upper cervical rotation, pressure-pain thresholds, and patient satisfaction were assessed at baseline, 4 weeks, 3, and 6 months. Headache frequency reduced significantly in group exercise + Mulligan manual therapy compared to group exercise post-intervention (MD −1.0 day, 95% CI −2.0 to −0.0) (p = .002), and at 3-month follow-up (MD −1 days, 95% CI −2.0 to 0.0) (p = .002), but only at post-intervention compared to group exercise + sham (MD 1.0 day, 95% CI 0.0 to 2.0) (p = .008). The clinical relevance is unclear as between-group differences did not reach a clinical threshold. No difference was observed at 6 months (p > .17). A similar trend was observed for other outcomes. There was no difference between groups exercise and exercise + sham for any outcome (p > .17). In episodic TTH, exercise + Mulligan manual therapy provided short-term clinically uncertain improvements in headache parameters. These results differ to studies of cervicogenic headache. Unsuitability of Mulligan manual therapy for underlying pathophysiological mechanisms in episodic TTH may explain these results. Practitioners should consider Mulligan manual therapy for selected patients and only as part of evidence-based multimodal management of episodic TTH. CTRI/2019/06/019506.